Where and how does TB fit into the AMR agenda?

by Gwen Knight

I feel sorry for TB. Somehow it always seems left out. At the infectious disease party, HIV would be the sexy one, COVID-19 the one starting up the karaoke machine and TB the quiet one doing tequila shots in the corner. And it’s the quiet ones you should watch out for.

TB currently causes more than a one third of all deaths attributable to antimicrobial resistance organisms. Yet it is not in the critical priority grouping of the WHO priority pathogens list for R&D of new antibiotics. Nor is it in the high or medium priority grouping. It is also not mentioned once in the recent annual reports of the Combating Antibiotic Resistant Bacteria Initiative (CARB-X). Nor is it mentioned in the latest Lancet Infectious Diseases Commission on AMR. I could go on…

What are the reasons for this exclusion? One often given is that there is a well-established TB programme with its own logistics and structures. How great! Can we harness them for AMR? Why not pull in TB to the AMR field and use these resources?

Another is that it is already a 'globally established priority' getting R&D for new treatments in other ways. But this doesn’t tally with estimates from the Treatment Action Group that less than 50% of the resources needed to tackle TB are currently being mobilised. Moreover, TB is just another disease caused by a bacterium. It needs new antibiotics like all the others. Yes, there is a long latent infection period, but other bacteria have long colonisation periods – why is TB set so separately?

Another which would appear more worrying is that often we seem to have a high-income slant on our AMR research seeing drug resistance as a problem for hospital patients. This biases our view towards those pathogens linked with nosocomial infection.

Or others would argue that it’s not fully excluded. For example, the WHO priority list has a whole chapter on TB in the full report, but it is literally a footnote to the main colour-coded table that is widely cited for this list. This is almost what worries me the most – this bacterial disease is a priority, but a different one to other bacterial diseases. Get back in your corner TB.

By constantly viewing TB as some 'other' we as an AMR community may not be able to harness the systems and the insights gained from tackling this global disease. TB, our biggest infectious disease killer before COVID-19, will suffer by being excluded from many AMR initiatives.

An open question is how much this matters? I feel that research silos are a problem, LSHTM is designing open plan offices to prevent them, but could it be that with enough awareness the detrimental effects can be minimised?  In a recent presentation, the Director of the AMR Global Coordination and Partnership of the WHO, Dr. Haileyesus Getahun, discussed how AMR should and could learn from the 20+ years of TB data gathering and programmes. It’s great to see this and to hope that despite silos we can tackle AMR and TB together. 

To read more on this, see the result of interesting discussions between myself, Richard White and Mario Raviglione on the TB / AMR intersect here, and work from others at LSHTM on this intersection here. The NY Times also recently had a great article on “The Biggest Monster’ Is Spreading. And It’s Not the Coronavirus” about TB, which further highlights the importance of drug resistance in TB.

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