Increase support for the fight against tuberculosis!

Sweden has chosen to reduce support for the fight against one of the world's deadliest diseases - tuberculosis. With a looming pandemic of multi-resistant tuberculosis, this is difficult to understand. The World Health Organization aims to reduce the number of tuberculosis patients by 90 percent by 2035, but then large research investments and new forms of collaboration are required. It is written by Gunilla Källenius, Knut Lönnroth and Claes Ånstrand.

Tuberculosis is one of the deadliest diseases in the world. It causes 1,5 million deaths each year - more than HIV and malaria - and a fifth of all deaths among adults in low-income countries. The disease has certainly decreased over time, but it has been very slow. And with the imminent threat of multi-resistant bacteria, the trend could be reversed at any time.

The world has an opportunity to eradicate tuberculosis, but in order to do so in the foreseeable future, new effective diagnostic tools, medicines and vaccines are needed. At the same time, both poverty reduction and sustainable health care systems are needed to ensure that the right care is achieved. It will not be easy. Nevertheless, the World Health Organization's (WHO) global strategy - linked to the implementation of Agenda 2030 - aims to reduce the number of tuberculosis patients by 90 percent by 2035. Against this background, it is difficult to understand how Sweden can choose to reduce support for the Global Fund against AIDS, Tuberculosis and Malaria by 35%, and in addition reduce funding for global health research.

Need for new tools

To prevent the spread of multi-resistant tuberculosis, it is necessary to diagnose and treat patients with both resistant and non-resistant tuberculosis at an early stage, and at the same time develop new ways of treating patients with resistant tuberculosis. The problem is that the tools available have major shortcomings. In low-income countries, microscopy of expectoration samples, ie to identify tubercle bacteria with a microscope, is the dominant test. This is an outdated method that misses half of all tuberculosis cases and works even worse when it comes to children and HIV-infected people. Only 10 percent of children with tuberculosis receive the correct diagnosis with that examination method. New rapid tests have been developed and more are on the way, but they are not designed to be used in primary care in poor countries where most people seek care.

Treatment of patients with multidrug-resistant tuberculosis is successful in only half of the cases. The treatment is very difficult for the patient and sometimes takes as much as two years. The patient needs to take up to 14 tablets and be given hundreds of injections, and severe side effects are common. There is a burning need for new, more effective and safer drugs, not only for multi-resistant tuberculosis but also to shorten the treatment time of all tuberculosis. A promising news is that a new drug was recently approved for the treatment of resistant tuberculosis, the first in 600 years. However, it has not yet been shown how effective it is, and there are very few other drugs under development.

Huge challenges, but no choice

We have the same problem when it comes to prevention. The BCG vaccine, the only existing tuberculosis vaccine, is not very effective. It protects young children from the most severe forms of the disease, but does little to protect against the most common form of tuberculosis: the contagious pulmonary tuberculosis. Therefore, the vaccine does not help the spread or stop new cases of tuberculosis. And despite the fact that several new vaccines are being tested, the BCG vaccine will be the only one available for many years to come.

New methods for diagnosing and treating latent tuberculosis are also needed. It is estimated that a third of the world's population carries the tuberculosis bacterium and can develop active and contagious disease at any time. The challenges are enormous, but with a looming pandemic of multi-resistant tuberculosis and millions of people at risk of dying, there is no alternative but to do our utmost. We need to do something about tuberculosis, and for that we need new tools. That is why research is needed.

More must contribute

The need for research is also clear from this research framework which is part of the WHO's global tuberculosis strategy, and which the Swedish Ministry of Foreign Affairs and Karolinska Institutet helped to develop. But to invest in new tools, more money is needed than is available today. It is estimated that € 1,73 billion is needed annually for research and development. In 2013, EUR 589 million was invested.

The investment from individual donors is also decreasing. The small number of donors available, especially governments and philanthropists in the OECD, reduced their donations by 10 percent last year. Currently, a single donor, the Bill & Melinda Gates Foundation, accounts for more than 25 percent of the research conducted to develop new tools in the fight against tuberculosis.

When it comes to business, the pharmaceutical companies have stopped conducting research on tuberculosis, as part of a general trend to withdraw from drug development against infectious diseases and instead invest in the development of drugs for chronic welfare diseases. Pfizer discontinued tuberculosis research in 2012, followed by AstraZeneca in 2013 and Novartis in 2015.

To fill the need for research grants and fight tuberculosis by 2035, many more must contribute. If the private sector does not want to do its part, others must take the initiative. Long-term, uninterrupted efforts are required until the disease that kills the most people - more than HIV and more than malaria - is eradicated. Sweden has an important task here. We must take responsibility as donors and we must create forms of cooperation that make it possible to achieve the goals we have committed ourselves through the adoption of Agenda 2030.

Gunilla Källenius
Knut Lönnroth
Claes Ånstrand

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