MSF: Tuberculosis remains a global health emergency amid pandemic

As governments and humanitarian organizations all over the world are trying to respond to COVID-19, other diseases have not stopped spreading. One such disease is tuberculosis (TB), which killed approximately 1.4 million people in 2019.

Treatment for TB can take anywhere from six months to two years. Some of the medicines used have toxic side effects. Many patients are unable to complete the treatment, while some contract forms of TB that are resistant to the drugs used for treatment. This is called DR-TB.

DR-TB is a global health emergency. The pandemic threatens to make the situation worse. 

Filipino Medecins Sans Frontieres/Doctors Without Borders (MSF) doctor Marve Duka observes, “With COVID-19 happening, the focus is taken away from TB and other diseases. There has been a 50% reduction in diagnosis and treatment in recent months.”

This is a global problem, as resources shift to responding to COVID-19. These factors risk increasing TB transmission, morbidity and mortality, due to delays in TB diagnosis, treatment and prevention. In an April 2020 survey of 20 high-burden countries, at least 40% of national TB programs reported that TB facilities were being used for COVID-19 response.

This is a cause for concern in India, Indonesia, Philippines and South Africa, four countries that account for 44% of global TB cases. Between January to June 2020, there was a 25-30% reduction in the reported number of people diagnosed with TB in the first three mentioned countries, compared to the same 6-month period in 2019.

Research and development for TB treatment              

While pharmaceutical companies are racing to develop COVID-19 treatments, vaccines and tests, MSF continues to work to end TB. One way MSF is doing this is through TB PRACTECAL, a clinical research project started in January 2017 with partners in medical research and the ministries of health in affected countries. Through a clinical trial compliant with international standards for good clinical practice, the project aims to find short, tolerable and effective treatments for people with DR-TB. 

In 2019, 32-year-old South African electrician Bonginkosi Emmanuel Mkhize became the 240th patient to enroll in TB PRACTECAL. “I decided to take part in TB PRACTECAL because I wanted to make a difference for my children’s future,” says Bonginkosi. “Having a shorter treatment for MDR TB would mean so much for me and people like me.” 

Current MDR-TB treatment involves taking up to 20 pills daily, for between nine and 24 months. By testing six-months, all-oral, once-a-day regimens, TB PRACTECAL hopes to radically improve the lives of people suffering from the disease.

Opinion and debate: Dr Jennifer Hughes makes an urgent call for better diagnostics and treatment regimens for drug-resistant tuberculosis. (from –

Campaigning for equitable access to medicines

Bedaquiline is the first new TB drug to be registered since 1963, and the first to be effective against DR-TB. The World Health Organization (WHO) recommends bedaquiline as the backbone of DR-TB treatment, to replace older, more toxic drugs that have to be injected daily and can cause intolerable side effects, such as deafness. 

In April 2014, delamanid was conditionally approved by the European Medicines Agency, and has since been used in combination with other drugs to treat DR-TB, including XDR-TB. 

In light of the COVID-19 pandemic, WHO has advised that people with DR-TB in the safety of their homes by using all-oral regimens instead of injections that require people to go to clinics. Being oral drugs, both bedaquiline and delamanid can play a crucial role in offering an all oral regimen. 

But access to these drugs had been mostly hampered by one major obstacle: price.

Since 2012, Johnson & Johnson (J&J), the pharmaceutical corporation that holds patents on bedaquiline, has been selling the drug for nearly US$1,200 per treatment course, out of the reach of many who need it. In July 2020, price for bedaquiline was finally lowered to US$1.50 per day after a long campaign by people with TB, civil society and treatment providers including MSF.

However, this price is still not available to all countries. MSF continue to urges J&J to further reduce the price, and to offer the lower price to all countries with a high DR-TB burden, so that more lives can be saved.

Delamanid continues to be one of the most expensive drugs for DR-TB. In June 2020, Mylan, which licenses the drug from the patent-holder Otsuka, announced the price of US$940 for a six-month treatment course for South Africa. This discounted price is still too high, and is not available to any other high burden country. Researchers from the University of Liverpool have calculated that delamanid could be produced and sold at a profit for much less – ranging from $5-16 per month if
the drug is scaled up by national TB programmes.

