Taking tuberculosis out of the shadows

Before COVID-19 took over, tuberculosis was the deadliest infectious disease in the world. Now it is number two but no less worrisome. World Tuberculosis Day is observed on March 24, with this years’ theme: “Yes! We can end TB!”. A vital and powerful message to inspire hope and encourage high level leadership and increased investment at a time of great setbacks towards the goal of ending tuberculosis. According to the Global Tuberculosis Report 2022, not only did tuberculosis incidence increase by 4·5% for the first time in 20 years, but also deaths increased from 1·5 million in 2020, to 1·6 million in 2021. The End TB Strategy milestones of 2020, with the aimed reductions of 35% for deaths and 20% for incidence, have not been reached with only 5·9% and 10% reductions from 2015 to 2021, and funding was half of what was committed to at the 2018 High-Level Meeting. Over the past 3 years, the COVID-19 pandemic—diverting attention but also resources such as testing technology and equipment towards the pandemic response—has further impacted tuberculosis outcomes. Tuberculosis is disproportionally affecting the most marginalised individuals in our societies—people who are homeless, migrants, people living with HIV/AIDS, people with harmful alcohol use, illicit drug users, and people who are incarcerated. This high susceptibility is driven by an increased risk of exposure due to poor living conditions, such as overcrowding and poor ventilation, and poor access to health care that delays detection, diagnosis, and prolongs infectiousness. In response, WHO updated their guidelines on tuberculosis in 2021 to recommend systematic tuberculosis screening for these groups at high risk—including in prisons and other penitentiary institutions. In this issue of The Lancet Public Health, Salome Charalambous and colleagues discuss practical considerations on how the screening recommendation in prisons could be implemented. While screening when entering the facility, annual mass screening, and screening upon release are effective strategies, in a high transmission setting mass screening twice a year or more would be required to bring incidence down. Importantly, the high incidence in prisons, estimated to be on average around 10-times the risk of the general population, driven by prison conditions as well as that people who are already marginalised and at high risk are more likely to be incarcerated. In 2022 there were an estimated 11·5 million people in prison and the number of people in prisons has increased by 24% globally since 2000. With 121 countries operating prisons above capacity, exacerbating infectious disease risks, there is a real need to reduce incarceration rates to limit overcrowding and to improve detention conditions. This includes upgrading prison infrastructure to meet standards for ventilation and cell occupancy, and offer good-quality primary health-care in prisons. Inevitably to improve prison health-care and enable systematic screening in prisons a trained and adequate number of health-care workers will be required. But above all, a successful response to tuberculosis in prisons requires political will. On Sept 22, 2023, the second UN High-Level Meeting on the fight against tuberculosis will be held. This will bring together heads of state worldwide and offer the opportunity for a strong political declaration to end tuberculosis, with a focus on scientific innovation and funding. The COVID-19 pandemic has inspired several innovative approaches to tackle tuberculosis, such as the implementation of digital interventions using video-supported telemonitoring to ensure treatment adherence and changes improving longer-term access to drugs. Another step in the right direction is the establishment of a new WHO TB Vaccine Accelerator Council with the aim to drive innovation in the area of tuberculosis vaccines. However, research and development for COVID-19 was also supported with a much larger budget. In 2020, more than US$100 billion were mobilised for research and development for COVID-19 and only $0·9 billion for tuberculosis. The upcoming UN High-Level Meeting should be a tremendous opportunity to reinvigorate the fight against tuberculosis and the political will to fund tuberculosis elimination and tackle its key modifiable risk factors—marginalisation and social inequality. Tuberculosis is the pinnacle of the social determinants of health. Yes, we can end tuberculosis—with strong political will, adequate funding, and an unambiguous commitment to address inequalities, the underlying determinant of tuberculosis.