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EDITORIAL | VOLUME 8, ISSUE 4, E247, APRIL 2023 $ % & ' (

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Taking tuberculosis out of the shadows

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The Lancet Public Health

Open Access • Published: April, 2023 • DOI: https://doi.org/10.1016/S2468-2667(23)00063-4 • PlumX Metrics

Before COVID-19 took over, tuberculosis was the deadliest infectious

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Article info disease in the world. Now it is number two but no less worrisome.
alerts from this journal
World Tuberculosis Day is observed on March 24, with this years’
theme: “Yes! We can end TB!”. A vital and powerful message to
inspire hope and encourage high level leadership and increased
investment at a time of great setbacks towards the goal of ending
tuberculosis. According to the Global Tuberculosis Report 2022, not
only did tuberculosis incidence increase by 4·5% for the first time in
20 years, but also deaths increased from 1·5 million in 2020, to 1·6
million in 2021. The End TB Strategy milestones of 2020, with the
aimed reductions of 35% for deaths and 20% for incidence, have not
been reached with only 5·9% and 10% reductions from 2015 to 2021,
and funding was half of what was committed to at the 2018 High-
Level Meeting. Over the past 3 years, the COVID-19 pandemic—
diverting attention but also resources such as testing technology
and equipment towards the pandemic response—has further
impacted tuberculosis outcomes.

Tuberculosis is disproportionally affecting the most marginalised

individuals in our societies—people who are homeless, migrants,
people living with HIV/AIDS, people with harmful alcohol use, illicit
drug users, and people who are incarcerated. This high susceptibility
is driven by an increased risk of exposure due to poor living
conditions, such as overcrowding and poor ventilation, and poor
access to health care that delays detection, diagnosis, and prolongs
infectiousness. In response, WHO updated their guidelines on
tuberculosis in 2021 to recommend systematic tuberculosis
screening for these groups at high risk—including in prisons and
other penitentiary institutions.

In this issue of The Lancet Public Health, Salome Charalambous and

colleagues discuss practical considerations on how the screening
recommendation in prisons could be implemented. While screening
when entering the facility, annual mass screening, and screening
upon release are effective strategies, in a high transmission setting
mass screening twice a year or more would be required to bring
incidence down. Importantly, the high incidence in prisons,
estimated to be on average around 10-times the risk of the general
population, driven by prison conditions as well as that people who
are already marginalised and at high risk are more likely to be
incarcerated. In 2022 there were an estimated 11·5 million people in
prison and the number of people in prisons has increased by 24%
globally since 2000. With 121 countries operating prisons above
capacity, exacerbating infectious disease risks, there is a real need to
reduce incarceration rates to limit overcrowding and to improve
detention conditions. This includes upgrading prison infrastructure
to meet standards for ventilation and cell occupancy, and offer
good-quality primary health-care in prisons. Inevitably to improve
prison health-care and enable systematic screening in prisons a
trained and adequate number of health-care workers will be
required. But above all, a successful response to tuberculosis in
prisons requires political will.

On Sept 22, 2023, the second UN High-Level Meeting on the fight

against tuberculosis will be held. This will bring together heads of
state worldwide and offer the opportunity for a strong political
declaration to end tuberculosis, with a focus on scientific innovation
and funding. The COVID-19 pandemic has inspired several innovative
approaches to tackle tuberculosis, such as the implementation of
digital interventions using video-supported telemonitoring to
ensure treatment adherence and changes improving longer-term
access to drugs. Another step in the right direction is the
establishment of a new WHO TB Vaccine Accelerator Council with the
aim to drive innovation in the area of tuberculosis vaccines.
However, research and development for COVID-19 was also
supported with a much larger budget. In 2020, more than US$100
billion were mobilised for research and development for COVID-19
and only $0·9 billion for tuberculosis.

The upcoming UN High-Level Meeting should be a tremendous

opportunity to reinvigorate the fight against tuberculosis and the
political will to fund tuberculosis elimination and tackle its key
modifiable risk factors—marginalisation and social inequality.
Tuberculosis is the pinnacle of the social determinants of health.
Yes, we can end tuberculosis—with strong political will, adequate
funding, and an unambiguous commitment to address inequalities,
the underlying determinant of tuberculosis.

Article info
Publication history
Published: April 2023

Identification
DOI: https://doi.org/10.1016/S2468-2667(23)00063-4

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© 2023 Published by Elsevier Ltd.

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