Tuberculosis: Urgent and immediate measures should be taken to accelerate the combat to the disease, alerts Dr. Julio Croda

Developing countries should have their own research agendas according to each reality, epidemiology and priority. These established agendas will only be performed if local governments allocate the necessary investments for their implementation

Tuberculosis (TB) is currently the deadliest infectious disease in the world. According to the World Health Organization (WHO), 1.3 million people died from TB in 2017, more than HIV and AIDS combined. Even so, public investments towards eliminating the disease have been insufficient. As an attempt to change this scenario, on September 26, New York hosted the first United Nations General Assembly on Tuberculosis. Under the theme An Urgent Global Response to a Global Threat, the event stressed the need of an immediate action to accelerate the progress towards the goal of eliminating TB until 2030 and showing a clear worldwide concern with the diseases expansion.

The president of the Brazilian Tuberculosis Research Network (REDE-TB), one of the three Brazilian organization approved to join the Civil Societys Interactive Audition and the High-Level Meeting, Dr. Julio Croda, ensures the meeting was a milestone in the war against the disease and stresses the approval of a concise intergovernmental political declaration oriented to the following actions: (a) enhance response to TB according to the 2030 Agenda for Sustainable Development associated to Goal No. 3 (health goals), including HIV/AIDS, universal health coverage and antimicrobial resistance; (b) increasing and supporting funding for multisector actions against TB; (c) intensifying research on new instruments and innovative approaches for prevention, diagnostic, treatment and attention to TB, aiming to end the epidemic by 2030.

Without investments it will be impossible to eliminate the disease until 2030

The WHO estimates that over 1.7 billion people had latent TB infection in 2017 alone; 10 million people developed active TB and another 500 thousand developed the resistant form of the disease. The UNs 2018 Global TB report shows that countries have not worked enough to combat the disease. According to Dr. Croda, the greater load of the disease is concentrated in developing countries, and to reach the 2030 Sustainable Development Goals, more investments to control the disease are necessary.

Local under-funding and dependence on external resources mean that external agendas have a strong influence on national priorities. Without a local innovation agenda, we will not be able to reach the WHOs goals. For that, we, developing countries, must have our own research agendas according to each reality, epidemiology and priorities, and these established agendas will only be put in practice if governments allocate the necessary investments for their executions. Currently, this is not the reality in most countries, Brazil included, he regrets.

Despite being listed among the worlds 10 greater causes of death, the budget for TB combat is only 0.25% out of the estimated US$ 265 billion allocated for research and technology development. According to the Global Plan against TB, less than half of the US$ 1.8 billion need have been invested in the past two decades. In the Americas, for example, 25 countries have reported complete financial information for 2017, in which they have required investments of US$ 455 million, but were only granted – and executed – an amount of US$ 323 million. This means there is a 29% deficit that should be used in innovation for the diseases control, he says.

The specialist points out the situation in the USA, where 30% of the global investment of TB research is performed by the National Institute of Health (NIH), a branch of the American government. The USA have recently reached the WHO goals while holding one of the lowest TB incidences in the world (3.1 per 100 thousand inhabitants). Despite this fact, they have announced an increase of 30% in research funding during a high-level meeting. From a geopolitical standpoint, although the disease is not a relevant local health problem, this strategic move evidences their power in determining a global agenda for science, technology and innovation, he says.

A global analysis of the Sustainable Development Goals by a team of economists who won the Copenhagen Consensus Nobel Prize, discovered that tuberculosis is one of the 19 development investments that should be prioritized worldwide. This conclusion was based on Anna Vassalls research, at the London School of Tropical Medicine and Hygiene. She assessed the investment case and concluded that, worldwide, every dollar spent controlling the disease would return benefits to the society of around US$ 43. Other studies have pointed numbers up to US$ 100 returned for every dollar spend controlling the disease.

Revolution in short-term treatment

Dr. Julio Croda says that worldwide, the best estimates point that 10 million people have developed symptoms related to active TB in 2017, and 500 thousand have the disease from that is resistant to the traditionally used antibiotics. Still according to him, most of the people who develop the disease are young adults, from 18 to 49 years-old, some of which will progress to death and others will take months, or even years, before diagnosis and treatment, generating high costs in terms of productivity to the entire society.

Regarding the increase of TB cases related to drug resistance, Dr. Croda explains that this is due to the low compliance to treatment, especially of MTD TB. He states that usually less than 50% of the patients are effectively cured, usually due to a long treatment period and to the severe side effects. This low cure rate associated to poor access to medications, globally favors the expansion of the transmission of these MDR strains. Nevertheless, Brazil is not considered a country with a high incidence of MDR strains. This is partly due to free access to drugs, provided by the Unified Health System (SUS), he says.

But the good news is that the short-term treatment for patients with MDR trains is revolutionizing. The infectious diseases specialist explains that the previous treatment was held with some injectable medications for over 12 months. Currently, South Africa, in an extremely innovative policy, has announced a new Bedaquiline-based treatment, with 100% oral medications and a 6-months duration. The practice of such policy will revolutionize the treatment of patients by increasing compliance, decreasing the side effects associated to the treatment, increasing cure and decreasing the transmission of MDR strains. However, it is necessary that other countries, including Brazil, follow South Africas model and adopt this new policy, says the researcher.

Brazils chances of eliminating tuberculosis until 2030

According to numbers from the Ministry of Health, the diseases incidence in 2001 was 42.8 per 100 thousand inhabitants and, in 2017, 35 per 100 thousand. The numbers show a slight decrease of 18.2% in 16 years, i.e., less than 1.13% per year. This indicator is well below the global annual average of 2% and much lower than the WHOs target of 4-5% per year. To Dr. Croda, these indicators reveal that, despite the efforts in recent years, regarding the improvement of the Human Development Index (HDI), the decrease of inequality and a broader access to health, the incidence reduction was insubstantial. From 2000 to 2017, Brazils HDI increased from 0.648 to 0.759 and the GINI (international parameter to measure social inequality) enhanced from 0.596 in 2001 to 0.495 in 2015. In other words, despite the reduction of inequality, we didnt get a real impact on the incidence of tuberculosis, he acknowledges.

To the specialist, the main reason were the budget cuts imposed to the Unified Health System (SUS) along the past years, directly affecting the diseases control actions. After the constitutional amendment 95, of 2016, which changed the Brazilian Constitution and established expenditure caps for government spending, investment in the SUS cannot be extended. Thus, according to him, we can expect a freeze at the current level of investment in the control of tuberculosis in Brazil.

In 2014, according to a report by the WHO, resources for disease control were around US$ 80 million in Brazil, but suffered a reduction of approximately 30% over the last four years, coming to a total of 57 million dollars. We expect a deficit in Brazil’s budget for TB control in 2018 of around US$8.7 million (15%). If, even after maintaining investments, the improvement of development and reduction of inequality, the incidence had little decrease between 2001 and 2017, the future scenario for Brazil is daunting, he says. In his opinion, if we maintain that investment, we will most likely be unable to achieve the established goals.

Probably, with the maintenance of the current investment in the years to come, with a backdrop of economic crisis and worsening inequality, we can expect a phenomenon similar to what occurs in Venezuela today, where from 2016 to 2017, the disease’s incidence increased around 28%. Before the crisis, previous index was similar to that of Brazil, i.e., 32 for 100.000 inhabitants, rising to 42 per 100.000 inhabitants, he concludes.…