At Kaneshie Polyclinic, a health center in a poor neighborhood of Accra, Ghana’s capital, there is a rule. Every patient who walks through the door—a woman in labor, a construction worker with an injury, a child with malaria—is screened for tuberculosis.
This policy, national in nature, is intended to address a tragic problem; Two-thirds of the people in this country with tuberculosis do not know they have it.
Tuberculosis, which can be prevented and cured, has regained the title of the world’s leading infectious disease, after being supplanted in its long reign by Covid-19. But worldwide, 40 percent of people living with tuberculosis receive no treatment or diagnosis, according to the World Health Organization. The disease killed 1.6 million people in 2021.
The numbers are even more worrying because this is a time of great hope in the fight against tuberculosis: important innovations in the diagnosis and treatment of tuberculosis have begun to reach developing countries, and the results of clinical trials are promising for a new vaccine. Infectious disease experts who have fought tuberculosis for decades express a new conviction that, with enough money and a commitment to bringing those tools to underserved communities, tuberculosis could almost be defeated.
“This is the best news we’ve seen on TB in decades,” said Puneet Dewan, an epidemiologist with the Bill & Melinda Gates Foundation’s TB program. “But there’s a gap between having an interesting channel and actually reaching people with those tools.”
A recent visit to the Kaneshie clinic revealed both progress and remaining barriers. Despite the clinic’s policy of screening everyone for tuberculosis, which most often attacks the lungs, asking a few questions about coughs and other symptoms, patients entered the single-story cinder-block building and were sent to receive care without such questions. It turned out that one member of the TB team was on vacation, another was on maternity leave, and a third was sick. That left only two, who were busy processing tests and handing out medications.
So no one was tested, neither that day nor any other day in the previous week.
“It’s a good policy, it works well when we can do it, but staffing is a problem,” said Haphsheitu Yahaya, the clinic’s tuberculosis coordinator.
When the screening policy works, the new drugs (the first to hit the market since the 1970s) can be taken in the form of just a couple of pills a day, instead of handfuls of pills and painful injections, as have been administered tuberculosis treatments in the past.
Those diagnosed with drug-resistant tuberculosis are given medications that they must take for six months, a much shorter time than previously required. For decades, the standard treatment for drug-resistant tuberculosis was to take medication daily for a year and a half, sometimes two years. Inevitably, many patients stopped taking the medications before they were cured and ended up with a more serious illness. The new medications have far fewer burdensome side effects than older medications, which could cause permanent deafness and psychiatric disorders. These improvements help more people stay on medications, which is good for patients and relieves pressure on a fragile health system.
In Ghana and most other countries with a high prevalence of tuberculosis, the drugs are financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, an international association that raises money to help countries fight the diseases. But contributions to the agency have been declining with each round of funding. Countries fighting tuberculosis are worried about what could happen if that funding runs out. Currently, WHO-recommended treatment for adults costs at least $150 per patient in low- and middle-income countries.
“If our patients had to pay, we wouldn’t have a single person receiving treatment,” Yahaya said.
Still, there have been advances in recent months to make drugs more affordable, and prices could soon drop even further. After prolonged pressure from patient advocacy groups, the United Nations and even novelist John Green, who dedicated his widely followed TikTok account to the issue, Johnson & Johnson has lowered the price of a key tuberculosis drug in developing countries. The company also agreed in September not to enforce a patent, meaning generic drug companies in India and elsewhere will be able to make a significantly cheaper version of the drug.
And for the first time in more than a hundred years, there is real hope for an effective vaccine: A promising candidate called M72, developed by the pharmaceutical company GSK with financial backing from the Gates Foundation and other philanthropies, is now in the late stages. . of clinical trials.
(However, as ProPublica recently reported, it is unclear who will have the rights to sell the vaccine, where it will be available, and how much it will cost. Taxpayer and philanthropy money has paid for much of the vaccine’s development, but GSK retains control of critical components.)
M72 is one of 17 vaccine candidates currently being tested in trials, offering a source of possibilities. The only tuberculosis vaccine used today was first given to people in 1921; It is useful primarily for infants and does little to protect adolescents and adults, who account for more than 90 percent of tuberculosis transmission globally.
