Why is it needed?

Tuberculosis has been a very serious disease for thousands of years that has resulted in millions of deaths. It was finally starting to be controlled through decades of work by multiple agencies. However, there still isn’t a vaccine that’s completely effective against. Why is it important to have one? What are the other benefits of one being developed?

TuberculosisTuberculosis (TB) isn’t a new disease. It’s been around close to 3 million years. Archeologists have found TB in the bones of ancient bison in Wyoming that lived over 17,000 years ago. It can still be found in many animals across the United States, such as cattle and deer. Approximately 1 million cattle are tested each year for TB. This is why it was initially thought to come from animals, but recent studies using molecular genetics show that human TB predates any other form. The mycobacterium tuberculosis complex (MTBC) is thought to have emerged in Africa and then spread throughout the world with the migrations of modern humans about 70,000 – 100,000 years ago. Archeologists found TB in the remains of a mother and child buried together in Atlit Yam, a city now under the Mediterranean Sea, off the coast of Israel. These bones were dated around 9,000 years ago. There are references to TB in medical texts from China (2700 BC) and Egypt (1550 BC). It was also identified in a Sanskrit hymn (Rig Veda) from India (1550 BC). Hippocrates describes a disease that caused “weakness of the lung” with fever and cough that was usually fatal in Book 1, Of the Epidemics (410-400 BCE). He refers to as phthisis and it was the commonest disease of the period. In his description, Hippocrates documented that the disease seemed to attack young adults between the age of 18 and 35.

The disease was common enough that throughout civilization it had many different names, Hippocrates and other ancient Greeks called it phthisis, ancient Romans referred to it as tabes and ancient Hebrew mentions it as schachepheth. During the Middle Ages, TB of the neck and lymph nodes was called scrofula, which was thought to be a different disease from TB in the lungs. In the 1700s, it was called “the white plague” since patients were often very pale. By the 1800s, it was known as consumption. In 1803 a French doctor, Rene Laennec, announced that he had discovered tubercles in all organs of the body, including muscle. This caused him to believe that the various lesions found in the lung were in reality different phases in the same pathological process. However, it wasn’t until 1834 that Johann L. Schonlein suggested that the word “tuberculosis” be used as a generic name for all the manifestations since the tubercle was the anatomical basis of the disease. Nowadays, our names for TB tell us where it’s located (pulmonary or extrapulmonary) and how to treat it (drug-susceptible, drug-resistant, multidrug resistant and extensively drug-resistant).

Before it was known that tuberculosis was caused by bacteria, it was thought to be hereditary. On March 24, 1882, Dr. Robert Koch announced the discovery of the bacteria, Mycobacterium tuberculosis, responsible for TB at the Berlin Physiological Society conference. This proved that TB was an infectious disease. As a result of his findings, Dr. Koch won the Nobel Prize for Medicine and Physiology in 1905. Seven years after Dr. Koch’s finding, Dr. Hermann Biggs convinced the New York City Department of Health and Hygiene to have TB cases reported to the health department. This resulted in the first published report on TB in New York City in 1893. The Center for Disease Control and Prevention (CDC) published nationwide TB data for the first time in 1953 with 84,304 cases of TB in the US at that time. In 1890, Dr. Koch extracted TB bacilli and developed tuberculin in hopes of finding a cure for the disease. Unfortunately, it was ineffective. In 1907, Clemens von Pirquet used a small amount of tuberculin and placed it under the skin to measure the body’s reaction to see if the person had been exposed to the bacteria at some point. This was the earliest known “skin test” for TB. He is the one who came up with the term “latent TB infection.” In 1921, Albert Calmette and Jean-Marie Camille Guerin developed the Bacille Calmette-Guérin (BCG) vaccine as a way to prevent TB. However, it doesn’t always protect the person from contracting the disease, especially adults, so it’ not widely used in the US, but is often given to infants and small children to prevent TB meningitis in countries where TB is more common. In the 1930s, American doctor, Florence Seibert, developed a process to create a purified protein derivative of tuberculin (PPD) for the skin test. This method was adopted by the US government adopted it in 1940 and still remains in use today. In addition to skin tests, TB blood tests, or interferon-gamma release assays (IGRAs), are performed as well.

