The Lancet Commission on tuberculosis: building a tuberculosis-free world
Eric Goosby, UN Secretary-General’s Special Envoy on Tuberculosis
Dean Jamison, University of California
Soumya Swaminathan, World Health Organization
Michael Reid, Zuckerberg San Francisco General Hospital and Trauma Center
Elizabeth Zuccala, The Lancet
The Sustainable Development Goals have prioritised ending the epidemic of tuberculosis by 2030. We are therefore at a critical juncture in implementing efforts to control and eliminate tuberculosis. Current efforts have averted 56 million deaths since 2000 (1). We also have better diagnostic tools and the promise of a few new, potent agents in the pipeline (2). Yet tuberculosis remains the leading source of infectious disease deaths globally, responsible for 1.7 million deaths in 2016 (1). The UN’s High-Level Meeting on Tuberculosis, due to take place in New York, USA, later in 2018, represents a unique opportunity to secure a commitment from heads of state and governments for a coordinated global response to end the epidemic. The Lancet Commission on tuberculosis aims to identify decisive global and country-specific actions necessary to ensure the success of that response. These recommendations will address the following priorities.
First and foremost, the global community needs to pivot to bold new strategies to address the tremendous burden of disease. We are not starting from scratch when it comes to the prevention and treatment of tuberculosis (3). Although new tools and innovations are urgently needed, we must not lose sight of what we already know works. Increasing access to molecular diagnostics for all patients and tuberculosis preventive therapy for those at highest risk for tuberculosis disease need to be prioritised. However, we can no longer rely on one-size-fits-all approaches to ending tuberculosis; current efforts are missing millions of people with tuberculosis every year. This Commission will explore how countries can improve outcomes and optimise use of available resources by realigning them to ensure that all tuberculosis care is people-centred and by prioritising interventions that increase efficiencies in the delivery of tuberculosis services. Without urgent action, drug-resistant tuberculosis will be the single largest cause of mortality from antimicrobial resistance (AMR) by 2050, responsible for a quarter of the projected 10 million annual AMR-related deaths (4). Therefore, this Commission will highlight how scaling up evidence-based strategies to address drug-resistant tuberculosis must be a high priority if we are serious about addressing this global health security threat.
"Tackling tuberculosis must occur in concert with a commitment to securing financial risk protection, access to quality essential health-care services, and use of safe, effective, and affordable necessary diagnostics and medicines."
Eric Goosby, Dean Jamison, Soumya Swaminathan, Michael Reid, Elizabeth Zuccala
Second, creating an enabling environment is essential to successfully ending tuberculosis. In most high-burden countries, tuberculosis efforts are undermined by social, financial, and clinical barriers to care. Tuberculosis is a disease of poverty and often has the worst outcomes among the most vulnerable—children, homeless people, prisoners, HIV-infected persons, and other marginalised populations. Tackling tuberculosis must occur in concert with a commitment to securing financial risk protection, access to quality essential health-care services, and use of safe, effective, and affordable necessary diagnostics and medicines. Moreover, health advocates cannot create an enabling environment to reduce burdens of tuberculosis within countries without engaging civil society and patient groups, acknowledging that they are a crucial constituency that should be involved in all aspects of tuberculosis programming. In addition, new multisectoral accountability mechanisms must be put in place to ensure progress at global, national, and local levels is achieved. The Commission will provide solutions to address the existing social, financial, and clinical barriers to care.
Third, investing in research and development must be a global priority. To date, global tuberculosis control efforts have been hindered by the lack of effective and acceptable diagnostic, therapeutic, and preventive tools. Furthermore, health-system frailties constrain proper uptake and delivery of existing tools, especially in areas where they are needed most. An intensification of tuberculosis research across the full continuum— extending from fundamental to operational research and addressing the formidable challenges of drug-resistant tuberculosis—is urgently needed to address these challenges. The Commission will outline research priorities at global and national levels to help address knowledge and implementation gaps.
Finally, countries need to dedicate substantial resources to implement strategies to end tuberculosis. Evidence on the cost-effectiveness and benefits of expanded financing for tuberculosis control suggests that such investments will yield a high return (5) Nevertheless, funding for tuberculosis programmes and research has stagnated in recent years (6) This Commission, which involves Commissioners from diverse backgrounds including government, civil society, non-governmental organisations, UN institutions, and academia (appendix), will review and extend the evidence base to provide up-to-date guidance for health and finance ministers.
There are grounds for optimism; ending tuberculosis is possible with better science, improved health systems, increased and sustainable financing, and renewed political will. The Lancet Commission, which we expect to report later in 2018, will provide concrete solutions to inform how governments and the global community should respond to end the tuberculosis epidemic once and for all.
(1) WHO. Global tuberculosis report 2017. Geneva: World Health Organization, 2017.
(2) Frick M, Gaudino A, Harrington M, et al. Pipeline report: HIV, TB, and HCV; drugs, diagnostics, vaccines, preventive technologies, research toward a cure, and immune-based and gene therapies in development. New York: Treatment Action Group, 2017.
(3) WHO. What is DOTS? Geneva: World Health Organization, 1999.
(4) O’Neill J. Review on antimicrobial resistance: tackling drug-resistant infections globally: final report and recommendations. London: Wellcome Trust and UK Government, 2016.
(5) The Economist. The economics of optimism. The Economist, Jan 22, 2015.
(6) Frick M. 2016 report on tuberculosis research funding trends, 2005–2015: no time to lose. New York: Treatment Action Group, 2016.