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Ending TB is within our reach – so why are millions still dying?

Ending TB is within our reach – so why are millions still dying?

At Kaneshie Polyclinic, a health center in a deprived area of ​​Accra, Ghana’s capital, there is a rule. Every patient who walks through the door – a woman in labor, an injured construction worker, a child with malaria – is tested for tuberculosis.

This policy, on a national scale, aims to resolve a tragic problem; In this country, two thirds of people with tuberculosis do not know they have it.

Tuberculosis, which is preventable and curable, has regained the title of the world’s first deadly infectious disease, after being supplanted after its long reign by Covid-19. But globally, 40 percent of people living with tuberculosis go untreated and undiagnosed, according to the World Health Organization. The disease killed 1.6 million people in 2021.

These figures are all the more worrying as this is a moment of great hope in the fight against tuberculosis: significant innovations in the diagnosis and treatment of tuberculosis have begun to reach developing countries, and clinical trial results are promising for a new vaccine. Infectious disease experts who have fought TB for decades are expressing a new belief: With enough money and a commitment to bringing these tools to neglected communities, TB could be nearly defeated.

“This is the best news we’ve seen about TB in decades,” said Puneet Dewan, an epidemiologist with the Bill & Melinda Gates Foundation’s TB program. “But there’s a gap between having an exciting pipeline and actually reaching people with these tools.”

A recent visit to Kaneshie’s clinic revealed both progress and remaining obstacles. Despite the clinic’s policy of screening everyone for tuberculosis, which most often attacks the lungs, with few questions about cough and other symptoms, patients flocked to the cement block building only one floor and were sent for treatment without any such questions. It turned out that one member of the TB team was on vacation, another on maternity leave and a third sick. Only two remained, busy taking tests and distributing medicine.

No one was therefore checked, neither that day nor any other day of the previous week.

“It’s a good policy, it works well when we can implement it, but staffing is a problem,” said Haphsheitu Yahaya, TB coordinator at the clinic.

When the testing policy works, the new drugs – the first to hit the market since the 1970s – can be taken in the form of a few tablets each day, rather than in handfuls of pills and painful injections, as treatments for tuberculosis. the past.

People diagnosed with drug-resistant TB are given medication to take for six months – a much shorter period than previously required. For decades, the standard treatment for drug-resistant TB was daily medication for a year and a half, sometimes two years. Inevitably, many patients stopped taking the medications before they were cured and ended up with more serious illness. Newer medications have far fewer serious side effects than older medications, which could cause permanent deafness and psychiatric disorders. Such improvements help more people stay on medications, which is good for patients and eases pressure on a fragile health system.

In Ghana and most other countries with a high prevalence of tuberculosis, drugs are financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, an international partnership that raises funds to help countries fight these diseases. diseases. But contributions to the agency decline with each funding cycle. Countries fighting TB are concerned about what could happen if this funding ends. Currently, WHO-recommended adult treatment costs at least $150 per patient in low- and middle-income countries.

“If our patients had to pay, we wouldn’t have a single person receiving treatment,” Ms. Yahaya said.

Still, progress has been made in recent months to make drugs more affordable, and prices could soon fall further. After prolonged pressure from patient advocacy groups, the United Nations and even the novelist John Green, who devoted his widely followed TikTok account on the issue, Johnson & Johnson lowered the price of a key tuberculosis drug in developing countries. The company also agreed in September not to assert a patent, meaning generic drugmakers in India and elsewhere will be able to make a significantly cheaper version of the drug.

And for the first time in more than a hundred years, there is real hope for an effective vaccine: a promising candidate called M72, developed by the pharmaceutical company GSK with financial support from the Gates Foundation and other charities, in is now in its final stage. clinical trials.

(However, as ProPublica recently reported, it is not clear who will have the right to sell the vaccine, where it will be available and how much it will cost. Money from taxpayers and philanthropists funded much of the vaccine’s development, but GSK retains control of critical components.)

M72 is one of 17 vaccine candidates currently being tested in trials, providing a source of possibilities. The only tuberculosis vaccine in use today was first administered in 1921; it is useful mainly for babies and does little to protect adolescents and adults, who account for more than 90 percent of TB transmission worldwide.

