As a young physician in my final year of medical school—and while I was house officer at my teaching hospital—I recall encountering many people who were ill with tuberculosis (TB). They were usually emaciated and suffered from prolonged coughing. Alarmingly, some of them could not be treated with drugs , because they had been sick for such a long time and had built up resistance. I felt so bad, wondering how they could be treated.
Today TB infects 25 percent of the world’s population, killing 1.6 million people every year. And as I saw firsthand years ago, it is becoming increasingly resistant to conventional drugs. This infectious disease must be taken seriously: it kills more people than HIV and malaria combined.
I recently led a team in evaluating TB and how it is treated in Nigeria. The findings were not good and confirm those of other studies. Simply put, tuberculosis is underreported, and confirmation of reported cases is weak.
While TB is a global problem, it is more prevalent in countries with poor urban planning and overcrowding. For instance, in 2017, there were 9,105 cases of tuberculosis in the U.S., and in 2018 there were 4,655 cases in England. In contrast, in 2017 South Africa and Nigeria, two countries with some of the highest TB burden globally, had 322,000 and 104,904 cases, respectively. Unsurprisingly, the burden of drug-resistant tuberculosis is high in Nigeria and South Africa.
The good news is there is a new drug that may help combat the resistance. The U.S. Food and Drug Administration has approved an oral combination for the treatment of multidrug-resistant tuberculosis (MDR-TB). The new combination (pretomanid with bedaquiline and linezolid) showed an 89 percent success rate when administered to 107 adult patients with highly drug-resistant tuberculosis. In contrast, the current drug regimen for treating MDR-TB is just 50 percent effective.
Because of the urgency for MDR-TB, the FDA’s approval was given under the Limited Population Pathway for Antibacterial and Antifungal Drugs—a pathway authorized by the U.S. Congress to fast-track the development of medications for infections that lack effective therapies. This novel drug combination could be a game changer in managing tuberculosis and lead to increased survival of individuals infected with TB.
Here are five interventions that could make its success more equitable and sustainable:
First, to treat tuberculosis patients, we must identify them. This can be very tricky, because most of those affected may not know they have the infection or have access to health care. In Africa, tuberculosis case identification is made possible through the World Health Organization’s Integrated Disease Surveillance and Response (IDSR) and national tuberculosis-control programs. Based on the results of the evaluation I led IDSR must be strengthened in countries with a high burden of tuberculosis so no case is missed.
Second, adoption of technology could help in enrolling and tracking patients, linking them to health facilities, distributing drugs to hard-to-reach communities and ensuring treatment adherence among those affected by tuberculosis. In the Philippines, the 99DOTS mobile health system enables patients to accurately report their adherence to treatment. This result is achieved using TB drugs repackaged in forms with a series of unpredictable, hidden toll-free phone numbers that are revealed each time a patients take their daily dose.
The patients call or text this number, and their adherence is automatically logged on a secure dashboard accessible to their health care provider. In Vietnam, video directly observed therapy resulted in high rates of TB treatment adherence in resource-poor settings. In Rwanda and Ghana, an American company called Zipline uses drones to deliver drugs and other commodities to hard-to-reach communities. Tuberculosis drugs, including the newly approved FDA combination, could be added to the list of treatments carried by drones.
Third, good urban planning and renewal could help reduce the number of new TB cases because overcrowding is a risk factor. In planning urban centers, priority should be given to low-income neighborhoods. Governments across the world should emulate Rwanda, which builds free houses for the poor under its Model Village program. The homes are connected to electricity and water and have modern markets, schools and good roads.
Fourth, more use of community health workers to monitor TB patients would ensure drug adherence and therefore reduce MDR-TB. The mainstay of TB management is DOTS (directly observed treatment short course). A core component of DOTS is ensuring the person affected by TB is supervised to take the drugs as prescribed. Skipping TB drugs leads to MDR-TB and worsens the patient’s condition. This problem is where community health workers’ role is paramount. They live in the same communities with the infected and are trained to provide adherence support. These health workers can keep track of a patient’s outcome and give regular updates to tuberculosis program managers.
Fifth, governments in countries with high TB burdens must ultimately ensure people are not denied health care for any reason. This directive means they should focus on the preventive component of universal health coverage. Tuberculosis is a disease of inequity because it disproportionately affects the poor and underserved. To achieve equity in health care, there must be equity in health education, according to the University of Global Health Equity in Rwanda.
A very common way to prevent TB is for every child to be given the bacille Calmette-Guérin (BCG) vaccine at birth. Further, because TB is spread through air when an infected person coughs, sneezes and disposes of sputum, communities must be informed on how these pathways are risk factors for tuberculosis. Community health workers can play a huge role in changing behaviors by providing the right health education.
It could take a while for the new FDA-approved drug combination to be widely available, especially in resource-poor settings. In the meantime, governments working with communities, health workers, the private sector and civil society organizations should intensify efforts to prevent tuberculosis, increase adherence to currently available treatments and deploy appropriate technologies in tuberculosis programming.
I am glad to see this option become available. I know it will change and save so many lives.