Investing in global health: Tackling tuberculosis

26 October 2023

By Maya Tabaqchali, Sustainable Portfolio Manager

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Deaths from tuberculosis, one of the world’s largest infectious killers, are rising after more than a decade of being in decline, as the COVID-19 pandemic reversed years of progress1. Here we discuss the scale of the challenge, and some of the emerging technologies that could help eradicate this devastating disease (and others). 

Tuberculosis (TB) is an infection that multiplies in crowds, spreading through the inhalation of tiny droplets lingering in the air2. Outbreaks are difficult to contain, requiring contact tracing, isolation and vaccination programmes. While much of this will sound familiar to us all, having lived through a global pandemic in recent years, unlike its SARS-CoV-2 cousin, this pernicious pathogen has been a persistent feature of life for centuries3

Mycobacterium tuberculosis, the bacterium that causes TB, launches its first attack on the lungs. A mild fever is often the first sign, followed by the unwelcome arrival of a painful cough and a shortness of breath. If undefeated by the immune system, it can cause pervasive lung damage – and ultimately spread to the skeletal system, the kidneys and intestines, and then finally the brain4

Source: UN Sustainable Development Goals Report 2022

Reversing 14 years of progress

In 2015, the United Nations (UN) set a target to end the tuberculosis epidemic by 2030, as part of the ambitious Sustainable Development Goals (SDG) agenda5. We are now halfway through this timeline and yet further away from reaching the goal than when we started. The last decade had seen monumental progress towards the eradication of TB, with 2019 marking an all-time historic low in global TB mortality. However, in 2020, the spread of COVID-19 consumed global health resources, diverted scientific and political attention, and paved the way for TB to make its comeback6

The latest annual TB report published by the World Health Organisation (WHO) estimates that TB killed 1.6 million people in 2021, a death toll last seen in 2005, effectively reversing 14 years of progress7. The 2020 survey results of Global Fund-supported programmes across 106 countries showed that, since the emergence of the COVID-19 pandemic, 80% of TB programmes worldwide reported disruptions in services as a result of lockdowns and supply chain difficulties8. A delay in TB diagnosis can lead to an increased severity of the disease, while interruptions to TB treatment can lead to the deadly development of drug-resistant strains – both of which further compound the problem9

While the impact of TB is currently felt most acutely in lower-income countries, which account for 80% of cases, as people migrate and wars displace refugees, strains of TB, in particular the highly drug-resistant variants that are immune to vaccines, are beginning to emerge in the West10.  

Source: World Health Organisation 2000-2021

Can we save the SDGs? 

The trifecta of the COVID-19 pandemic, a devastating war in Ukraine and a deepening climate emergency has reversed years of global sustainable development across the SDGs more broadly. The UN’s Sustainable Development Goals 2022 report revealed that more than four years of progress against poverty have been erased, with millions more people now living in extreme poverty and suffering from increased hunger compared to pre-pandemic levels11.  

The report also showed a stark worsening of inequality both within and between nations, with women disproportionally affected by the increased burden of unpaid work. Additionally, we’re witnessing the highest number of conflicts concurrently since the creation of the UN, with two billion people estimated to live in conflict-affected regions12. And all the while, climate change is acting as a “crisis multiplier”, further escalating poverty, hunger and inequality13.

Despite the scale of the challenges, the solutions humanity so desperately needs could still be in reach, thanks to the transformative potential of science and technology. Indeed, we witnessed extraordinary innovation as the world grappled with an unprecedented global health emergency. Despite the typical vaccine production timeline being between 10-15 years, we saw the development of multiple high-quality COVID-19 vaccines in the record-shattering time of less than one year.  

While mRNA vaccinology may seem like it came out of the blue, like the emergence of many ground-breaking discoveries of recent years, it really owes its success to decades of foundational research. If the pandemic showed us anything, it’s that patient, forward-thinking investment into the world’s most innovative companies can work.  

Building better diagnostics

Effectively overcoming the rising number of TB cases, starts with better diagnostics. We need to move from a global public health model that relies solely on passive case finding, where those affected are required to self-report when they have symptoms, to a model of both passive and active case finding, where diagnostic capabilities are taken into the community to seek out those infected. This is far more equitable and allows for earlier detection of TB, which in turn allows for earlier treatment and helps to limit the spread of the disease14.  

This kind of community-based active diagnostics has only been made possible in recent years with the breakthrough of portable testing devices. Access to best-in-class molecular diagnostics had previously been limited by the systems needed to run them. However, through the automation of highly complex and time-consuming manual procedures, the most vulnerable populations can now access high-quality, battery-operated devices that can provide accurate and fast diagnosis, even in hard-to-reach areas with limited electrical supply.  

Once diagnosed, patients need access to antibiotics capable of fighting the pathogen effectively. This can be difficult, given the prevalence of drug-resistant TB strains that are immune to existing treatments. Typical drug development timelines can also range from between 10-15 years, making it incredibly challenging to respond to the mutating pathogen.  

Revolutionising drug development 

However, the technological progress unfolding in this area is particularly exciting and has the potential to revolutionise the drug development landscape. Cheap gene sequencing, combined with cheap computing, has enabled advances in mRNA technology, synthetic biology, stem-cell therapy and the development of CRISPR gene editing15. Scientists are able to study the molecular composition of a pathogen and strategically design drugs that target weak points. This expedites the drug discovery process, particularly when using machine learning, and has the potential to be far more effective, and so shortening the time drug regimens are needed.  

Vaccines are another area seeing monumental progress. The only licensed vaccine for use against TB today – the BCG vaccine – was first developed over 100 years ago. Although known to provide moderate protection against TB in infants and young children in some countries, it is less effective in areas with high incidence of the disease and it is ineffective in preventing TB in adults16. Building on the success seen during the pandemic, we have entered a golden age of vaccine technology. In the year 2000, we had no new TB vaccines in development, but today there are 14 promising vaccine candidates currently in clinical trials, a number of which the WHO expects to be ready in the coming years17. A new, more effective vaccine that provides immunity to all age groups would be a game-changer for TB eradication, providing the antiviral weaponry we need to contain the spread of multi-drug resistant TB effectively.  

In innovation we trust 

Eradicating TB is within reach if capabilities are harnessed. To put the global decline in TB incidence back on track, we need better tools for prevention, diagnosis and treatment. Although government action and global co-operation are undoubtedly critical in the sustainable development toolbox, technological advancement is the workhorse that will deliver the solutions humanity needs at this important juncture. We’ve said it before, and we’ll say it again: in innovation we trust.

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