Although tuberculosis had been present in Europe for centuries, it was in the seventeenth century that it reached astounding epidemic proportions. According to the London Bills of Mortality, by the mid seventeenth century one in five of the deaths in the city was due to consumption. From then to the nineteenth century, it continued to sweep throughout the country. It was so bad that it was called the White Plague of Europe. Tuberculosis mortality probably peaked in England in 1780, at a death rate of 1,120 for each 100,000 living people each year, which means that 1.25% of the entire population died of the disease each year. By the end of the 18th century one in every four deaths in England was attributed to the disease. At the beginning of the 19th century, the worldwide death rate was estimated at 7 million people a year and 50 million people infected. In colonial America, consumption was probably the most common killer of adults with being responsible for more than 25% of deaths in New York city between 1810 and 1815. At the time of Dr. Koch announcement in 1882, TB killed one out of every seven people living in the United States and Europe. It remained the widespread cause of death among until the 1940s. The decrease in mortality in the second half of the nineteenth century was so unexpected that it remained unnoticed for several decades. By 1900, the estimated death rate for white Americans was between 190 – 200 per 100,000 and was 400 deaths per 100,000 among black Americans.

Thankfully, the treatment for tuberculosis has improved greatly. In the Middle Ages, treatment was the “royal touch.” This meant people lined up in front of the English and French monarchs hoping to be touched by them and that this would cure them of the disease. Later treatment was limited to warmth, rest and good food. By the early 1800s, cod liver oil, vinegar massages and inhaling hemlock or turpentine were considered the best treatments. In order to help prevent the spread, people were isolated. Infected individuals were taken out of their home to a sanatorium, which helped decrease the chances of spreading TB to family members. Here, the individuals were treated with fresh air, good food and sometimes surgery. The first sanatorium was opened in 1854 by German physician Dr Hermann Brehmer in Gorbbersdorf, Silesia. The first American sanatorium was opened in Asheville, North Carolina in 1875 by Joseph Gleitsmann. In 1884, Edward Livingston Trudeau opened the second, Adirondack Cottage Sanatorium, in Saranac, New York. In 1894, he also built the first laboratory for the research of TB in the US. In addition, he founded the National Association for the Study and Prevention of TB (1904) and American Sanatorium Society (1905). These organizations eventually became the American Lung Association and the American Thoracic Society, which continue to research and fight TB today. Unfortunately, he later died from the disease. America built many sanatoriums. In 1904, there were 115 with the capacity for 8,000 patients. By 1953, there were 839 with the capacity for 136,000. In 1888, Italian doctor, Carlo Forlanini, brought about the first artificial pneumothorax in a patient with TB. A pneumothorax, or collapsed lung, is when air gets into the space between a lung and the chest wall, which results in air pushing on the outside of the lung making it collapse. The creation of an artificial pneumothorax was probably the first surgical treatment for TB. This continued as a treatment choice for a while because a number of patients appeared cured. Around 1956, the Madras Experiment was carried out in India. The goal was to see if treatment in a Sanitorium provided any benefits over being treated at home. The results showed that there was no difference between the two groups, which led to many sanitoriums closing or radically changing the services they provided. The history of TB drugs starts around 1940 with the development of para-amino salicylic (PAS). However, the game-changer has been antibiotics. The four main drugs that are used today are isoniazid (1951), pyrazinamide (1952), ethambutol (1961) and rifampin (1966). Today, treatment involves patients being in their own homes and being visited by public health workers who deliver medications and monitor treatment. Thanks to advances in technology, some public health departments are using video via webcams or smartphones to connect with patients.

The bacteria that causes tuberculosis is spread from one person to another through tiny droplets that are released into the air when someone with the untreated, active form of tuberculosis coughs, speaks, sneezes, spits, laughs or sings. While it’s contagious, it’s not easy to catch. This means that you’re more likely to get it from someone you live with or work with than a stranger. Typically, what happens is the bacteria enters your body, but your immune system is strong enough to prevent you from becoming sick, which means that you’re infected, but don’t have symptoms and can’t spread it to others. This is known as latent TB, inactive TB or TB infection. There are an estimated 2 billion people worldwide who have latent TB. The concern lies in latent TB becoming active TB or TB disease. This is why it’s important for the person with latent TB to be treated, so this doesn’t happen. Not only does this protect the individual from having active TB, which can be fatal without treatment, it helps to control the spread of the disease to others. A person can go from latent TB to active TB in the first few weeks after infection or years later.