Bedaquiline is a crucial TB drug recommended by the WHO as the backbone of treatment for drug-resistant forms of TB (DR-TB). It is part of an oral regimen that could replace older, more toxic drugs that have to be injected daily and can cause intolerable side effects, such as deafness. MSF has been pressuring J&J on the price of the drug since it came to market in 2012. This is big news, but there is still more work to be done to ensure *everyone* who needs this lifesaving drug can access it. (Photo from MSF Philippines Facebook Page, July 8.)

Ananth Ganesan, MSF Access Campaign’s Regional Advocacy Officer. “At this time, when governments and humanitarian organizations are racing to keep this pandemic in check, it is even more urgent to make sure diseases like tuberculosis do not take more lives.”

As of 2019, across MSF projects in 14 countries, more than 2,000 people have been treated with the newer drugs. Globally, an estimated 465,000 people developed DR-TB in 2019, but less than 40% received treatment.

Quick Facts About Tuberculosis

  • TB is an infectious disease caused by a bacterium called Mycobacterium tuberculosis.
  • Even though most commonly TB attacks the lungs, this disease can also occur outside the lungs. Extrapulmonary TB can affect other parts of the body, such as the spine, kidneys, brain, and lymph nodes.
  • In 2019, the World Health Organization (WHO) estimated 10 million people developed TB.
  • Two-thirds of all people with TB can be found in these eight countries: India (26%), Indonesia (8.5%), China (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh (3.6%) and South Africa (3.6%)
  • Worldwide in 2019, close to half a million people developed rifampicin-resistant TB (RR-TB), of which 78% had multidrug-resistant TB (MDR-TB). The three countries with the largest share of the global burden were India (27%), China (14%) and the Russian Federation (8%).
  • About 465 000 people were newly diagnosed with drug-resistant TB in 2019.
  • Many countries have large numbers of people living with both HIV and TB; this is known
    as TB/HIV coinfection.
  • There were an estimated 1.2 million TB deaths among HIV-negative people in 2019, and
    an additional 208,000 deaths among HIV-positive people.
  • TB is one of the top 10 causes of death worldwide.

Tuberculosis in Asia

  • In India, Indonesia, the Philippines and South Africa, four countries that account for 44% of global TB cases, there were large drops in the reported number of people diagnosed with TB between January and June 2020 (Fig. E.3). Compared with the same 6-month period in 2019, overall reductions in India, Indonesia and the Philippines were in the
    range 25–30%.
  • Geographically, most people who developed TB in 2019 were in the WHO regions of South-East Asia (44%), Africa (25%) and the Western Pacific (18%). Eight countries accounted for two thirds of the global total: India (26%), Indonesia (8.5%), China (8.4%), the Philippines (6.0%), Pakistan (5.7%), Nigeria (4.4%), Bangladesh (3.6%) and South Africa
  • Indonesia ranks second for the incidence of TB globally, with their numbers rising from 331,703 in 2015 to 562,049 in 2019.
  • In the Philippines, WHO estimates 599,000 people were diagnosed with TB in 2019. Anti-TB coalitions in the Philippines estimate around 27,000 Filipinos died from TB in 2019.
  • In Myanmar, an estimated 174,000 people had TB in 2019.
  • Myanmar is also a high MDR-TB burden country; an estimated 9,000 acquired a drug-resistant form of the disease in 2016. Myanmar also has one of the most severe HIV/AIDS epidemics in Asia. Each year there are about 20,000 new cases of TB/HIV co-infection.
  • According to WHO, in 2019 Cambodia had 47,000 incidences of TB.
The featured photo is from MSF A Year in Photos 2019. Captioned: April 2019, MSF staff demonstrated outside a shareholders meeting at Johnson & Johnson’s headquarters in New Brunswick, New Jersey, calling on the company to lower the cost of the tuberculosis drug bedaquiline to $1 per day

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