Better technology to diagnose tuberculosis is slowly arriving in clinics in developing countries. Clinics across South Asia and sub-Saharan Africa, including that of Ghana, now have machines to use rapid molecular diagnostic tests – equipment that was donated as part of the Covid response. This means that many health centers have finally stopped using an unreliable diagnostic method, developed in the 1800s, of examining sputum smears under a microscope.

However, in 2021 only 38 percent of those diagnosed with tuberculosis first underwent a molecular test; the rest were diagnosed microscopically or, in many cases, by their clinical symptoms.

Molecular diagnostics can also immediately detect drug-resistant tuberculosis. (The old way was to start a person on treatment with the most common drugs and wait to see if the treatment worked; if patients had the drug-resistant form of the disease, they simply got sicker.)

Joshua Dodoo, a driver, showed up at the Kaneshie clinic in March with a persistent cough. He had lost weight and couldn’t sleep. When he sought medical attention for what he thought was malaria, he was sent for a tuberculosis test. The clinic lab’s single PCR machine was heavily used, so it took a few days before he learned from a nurse that he had tuberculosis.

“I was so scared,” Mr. Dodoo said, adding that he did not realize people were still contracting the disease.

His wife, Sadia Ribiro, was calmer and was able to hear the nurse, Richard Boadi, explain that there is a cure and that Mr. Dodoo would receive the treatment free of charge.

Ms. Ribiro was tested; people living in close contact with someone with TB account for a significant percentage of the 10.6 million new infections each year. Her result was negative and she was put on preventive treatment for three months. These drugs are also new: until recently, preventive treatment could take a year or more, and few patients completed it.

But then the system collapsed. The couple’s two children, aged 3 and 11, have not been screened. Mr Dodoo said they were at school so it was difficult to get them to the clinic and they appeared healthy. Then, just as he began to gain weight and feel better, the children began coughing and complaining of fatigue.

But they were not tested until months later, when Mr. Boadi found them at their home. Only 30 percent of tuberculosis infections in children are diagnosed.

Ms. Yahaya, the clinic director, said that although preventive therapy worked remarkably well, Mr. Dodoo’s family’s experience was typical. Newly diagnosed people do not want anyone to know they have the disease, which is associated with poverty and suffering, and so they do not volunteer information about other people who may have been infected . And the health system, understaffed, is struggling to keep up with them.

Only 169 health centers in Ghana have the capacity to use the new testing method. Usually samples have to be sent – ​​up to a three-hour drive in some rural areas. By the time results come in, it can be difficult to track down those who have been tested.

“The equation is simple: if we devoted more resources to testing for TB, we would find more TB,” said Dr. Yaw Adusi-Poku, who heads Ghana’s national TB program.

This will require more molecular testing sites, more staff trained to detect disease, more people to ask questions at the clinic door, more nurses like the intrepid Mr. Boadi, who shows up at the door of his patients to encourage them to take their test. families tested (and who frequently dips into their own pockets to help patients pay the bus fare to collect their medications).

Molecular diagnosis is considerably more expensive than the old method. Cepheid, the company that makes cartridges for the testing machines, recently agreed to reduce the price of each of them from $10 to $8. An analysis commissioned by Doctors Without Borders found that the cartridges could be made for less than $5. Cepheid continues to charge $15 per test for diagnosing extremely drug-resistant tuberculosis, the deadliest form of the disease.

Funding for TB services in low- and middle-income countries has fallen to $5.8 billion in 2022, from $6.4 billion in 2018, only half of what is needed according to the WHO. About $1 billion is available each year for TB research, half the amount required according to the United Nations.

At a special meeting on tuberculosis at the United Nations in September, governments pledged to spend at least $22 billion a year on fighting tuberculosis by 2027. But at a similar meeting in 2018 , the same donors promised to spend $13 billion by 2022, less than half. which materialized.

“I am happy that we have these innovations, but the fact that they exist, that WHO recommends them, does not mean that people have access to them,” said Dr Madhukar Pai, associate director of the International Tuberculosis Center McGill. at McGill University in Montreal. “The costs are still too high and someone needs to deliver them. »

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Eric D. Eilerman

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