The main symptoms of an active TB infection are having a cough that lasts three or more weeks, coughing up blood, chest pain, pain with breathing/coughing, unintentional weight loss, fatigue, fever, night sweats, chills and loss of appetite. Tuberculosis can impact other parts of your body, such as your kidneys, spine or brain. When it does, symptoms vary according to the organs involved, like spinal pain, joint damage, swelling of the membranes that cover your brain (meningitis), liver /kidney problems and heart disorders (rarely). If you have a fever, unexplained weight loss, drenching night sweats or a persistent cough, you should see your doctor.

Anyone can get tuberculosis, but certain factors can increase your risk with the main factor being having a weakened immune system. A number of diseases, conditions and medications can weaken your immune system, like HIV/AIDS, diabetes, severe kidney disease, certain cancers, cancer treatment (ex. chemotherapy), drugs to prevent rejection of transplanted organs, some drugs used to treat rheumatoid arthritis, alcohol/drug use, Crohn’s disease, psoriasis, malnutrition and being very young/old. There are two main “at risk” groups, those that are at high risk for exposure/infection and those at high risk for progression to TB disease once infected. The CDC recommends that people who have an increased risk of exposure for TB be screened. This includes people who have HIV/AIDS, use IV drugs, smoke, are in contact with infected individuals, are from a country where TB is common (ex. Latin America, Africa, Eastern Europe, Russia, Caribbean Islands and Asia), live/work in areas where TB is common (ex. prisons or nursing homes), work in healthcare setting that treat people with a high risk of TB and are children who are exposed to adults at risk of TB. Other important considerations are if you receive a low/fixed income, live in a remote area, have recently immigrated to the US, or are homeless, you may lack access to the medical care needed to diagnose and treat TB. People at high risk for progression to TB disease are those with a HIV infection, who were infected within the past 2 years (especially infants and very young children), who have underlying medical conditions known to increase the risk of progression to active TB disease, who inject illicit drugs and with a past history of inadequately treated TB.

The most commonly used diagnostic tool for tuberculosis is the PPD skin test. Usually, it’s injected just below the skin of your inside forearm. If you’ve been exposed, within 48 to 72 hours, there will be a hard, raised red bump at the injection site. The size of the bump determines the significant of exposure. However, the skin test isn’t perfect and sometimes suggests that people have TB when they really don’t. It can also show that people don’t have TB when they really do. This is why blood tests are often used to confirm the results of skin tests, particularly those that are positive. You’ll probably get a chest X-ray or a CT scan as well because this can show white spots in your lungs where your immune system has sealed off TB bacteria. Your doctor may want to take samples of your sputum (the mucus that comes up when you cough) to test it for TB bacteria. This is helpful in identifying drug-resistant strains of TB, which is vital to know when selecting medications to treat the infection. All of these tests can take four to eight weeks to complete. If you’re diagnosed with active TB, a contact investigation is done to find and test people who may have been exposed. New technology, such as whole genome sequencing, is helping public health professionals see patterns of TB transmission, which assists them in finding and treat persons with TB disease and latent TB infection.

If you have active TB, it takes a few weeks of treatment with TB medications before you’re not contagious anymore. During this time, it’s crucial to do everything you can to prevent the transmission of the bacteria to your friends and family. The best thing to do is to stay home and don’t sleep in a room with other people during the first few weeks. Be sure to ventilate the room since germs spread more easily in small closed spaces where air doesn’t move. One way to do this is to open the windows and use a fan to blow indoor air outside (it must be warm enough outside for you to do this). Any time you laugh, sneeze or cough, cover your mouth with a tissue. When you’re done, put the dirty tissue in a bag, seal it and throw it away. If you’re going to be around people, wear a mask, this helps to lessen the risk of transmission from you to them. Besides staying home, the most important thing you can do is to finish your entire course of medication. If you don’t, the TB bacteria have a chance to develop mutations that allow them to survive the most potent TB drugs making them much more deadly and difficult to treat. To help people stick with their treatment, a program, directly observed therapy (DOT), is usually followed. This is where a healthcare worker comes to your house and gives you the medications. Treatment is a complicated and lengthy process, which is why it’s important to try to maintain your normal activities/hobbies as much as possible and stay connected with family and friends. It’s normal to feel denial, anger and frustration. If you’re having trouble dealing with your emotions, professionals, such as therapists or behavioral psychologists, can help you develop positive coping strategies.

