he World Health Organization — the world’s most influential health agency — published its first-ever global priority list of antibiotic-resistant bacteria. It is a catalog of the 12 families of bacteria that the WHO says “pose the greatest threat to human health — and for which new antibiotics are urgently needed.”
More than an academic exercise, the document is an advocacy tool designed specifically to help decision-makers prioritize investments in pharmaceutical research and development. While the list is welcome, it contains an enormous flaw that requires immediate correction. The experts compiling the list failed to include Mycobacterium tuberculosis, the bacteria that cause tuberculosis (TB), even though TB kills more people than any other infectious disease and has developed such extensive resistance to antibiotics that WHO itself labels it “a crisis.”
WHO’s rationale for excluding TB from consideration is that “it is already a globally established priority for which innovative new treatments are urgently needed.” In other words, TB was not considered for inclusion in a list of global priorities because it is a global priority. This explanation defies reason.
Tuberculosis is a global pandemic. The WHO estimates that an astounding 10.4 million people contracted this airborne disease in 2015 (the last year with complete statistics) and 580,000 of them have drug-resistant forms of it. Only 1 in 5 people with drug-resistant TB gets diagnosed and treated. The rest remain sick and contagious for months or even years, spreading the disease to others before they usually die from it.
See related First Opinion: WHO’s new priority list of antibiotic-resistant bacteria looks beyond the scourge of tuberculosis
Drug-resistant TB is exceedingly difficult to treat. Individuals with it must take large amounts of uncommon (read: highly expensive) antibiotics for at least nine months and as long as two years. Among those who do manage to get access to treatment, only about half survive. Those who do survive commonly experience harmful effects from the medicine, such as organ damage and permanent hearing loss.
In the face of extreme odds, health care workers and patients are struggling to make the best use of what should be yesterday’s medicines. Almost all antibiotics used for treating TB were invented before astronauts walked on the moon. Only two new TB medicines have been approved since that era — bedaquiline in 2012 and delamanid in 2014 — and their access has been restricted to a small number of patients with the most resistant forms of the disease. Meanwhile, support for research into new TB antibiotics is low and declining. Current research funding is now less than a third of what is needed to bring new treatments to market.
That’s why the exclusion of TB from the global priority list is a sudden broadside to the TB effort. And it could not have come at a worse time.
We are poised to see what might be one of the most important breakthroughs in the fight against TB in decades: the first-ever meeting of heads of state specifically on TB. The release of the global priority list, in fact, was timed to coincide with a meeting of top health officials from 20 countries representing the world’s largest economies. In November 2017, national secretaries and ministers of health from around the world will meet in Moscow at a summit focused specifically on charting a response to TB. And next year, the world’s presidents and prime ministers will convene, for the first time in history, to negotiate and announce actions they will take to end the epidemic.
The decisions that national policymakers negotiate at these summits will have tangible effects on TB research and development budgets that will, in turn, affect the delivery of new antibiotics desperately needed to end the epidemic. That TB has inexplicably been left off a list designed to influence policymakers’ priorities, marked with the imprimatur of the WHO, sends a misguided signal that TB is not a priority, all evidence to the contrary.
As drug-resistance builds, the power of our antibiotics is fading. To be sure, we urgently need new antibiotics for treating the pathogens included in the WHO’s new global priority list. This list is a critical tool for educating policymakers, who often look to the WHO for expert guidance when crafting policies. It’s because the WHO’s guidance is so influential that its error in omitting TB from the list is so potentially damaging.
After publishing the list, WHO Director-General Margaret Chan issued a statement saying, “Addressing drug-resistant TB research is a top priority for WHO and the world.” The message is welcome, but likely to be lost in the future as policymakers reference the global priority list itself.
Fortunately, the WHO states that the list is subject to revision.
Rather than arbitrarily limiting the scope of the list, the WHO should evaluate a broader range of pathogens — including viruses, fungi, and other microbes — that are increasingly drug-resistant, and revise the list to portray a more evidence-based picture of public health research priorities.
José Luis Castro is executive director of the International Union Against Tuberculosis and Lung Disease.