The world remains fixated on getting new TB vaccines. But expanding the circle of progress on shorter TB regimes, and more early detection, may be more important to overcoming setbacks of the COVID pandemic, says one expert on World TB Day. 

IBADAN, Nigeria – The Government Chest Hospital in the city’s Jericho neighborhood is regarded as one of the top hubs for TB testing, treatment and care in Nigeria. Even though health workers at the facility try to encourage TB patients to sustain their course of treatment until the very end, they often see patients are unwilling to do so.

“We have those that do not want people around them to know they have TB, so it’s difficult for them to meet all of their appointments. We also have those that live very far from here. They often start well but over time, as the symptoms clear, they default and drug resistance may arise,” a nursing officer at the hospital told Health Policy Watch.

So the World TB Day 2022 announcement of an updated WHO guideline recommending a shorter four-month treatment course for children with “non-severe” TB was a much-heralded development in the TB space as further highlighted the existing research gaps in TB. The latest recommendation relied heavily on the findings of the University College London’s SHINE Study that was conducted in South Africa, Uganda, Zambia and India.

In an interview with Health Policy Watch, the study’s principal investigator, Professor Diana Gibb of University College London noted that the focus of TB treatment research for both adults and children now is shorter treatment plans considering its effectiveness in preventing resistance.

“That’s where the research of both adults and children is focused because you can give shorter treatment and people take it properly, you’re less likely to get drug resistance, which is of course a major issue in some parts of the world,” she told Health Policy Watch.

Estimates for total number of people who died from any form of TB in 2020.On World TB Day, WHO Director General, Dr Tedros Adhanom Ghebreyesus, revealed that the spotlight is on the urgent need to invest in the fight against TB to achieve the commitments made by global leaders.

“Tuberculosis kills more than 1.5 million people each year and affects millions more, with enormous impacts on families and communities. Ending this debilitating disease remains a priority for WHO,” he said.

Better treatment with shorter courses

With no new TB vaccines yet in site, shortening TB treatment duration is gradually becoming a more immediate goal considered to be within reach near-term, one which could provide the TB ecosystem opportunities to recoup the big setbacks seen in treatment coverage during the pandemic. 

Along with the new four-month course for children, other recent treatment gains have included a six-month regimen for TB meningitis instead of 12 months. Moreover, bedaquiline and delamanid, two of the newest TB medicines to treat drug resistant TB, are now recommended for use in children of all ages, making it possible for children with drug-resistant TB to receive all-oral treatment regimens regardless of their age.  

Currently, however, treatment regimens for adults still require a six month course. And with patients seeing improvements in the early days of the treatment, it remains  difficult to ensure adherence to the end of the regimen. That, in turn, can pave the way for resurgence and even multi-drug resistant TB. 

Gibb, for one, is hopeful that new studies targeting adults with non-severe TB could also yield similarly shorter treatment courses in the near future –  although this remains more challenging  because adult TB diagnosis is still often delayed and their symptoms are more severe at the commencement of treatment.

“I think if you get adults at an early stage, it may be beneficial,” she told Health Policy Watch.

Progress on vaccine candidates 

One major feature of conversations during World TB Days since the COVID-19 pandemic in 2020 has been the stark comparisons between the fact that available TB vaccines remain limited to the century-old BCG vaccine, which is only partially effective and primarily targeted to children, in comparison with the tens of new COVID-19 vaccines that have become available just one year after the pandemic – with more in the pipeline. 

However, with the huge shortfall in TB investments seen to date – including investments in R&D, money is sorely needed to bring the most promising candidates to clinical trials and market. 

In a statement for this year’s World TB Day, the World Health Organization (WHO) called for the need to build on lessons learnt from COVID-19 research to catalyze investment accelerated  development of new TB vaccines. 

An additional US$ 1.1 billion per year is needed specifically for TB research and development – aside from the $13 billion required for TB diagnostics, treatments and prevention – asks for which only one-third or less has actually been received.

“Urgent investments are needed to develop and expand access to the most innovative services and tools to prevent, detect and treat TB that could save millions of lives each year, narrow inequities and avert huge economic losses,” said Ghebreyesus. “These investments offer huge returns for countries and donors, in averted health care costs and increased productivity.”

Improving TB detection 

Improving TB diagnosis, especially among children is another attainable goal that needs to rank high on health system agendas, Gibb said. This can be done if public health systems  channel the financial gains of shorter regimens and more affordable drugs towards improving TB testing.

She also noted the need to improve TB treatment for other forms of TB, such as TB meningitis in children in which there is TB infection around the brain. 

Taken together, new point-of-care testing kits, early detection of latent TB, and related to that, the ability to predict the transition from latent to active TB cases offer a cascade of solutions that can enable earlier detection of disease, when less of the lung is affected. And that, in turn, will lead to options for shorter treatment duration over time, she said. 

Overcoming previous side effects and limitations

One of the major concerns that plagued the adoption of new TB treatment recommendations is the concern of serious side effects ranging from deleterious impacts on cognitive functions to impairment of liver functions.

While admitting that these were real concerns in the past, Gibb, however, noted that new regimens have been able to overcome the side effects barrier in addition to requiring fewer daily tablets, better tasting tablets, and doing away with injections.

“Actually the children tolerate the medicine very well,” said Gibb. “And we are using new medicines, in which the drugs are taken all together in one pill, which then can be dissolved in a little bit of liquid. 

“So it’s not as bad as it used to be in the old days when you had to take them more often. And we no longer use injections for children to get them as it used to be part of the old TB treatment,” she added.

Image Credits: USAID, Southern Africa/Flickr, STOP TB Partnership , Fatola Babafemi/Google Maps, Fatola Babafemi/Google Maps .