Rise in tuberculosis highlights broader global health security concerns

Global health leaders are paying close attention to the recent resurgence of tuberculosis (TB) in Venezuela, recognizing that the rise of a deadly infectious disease anywhere in the world is of international concern.

Unfortunately, as epidemics like Ebola and Zika fade from the headlines, support among policymakers about the importance of investing globally to prevent infectious diseases is trending in the wrong direction. This outbreak is the latest reminder of the urgent need for governments to boost funding for initiatives that bolster the front lines of epidemic prevention and response.

{mosads}It is no surprise that the World Health Organization selected building political and community commitments to end TB as the theme of this year’s World TB Day, which will be commemorated on March 24. Venezuela is a striking case study.

TB was, until recently, thought to be largely under control in the South American country, but an economic crisis has left many families poor, hungry, and living in crowded conditions, fueling a nearly 40 percent increase in TB cases in Caracas, Venezuela’s capital and largest city. The substantial increase in cases stands in stark contrast to what was once one of the most robust and successful TB prevention and control programs in the southern hemisphere.

Venezuela is not alone in struggling to control tuberculosis. The annual number of deaths globally caused by TB now rivals that of HIV, and TB is now one of the top 10 causes of death worldwide. The current inability of Venezuela and other countries to properly prevent, detect, and respond to diseases such as TB is an ominous sign for the health security of the United States, as well as global health security.

If countries are not well equipped to control routine infectious diseases, they will likely be unable to adequately contain epidemic threats such as pandemic influenza, Zika, or Ebola. And when countries fail to contain outbreaks, it substantially increases the likelihood that these diseases will spread across borders and oceans.

Reducing the spread of tuberculosis will require a shift from the current global mechanism for identifying TB cases via “passive case finding,” which relies on an individual seeking out care if they are experiencing TB symptoms, to “active case finding.”

In the active approach, TB screening of specific risk groups (eg, those with HIV, those in close contact with someone who has tested positive for TB) is initiated by healthcare providers, and public health officials proactively investigate all identified TB cases and their contacts to find, treat, and cure anyone who is infected.

This will require many countries to allocate additional resources to develop these new capacities, but these capabilities will provide benefits beyond enhanced TB control. Improving active case finding would also strengthen core public health capacities that would be critical during an emerging pandemic or other health security threat.

Fortunately, a global initiative exists to improve core public health capacities. In 2014, the United States launched the Global Health Security Agenda to help strengthen countries’ capacities to prevent, detect, and respond to infectious disease threats. Following the devastating Ebola epidemic in West Africa, the United States allocated more than $1 billion to fund the GHSA’s efforts to strengthen public health capacities in countries around the world in an effort to prevent future epidemics.

To date, work accomplished via GHSA-supported programs has led to more rapid detection and containment of epidemic threats, such as outbreaks of Marburg in Uganda and Ebola in the Democratic Republic of the Congo.

Despite these successes, the unchecked spread of tuberculosis in Venezuela highlights the considerable work that remains in order to protect countries across the globe — including the United States — from infectious disease threats.

Many of the GHSA’s focus areas, or “action packages,” overlap with capacities that would facilitate active identification and treatment of TB cases. Efforts to strengthen public health capacities to improve TB control could not only help to decrease the global burden of TB, but also strengthen global health security more broadly.

The initial pot of money that the United States allocated for GHSA capacity building is running out, and future funding for the program is uncertain. In January, the Wall Street Journal reported that the CDC will be shuttering close to 80 percent of its overseas GHSA efforts due to dwindling funds.

A recent outbreak of multidrug-resistant (MDR) TB in Minnesota, which likely began with an initial case imported from abroad, killed several people and required contract tracing of hundreds of individuals, highlighting the importance of continuing to fund US efforts to contain infectious disease threats at their source.

While the Trump administration has proposed $59 million to support the GHSA, this investment is far from sufficient to support the development of capacities that could avert costly global and domestic epidemics. In responding to Ebola in West Africa the global community donated more than $3.6 billion. A single outbreak of tuberculosis in one Wisconsin county cost $5.6 million, alone. By comparison, restoring GHSA funding to its previous levels — $200 million per year — seems like a bargain.

Recognizing the threats that epidemics and pandemics, like those caused by Ebola and Zika, pose to national economies, the World Bank issued a report examining how to break the cycle of “panic and neglect” that seems to describe global reaction to such threats.

In the report, the World Bank calls upon national governments and development partners to invest in strengthening core public health capacities. As global concerns about Ebola and Zika trend towards the “neglect” phase of the cycle, an uptick of tuberculosis in Venezuela and an outbreak of MDR-TB in Minnesota are reminders that deadly infectious diseases remain a threat to health and economies, and the time to invest in preparedness is now.

Jennifer Nuzzo, DrPH, and Diane Meyer, RN, MPH, are faculty at the Johns Hopkins Center for Health Security​ at the Johns Hopkins Bloomberg School of Public Health and are members of the Outbreak Observatory project team. This article is made in a personal capacity and is independent of their affiliation with Johns Hopkins University.