To prepare for the next pandemic, we must spend now on TB and other major diseases
The Ravages Of COVID-19 And The Imperative To Invest Wisely In Pandemic Preparedness
The COVID-19 pandemic has killed at least 7 million people worldwide as of December 2023. The virus has revealed systemic weaknesses in health systems, particularly in supply chains and service delivery, through a combination of the stress the virus placed on human resources and the lockdowns and other restrictions countries put in place to try to contain COVID-19’s spread. As health systems buckled, millions more deaths also occurred from routine conditions that might otherwise have been treated. Global excess deaths between 2020 and 2023 have been estimated to be 27.4 million, including COVID-19 and other all-cause mortality.
Calls for strengthening health systems in preparation for the next pandemic have intensified in the wake of COVID-19, with estimates ranging from $15 billion to $50 billion needed annually to scale up global capacity to prevent, detect and respond to emerging pandemics. A new Pandemic Fund was created in November 2022 with $2 billion initially pledged, against which over $7 billion of proposals were submitted during the Fund’s first call for proposals. This large excess demand underscores the importance of spending limited resources wisely and strategically to get ready for the next pandemic.
This raises two questions: First, which areas of pandemic investment have the biggest payoff and should thus be prioritized? Second, if these investments do not have an immediate benefit against future pandemics, since we do not know when the next one will hit, can they help in the meantime to support ongoing efforts in low- and middle-income countries (LMICs) to battle infectious diseases like AIDS, tuberculosis (TB), and malaria that kill more than 2.5 million people each year? Can pandemic preparedness investments thus be dual-purpose, delivering health benefits now in “peacetime” and again against a global pandemic in “wartime”?
Finding Health Systems Investments With Dual Benefits—The Evidence From Tuberculosis
Our answers to both questions, based on our experience working on global epidemics like AIDS and hepatitis and on the recent COVID-19 pandemic, are emphatically “yes.” Key parts of any country’s health system—including disease surveillance, laboratories, supply chains for medicines, vaccines and diagnostic tests, frontline health workers, and health information systems—are vital for countries to detect quickly, prevent, and respond to a pandemic. These same investments enhance the ability of LMIC countries to tackle other infectious diseases like HIV, TB, and malaria, generating a second “peacetime” benefit.
Maintaining infectious disease program capacity can also help lower the clinical severity of a respiratory pandemic like COVID-19. Researchers found that the risk of developing severe fatal COVID-19 was 38% greater for HIV-positive individuals, the COVID-19 mortality rate was two-fold higher in populations with active tuberculosis infection, and coinfection with COVID-19 and malaria was associated with significantly higher all-cause in-hospital mortality.
The example of TB and recent investment in national TB control programs during COVID-19, based on our ongoing examination of the evidence and a Yale University research project that one of us has been supervising, illustrates how these double gains can be achieved.
Most countries’ TB programs took a large hit during COVID-19, especially in 2020 and 2021 (many but not all bounced back in 2022). Globally, TB deaths increased in 2020 for the first time in a decade, and funding for TB programs decreased to 2012 levels, as most countries reprogrammed their TB funding towards COVID-19 response. Surveys conducted in June 2020 found that across 108 Global Fund countries, 78 percent reported disruptions to TB services (17 percent with high levels of disruptions) and 9 percent experienced significant shortages of key TB supplies including drugs and testing materials. Case detection rates—the share of the estimated new TB infections that were tested and confirmed—fell 18 percent on average between 2019 and 2020, with the biggest declines in Europe (-22 percent), the Americas (-10 percent), and Southeast Asia (-11 percent).
Countries that suffered large downturns tended to curtail their TB programs during the pandemic, either because they shuttered health facilities during lockdowns or because health care workers were unwilling to receive patients with TB, which has similar presenting respiratory symptoms to COVID-19.
However, some countries managed to stand out by continuing to operate their TB programs despite the significant disruptive pressures caused by the pandemic, effectively addressing COVID-19 and TB together as co-respiratory pandemics. They tended to use their TB budgets fully, including major outside support from the Global Fund.
TB treatment coverage is estimated as the percentage of total estimated incident TB cases that are detected and treated in a given year. Nigeria (+18 percent), Democratic Republic of Congo (+8 percent), Tanzania (+8 percent), Ethiopia (+3 percent), and Central African Republic (+2 percent) notably increased their TB treatment coverage rates in 2021 as compared to 2019, before the pandemic started. At the same time, TB treatment coverage rates declined globally by an average of -16 percent, including in Kyrgyzstan (-29 percent), the Philippines (-24 percent), and Peru (-23 percent).
