World TB Day 2018 - the ‘one-in-seven’ and 'the law of thirds'.

One hundred and thirty-six years tomorrow (on March 24th 1882) Robert Koch, the so-called ‘father of immunology’ announced in Berlin that he had identified the pathogen that caused TB – the pathogen (as he put it at the time) that was killing one in seven people in Europe.

Thankfully, countries like Germany are today way down in the list of countries with TB burdens. Koch would surely be pleased by this, although he’d certainly be astonished and dismayed that (136 years down the road) not one single country in the world has yet been able to announce that it’s TB free. But he would be even more dismayed by how much TB is still rampant in other parts of the world, and also how, despite the disease having been technically curable in the vast majority of cases for over seventy years, it is STILL mankind’s number one infectious killer – still killing nearly 2 million each year and infecting over 10 million more.

What’s this down to? Well today this isn’t down to any one-in-seven ratio as in Koch's time – it’s rather down to a sorry list of ‘one-in threes’ (or what we’re calling today on World TB Day 2018 TB's deadly Law of Thirds').

The first one on the list is this: despite TB having been declared a Global Emergency in 1993, still fewer than one-in-three TB patients ever see diagnosis or treatment. (around 4 million of the 10.4 million new patients each year unbelievably never see treatment – and the truth is that this number is probably higher..).

The second: TB is such a big killer for those infected with HIV-AIDS. Of those who are dying today with an HIV infection, roughly one-in-three actually die of TB. Until only recently these deaths weren’t even being properly registered as TB mortalities by the way. This was because of the focus on controlling HIV: it was technically impossible to record a death as having been caused by TB if the victim was known to be HIV positive (HIV was always registered as the cause of death) because otherwise the name death would have been counted twice and screwed up the numbers. Thanks to massive efforts by HIV/TB stakeholders this insanity has now changed, but we’re still catching up on the consequence of the neglect that this caused.

The third: roughly one-in-three global AMR deaths are MDR-TB. These relate to those that are notified as being caused by an AMR (anti-microbial resistant) agent - i.e. a pathogen that is defined as being resistant to the drugs designed to kill it) a third of whom are estimated to have MDR-TB (multi-drug resistant tuberculosis). What’s more we’d suggest that this number is almost certainly much higher as well. Both MDR- and XDR-TB are still being appallingly neglected, and whatever the true numbers are today they’re going to rise and are threatening every tiny bit of progress that’s been made since 1993. (It’s not just Koch that would be shocked by this, by the way – so would Alexander Fleming who identified the risk if anti-microbial-resistance at the same time as accepting his Nobel prize for discovering penicillin over 70 years ago).

The fourth: TB's R&D budget is only about a third funded – this is the budget that’s been forecast to be needed to meet the so-called ‘END TB’ strategy (that intends to see TB defeated in the next 12 years). What's more, because of the shifts in global politics TB funding is more risk now than it’s been in the last fifteen years. (Koch, as a biochemist, would also surely note with horror and shame that the pharmaceutical industry’s spending on TB research dropped last year for the fifth successive year). Not just that but the global budget set out by the WHO for reducing TB is also nearly a third short - that's the forecast that's needed for prevention, diagnosis and treatment. More money is needed (and this is a no-brainer because it’s been well proved for years, investment in TB control pays back very effectively).

The fifth: more than one third of the world lives on less that $2.50 a day (an estimated 2.7 billion people in fact). It might not seem obvious that this might be directly connected with TB, but this level of poverty (more than any other factor) is the driver for the TB pandemic. Poverty was equally the driver of the European epidemic in Koch’s day: it’s well known that under-nutrition as much as anything else that makes this disease so difficult to defeat (something that presents a massive challenge to the laudable END TB goal unfortunately).

The sixth: nearly a third of mankind today is currently infected with tuberculosis. This sounds an incredible number because it adds up to nearly 2 billion people but this estimate has recently been re-worked. It was reduced a little from what it was (which was 32%) but still stands as an appalling testimony of neglect (as well as to the fact that the most widely used vaccine in the history of medicine [BCG] isn’t very effective and desperately needs a replacement). It's important to stress that these 2 billion current infections aren’t ‘active’ (like a ‘flu infection would be for instance) and nor are they immediately life-threatening, but every single one of them is potentially life-threatening. This is because it means that the TB mycobacterium has successfully made its home in another human lung, hunkered down and lying low, waiting for an opportunity to break out into active disease – which can be expected to happen in about 10% of cases. What this means is that today there are already about 200 million cases of TB in today's existing pipeline of disease. Unless things change dramatically this number of cases can and should be expected to pop out, infect others, create more suffering and destitution and cause 40 million more avoidable deaths. And at least 10 million should be expected to be drug-resistant.

So today Moxafrica joins the call that IT’S TIME TO STEP UP FOR TB. This year is without question going to be a critical one, and the key players are going to be the world’s politicians. This year they’re going to be called on to do something about this stain on our collective humanity. Will they make promises they won’t keep (the story of TB management so far) or will they stick to them and be called to account if they don’t?

They need to know that from now on

the whole world will be watching.