The treatment time for TB is much longer than other bacterial infections. In most cases, you’ll be taking antibiotics for at least six to nine months. The exact medications and length of treatment depend on your age, overall health, possible drug resistance and the infection’s location in your body. For those with latent TB, you’ll need to take only one or two types of drugs. For those with active TB, particularly if it’s a drug-resistant strain, you’ll need to take several drugs at once. If you have a drug-resistant strain, a combination of antibiotics called fluoroquinolones and injectable medications, such as amikacin or capreomycin (Capastat), are generally needed for 20 to 30 months. Scarily, some types of TB are developing resistance to these medications as well. Serious side effects aren’t common but can be dangerous when they do occur. All of the drugs can be highly toxic to your liver. So, if you experience any nausea/vomiting, loss of appetite, a yellow color to your skin (jaundice), dark urine and a fever that lasts three or more days with no obvious cause, call you doctor immediately.

There are two factors that have made tuberculosis very difficult to treat. The first is the development of drug resistant strains. The first signs of drug resistant tuberculosis were noticed 1948. At the time, it was to only one drug, but it has expanded to strains of the disease that are resistant to two or even more drugs. These strains emerge when an antibiotic fails to kill all of the bacteria it targets. The surviving bacteria become resistant to that particular drug and often other antibiotics. While some strains have developed resistance to the most commonly used treatments, others have also developed resistance to drugs less commonly used too. The other major factor is the spread of HIV. Since the 1980s, the number of TB cases has risen dramatically because of HIV. This is because HIV suppresses the immune system, which makes it hard for the body to control TB bacteria. People with HIV are significantly more likely to not only get TB, but for it to progress from latent to active than are people who don’t have the immune disorder.

Tuberculosis is incredibly important to study throughout the world, but especially here in the US because we’re one of the most significant low burden TB countries and even in low burden countries there are deaths that can be prevented. In 1984, the then director of the CDC, Dr James Mason, challenged the public health community to come up with a plan to eliminate TB from the US, which resulted in the creation of the Advisory Council for the Elimination of Tuberculosis (ACET) and the publication of a national TB elimination plan in 1989. The elimination of TB was defined as achieving a TB case rate of one per one million people a year. In the early 1900s, TB rates declined steadily from approximately 200 deaths per 100,000 people per year that were seen in 1985 to less than 1 death per 100,000 people. As a consequence, experts believe that TB could be virtually eliminated from the US by 2010. However, starting in 1972, when medical advances led to a declining number of cases, Congress cut all funding dedicated to fighting the disease, which caused the TB public health systems to collapse, infection rates to rise and deadly drug resistant strains emerged. This decision has cost the US billions of dollars from federal, state and local governments to combat this resurgence of TB. The cost of treating drug resistant strains is also very expensive. In 2018, for each patient, the cost of treating drug sensitive TB was $49,000, treatment costs for multi-drug resistant TB (MDR-TB) averaged $393,000 and treatment costs for extremely drug resistant TB (XDR-TB) was around $758,000. The resurgence of TB in the early 1990s led to the publication of “Ending Neglect” in 2000 by the Institute of Medicine. The report outlined steps needed to eliminate TB, which epidemiology and modeling studies suggest can only be reached if the strategy includes a major increase in latent TB infection testing and treatment. It concluded that TB elimination was still possible, but would require “aggressive and decisive action beyond what is now in effect.” The new target date for elimination is 2035 and there are five main groups of steps that were recognized as being needed in order to achieve it. Two of these steps included paying much greater attention to the screening of “at risk” populations and people with latent infection should be actively treated. It was estimated that if TB could be eliminated by 2035, then there would be 15,200 fewer TB related deaths, 253,000 fewer cases of TB and $1.3 billion less in TB treatment costs. However, key elements of the plan were never adequately funded or fully implemented. Nine years after the IOM report was released, there was an assessment of how and why it had not been fully implemented. It said that the TB elimination effort failed not for want of the right goals or specific recommendations but because the IOM recommendations had not been fully implemented. While there is currently a year by year decline in cases, it’s very slow and at the current rate of progress the goal of elimination by 2035 is unlikely to be achieved.