Better technology for diagnosing tuberculosis is gradually reaching clinics in developing countries. Clinics across South Asia and sub-Saharan Africa, including Ghana, now have machinery to use rapid molecular diagnostic tests, equipment that was donated as part of the Covid response. That means many health centers have finally stopped using an unreliable diagnostic method, developed in the 19th century, of looking at sputum smears under microscopes.
Still, in 2021 only 38 percent of people diagnosed with tuberculosis received a molecular test for the first time; the rest were diagnosed under the microscope or, in many cases, by their clinical symptoms.
Molecular diagnosis also makes it possible to immediately detect drug-resistant tuberculosis. (The old method involved starting treatment with a person’s most common medications and waiting to see if the treatment worked; if patients had the drug-resistant form of the disease, they simply got worse.)
Joshua Dodoo, a driver, arrived at the Kaneshie clinic in March with a persistent cough. He had been losing pounds and couldn’t sleep. When he saw a doctor for what he thought was malaria, he was sent to be tested for tuberculosis. The only PCR machine in the clinic’s lab was in heavy use, so it was a few days before a nurse told him he had tuberculosis.
“I was very scared,” Dodoo said, adding that he didn’t realize people were still contracting the disease.
His wife, Sadia Ribiro, was calmer and was able to hear nurse Richard Boadi explain that there is a cure and that the treatment would be given to Mr. Dodoo free of charge.
Mrs. Ribiro was subjected to tests; People living in close contact with a person who has tuberculosis account for a significant percentage of the 10.6 million new infections each year. She tested negative and was treated with preventive medications for three months. These drugs are also new: Until recently, preventive therapy could last a year or more and few patients completed it.
But then the system collapsed. The couple’s two children, ages 3 and 11, were not tested. Mr. Dodoo said they were at school so it was difficult to get them to the clinic and they seemed healthy. Then, even as he began to regain weight and feel better, the children began coughing and complaining of fatigue.
But they were not tested until months later, when Boadi located them at his home. Only 30 percent of tuberculosis infections in children are diagnosed.
Ms Yahaya, director of the clinic, said that while the preventive therapy worked remarkably well, Mr Dodoo’s family’s experience was typical. Newly diagnosed people don’t want anyone to know they have the disease, which is associated with poverty and suffering, so they don’t volunteer information about other people who may have been infected. And the understaffed health system struggles to track them.
Only 169 health centers in Ghana have the capacity to use the new testing method. Typically, samples must be shipped far away, up to a three-hour drive in some rural areas. When the results come in, it can be difficult to locate those who were tested.
“The equation is simple: if we put more resources into TB testing, we would find more TB,” said Dr. Yaw Adusi-Poku, who heads Ghana’s national TB control program.
That will require more molecular testing sites, more staff trained to detect the disease, more people asking questions at the clinic door, more nurses like the intrepid Mr. Boadi, who arrives at his patients’ doors to encourage them to get their tests done. screened families (and often comes out of his own pocket to help patients pay for the bus fare to pick up their medications).
Molecular diagnosis is considerably more expensive than the old method. Cepheid, the company that makes cartridges for the testing machines, recently agreed to reduce the price of each from $10 to $8. An analysis commissioned by Doctors Without Borders found that the cartridges could be manufactured for less than $5. Cepheid continues to charge $15 per test to diagnose extensively drug-resistant tuberculosis, the deadliest form of the disease.
Funding for tuberculosis services in low- and middle-income countries fell to $5.8 billion in 2022 from $6.4 billion in 2018, which is just half of what the WHO says is needed. About $1 billion is available each year for tuberculosis research, half the amount the United Nations says is needed.
At a special meeting on tuberculosis at the United Nations in September, governments pledged to spend at least $22 billion a year on tuberculosis by 2027. But at a similar meeting in 2018, the same donors pledged to spend 13 billion dollars by 2022, less than half. of which materialized.
“I’m happy that we have these innovations, but just because they exist, just because the WHO recommends them, doesn’t mean people have access to them,” said Dr. Madhukar Pai, associate director of the McGill International Tuberculosis Centre. at McGill University in Montreal. “The costs are still too high and someone needs to cover them.”