While many other factors including demographics (African countries have younger populations, which tend to have lower mortality rates from COVID-19) and incomplete COVID-19 reporting systems may help to explain these differences, it appears that the countries that were more successful against COVID-19 used their TB and other pre-existing health infrastructure—including community health workers and diagnostic machines originally purchased for TB—to test for and detect COVID-19 as part of a co-epidemic response.
Interestingly, these standout countries also had above-average regional success in managing COVID-19 as compared with their peers. On average, countries in Africa confirmed 216 COVID-19 deaths per million from 2019 to 2023. This death rate was much lower for the region's standout TB program recovery countries mentioned above, including a low of 14 COVID-19 deaths pers million in Nigeria, followed by Democratic Republic of Congo (15), Tanzania (16), Central African Republic (21), and Ethiopia (61). Conversely, African countries that failed to sustain and increase their TB program coverage reported higher COVID-19 death rates including 1,187 per million in Eswatini, followed by Botswana (1,064) and Zimbabwe (350). The strong correlation between higher TB coverage rates and lower confirmed COVID-19 case and death rates suggests that TB program strength may contribute to better pandemic preparedness.
Factors That Make For Stronger TB Programs Can Be Used For Other Respiratory Pandemics
Successful TB programs leverage community trust and outreach, often with a network of community health workers and other health professionals who encourage patients to get tested and improve case detection rates. These community workers are vital to ensure timely case notifications and linkage to care, and to provide support and encouragement to patients to complete lengthy drug regimens of more than six months for drug-susceptible TB and more than two years for multi-drug resistant TB. These human resources trained in infection control and patient support can be used for the prevention, detection, and supportive treatment of other respiratory pathogens in addition to TB.
There is also a major crossover benefit from TB testing to COVID-19 and respiratory diseases. During 2020-2021 the high-performing countries used their TB diagnostic equipment, especially GeneXpert and other PCR diagnostic machines, to test simultaneously for TB and COVID-19. Nigeria and Guinea were early adopters of such bi-directional screening, showing how TB programs can pivot quickly to accommodate screening for additional respiratory pathogens.
Many successful countries also deployed community health workers to screen patients for TB and COVID-19 and used pharmacies and postal services to safely deliver TB drugs to patients while minimizing contact during lockdowns due to COVID-19. Sierra Leone trained traditional healers to screen for both TB and COVID-19.
Health Systems’ Investments For Other Killer Diseases Can Build Countries’ Pandemic Preparedness Capacity
Our work suggests that strong and flexible programs to combat a widespread chronic pathogen like TB are vital to ensure that long-standing global epidemics do not worsen during a crisis like COVID-19. The fact that some LMICs protected and advanced their TB programs even during an unprecedented health shock like COVID-19 while others saw major downturns points to actions that we can take to preserve TB and other infectious disease programs during pandemics.
Conversely, countries getting ready to meet the challenges of a future pandemic must invest in national disease surveillance, supply chains, labs, information systems, and health workers. These investments, which are “always on” for diseases like TB, will make it easier for LMIC countries to rapidly pivot and surge to fight a pandemic.
We have here used the example of TB. But investments in fighting HIV can be repurposed for blood-borne pandemic pathogens, while investments in malaria control can also be used for vector-borne pandemic pathogens. Since we do not know that the next severe pandemic will be airborne and respiratory, we need to make sure that we have these other delivery platforms ready for any type of outbreak that might occur.
Health system investments thus need to be seen as bivalent: focusing on both known endemic diseases and on lurking or emergent pandemics.
We recommend that LMIC country health leaders continue to invest in health systems for existing infectious diseases, using a flexible and innovative mindset that enables them to redeploy these “always on” capabilities to rapidly respond to new pandemic threats as they emerge.
Similarly, outside funders including the US President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative, the Global Fund, and the World Bank should also adopt this dual perspective, identifying health systems investments that save lives today while preparing for the next pandemic to follow COVID-19, and thus maximizing the health benefits on the more than $20 billion they provide each year in health aid. Each of these donor programs should explicitly allocate funding to areas with this double benefit, spelling out the expected gains in lowering TB, HIV, and other infectious disease burden over the next decade, while also specifying and quantifying the anticipated improvements in country readiness to address the successors to COVID-19 that surely lie in our future.
By Shan Soe-Lin, Whitney Bowen and Robert Hecht
Authors’ Note
Our non-profit Pharos Global Health Advisors has been a technical consultant over the years to the Global Fund, the Joint United Nations Programme on HIV/AIDS (UNAIDS), Unitaid, the World Health Organization (WHO), and other global health organizations that fight infectious disease, help with pandemic preparedness, and invest in health systems around the world. The views expressed in our Forefront piece are our own independent observations and suggestions. Our thanks to Chris Collins, President of the Friends of the Global Fight Against HIV, TB, and Malaria, for his support to the Yale Jackson Institute capstone project for fall 2023.
Source: Health Affairs