The United States isn’t the only place that needs to manage tuberculosis. In fact, it’s a much bigger problem in many other parts of the world. This is why in 1994 the World Health Organization (WHO) announced it was going to follow the new strategy, DOTS (Directly Observed Treatment), in an effort to gain worldwide control of TB. The program had five components: sustained political and financial commitment, diagnosis of TB by quality ensured sputum smear microscopy, standardized short course anti-TB treatment given under DOTS, a regular uninterrupted supply of high-quality anti-TB drugs and standardized recording and reporting. DOTS treatment included a four drug regimen, isoniazid, Rifampicin, Prazinamide and Ethambutol, for 6-9 months. By 1996, the WHO stated that “where the health system is working even moderately well, the DOTS strategy is extraordinarily effective achieving cure rates over 90%.” Five years after it was started, 120 countries had at least technically adopted the program. However, while DOTS was successful in some areas, it wasn’t perfect and a universal solution hadn’t been found because it failed to take in to account the influence of HIV and drug resistant TB. As a result, in 1999, the WHO unleashed DOTS-Plus, which was based off of DOTS, but would put into place steps to address specific issues, like the use of second line anti-TB drugs for MDR-TB. The challenge of this was that high quality second line anti-TB drugs were normally very expensive and difficult to obtain. To help with this, the WHO and their partners set up an arrangement with the pharmaceutical industry for better prices for the drugs used for the pilot projects. By 2005, there had been 36 DOTS-Plus pilot projects established in 27 countries that treated over 10,000 MDR-TB patients. This led to the belief that management of MDR-TB was feasible and effective in resources with limited settings. Since some global TB targets had still not been met by 2000, a new declaration was made and called the Amsterdam Declaration to Stop TB with the same goals being set, but the new target time was 2005. In addition, the Stop TB Partnership was set up in 2001. Initially, it only included just six organizations, but by October of the same year at the Stop TB Partnership Forum, it had grown to over 120 organizations. At the Forum, the unveiling of the Global Plan to Stop TB 2001-2005 took place with the goal of providing a path towards a TB free world. Part of the plan was to have a global DOTS case detection rate of at least 70% while maintaining a treatment success rate of at least 85%, effective responses to TB/HIV and MDR TB would be developed and a Global Plan to Stop TB for the period 2006-2010 would be created. In 2006, WHO redefined DOTS to say that it would diagnosis, treatment and care for all patients, including drug resistant TB and co-infected with HIV. This change meant that DOTS Plus no longer existed. Since the targets had once again not been reached, a new global plan for 2006-2015 was created. The targets were a wide range covering specific areas, like the development of improved diagnostics and drugs. In 2009, the Stop TB Partnership released a report on the progress that had been made toward the goals between 2006 and 2008. In some areas, significant progress had been made, but in others, not so much with one particular area of struggle being a funding gap still existing of over $1 billion (US) per year. This resulted in the plan being updated in 2010 and became known as the “Global Plan to Stop TB 2011-2015.” In 2015, new targets were set, called the Global Plan to End TB 2016 – 2020. Part of this plan said that there needed to be a fundamental change in how TB was viewed and set out plans regarding resources needed and how the targets could be met, but didn’t explain as to how this time it would be any different from previous goals.

COVID-19 is having a significant impact on the health of millions of people around the world. However, it’s not just the virus itself that worries scientific experts, but the impact it’s having currently and will continue to have on other diseases. Global vaccinations and screenings for measles, tuberculosis and other infectious diseases are down because people around the world are hesitant to seek care, including tests for TB and HIV, at medical facilities because they’re concerned about catching COVID-19. This is problematic for disease detection and may result in many treatable conditions going undiagnosed leading to additional illness and death. For example, TB deaths have gone down almost 50% (1.3 million) yearly worldwide in the past two decades, but it’s likely to return in many countries right now and experts estimate we could see as many as 1.4 million extra TB deaths in the next five years. This rebound is expected even in the US. This elevated risk will also add more strain to the healthcare system. In addition, in theory, a TB diagnosis could make someone lower priority for receiving treatment for COVID-19 should they contract the virus, so some individuals may be hesitant to be tested for TB.

Experts are also concerned about the vulnerability of countries that are facing multiple threats, such as the Democratic Republic of Congo, which is currently fighting COVID-19 alongside Ebola and the world’s largest outbreak of measles, and Yemen, which is battling the virus in the midst of devastating armed conflict and a massive cholera outbreak. However, the country that has cause for the most concern is India, which the WHO said had the highest number TB cases worldwide. Including India, other low and middle-income countries, including China, Indonesia, Philippines, Pakistan, Nigeria, Bangladesh and South Africa, account for two-thirds of new tuberculosis cases. In 2019, the annual report from India’s national tuberculosis elimination program said that more than 79 thousand death occurred that year, which was a 14 % increase over 2018. What’s extremely concerning is that in early April of this year, India saw an 80% drop in TB reporting. A study published in the European Respiratory Journal (ERJ) estimates that close to 95,000 people in India may die from TB as a direct result of overwhelmed health services and delays in diagnosis/treatment as a result of the pandemic.

There is some possible good news about TB and the COVID-19 pandemic. New evidence seems to suggest that the BCG vaccine used in some places to hopefully prevent TB in infants might enhance the immunity of patients. According to a new study, people vaccinated with it were found to have fewer infection issues. The reason behind is related to immune cells, which while diverse, originate from the bone marrow like all other human cells. They contain in their nuclei numerous thousands of genes and can access these for instructions whenever they want to produce a molecule. The issue is that it’s not always possible or easy for cells to gain this access. This is where the BCG vaccine comes in because it changes the cells ability to access the information, in a sense, making it easier for the cells to obtain this information more frequently. This alteration makes the genes accessible for many months or even years, which is helpful because it increases production of cytokines, which helps to mediate and regulate immunity and leads to stronger immune systems. Another interesting finding was that vaccination made cells more efficient in fighting pathogens. It does this through a molecule, hepatic nuclear factor (HNF), which causes the cells to release cytokines only when there is a real threat. Vaccination also appears to promote the activity of entirely different genes than those targeted and this is thought to activate other components of the immune response to fight other infections. So, the idea isn’t for the vaccine to be used to prevent COVID-19, but they might decrease the severity of disease and train the immune system to fight off the virus for a short period of time. Tests are already underway to see if the BCG vaccine can actually do this. If effective, the BCG vaccine could potentially provide some level of protection against the second wave of coronavirus, which is likely to happen before a specific vaccine for the new virus is available because new vaccines take a long time to develop and before they can be used widely, scientists need to test them in people to make sure they’re safe. The good news about the BCG vaccine is that it has already been used safely in millions of people, so it could be implemented right away provided that it proves to be effective in trials.

The WHO has issued a warning that there currently isn’t any evidence that the BCG vaccine protects against COVID-19. Skeptics point to research that compares rates of infection of the new virus in countries that widely use the BCG vaccine against those that don’t and haven’t found any major differences in the number of infections. Take Brazil as an example, which has a massive outbreak despite broadly using the BCG vaccine. Or, Israel, which routinely gave the BCG vaccine to all newborns as part of the national immunization program between 1955 and 1982 and since then only to immigrants from countries with high prevalence of tuberculosis, they haven’t seen a significant difference of COVID-19 infections between those who received the vaccine and those who didn’t. However, proponents of using the BCG vaccine argue that it’s not like the people in these countries aren’t getting the infection, they’re just not dying from it. For instance, Pakistan widely used the BCG vaccine and has experienced 2,255 deaths related to the virus in a nation of 212 million while the US contains two-thirds of the world’s unvaccinated population and has had more than 129,000 deaths in a nation of 330 million. These experts say that many other factors, such as differences in testing, healthcare systems and migration of people between countries with different BCG vaccine policies could explain some of the differences. Other experts are concerned that there is a chance the BCG vaccine could have the opposite of the intended effect, which means the person’s immune response becomes too strong and result in the cytokine storm that can have catastrophic effects on the body. Obviously, further information and testing is needed before deciding if using the BCG vaccine against COVID-19 is a beneficial move.

Another concern the pandemic has created regarding treating known infections along with the new virus is how to allocate limited resources. There is some concern that there will be collateral damage if we shift resources away from other infectious diseases, like TB, and that this damage could be lasting. Public health experts say we can’t afford to sacrifice the progress we have made on getting rid of other infectious diseases in order to lessen the effects of this one. All this will do is shift the burden of morbidity and mortality. The WHO has spent decades helping to bring about many improvements in global health that has helped to reduce the rates of HIV infection, tuberculosis and malaria. Many of these advances have been in low- and middle-income countries that couldn’t control infectious diseases through testing, data collection, medical supplies and more without the WHO’s assistance. The US provided about 15% of the WHO’s total funding last year and by removing this funding, the US is hindering the ability of these countries to respond to disease outbreaks, which further increases the risk of infectious disease outbreaks in the US.

One thing is for sure and that is we, as a global society, need to better manage how tuberculosis is diagnosed and treated. If there were better public health infrastructure throughout the world, it would help to do this. In addition, it would’ve helped to combat pandemics, such as COVID-19. Thankfully, drug development and vaccine research related to TB is continuing because this is what is need to eventually be able to eliminate the disease and reduce the number of deaths associated with it. In the meantime, the BCG vaccine might be one of the many tools we can use to decrease the severity of infections from COVID-19.