Slow Progress, Big Plans on Tuberculosis

The 49^th World Congress on Lung Health held in The Hague, Netherlands concluded on 27 October 2018. Four thousand delegates from over one hundred countries gathered for five days to review progress, and sometimes the lack of progress, against what is now the largest communicable disease on the planet. Worldwide there are ten million new infections each year and 1.6 million die – approximately 4,400 each day.

 As HIV/AIDS has increasingly been brought under control, the death toll per year from tuberculosis (TB) has surpassed that from AIDS as annual deaths from HIV infection have fallen to approximately 1.3 million. However, while HIV is an infectious disease transmitted primarily through unprotected sex, TB is a contagious disease that like influenza can be transmitted through the air, although not nearly as easily as flu can be. TB is caused by a mycobacterium, a small bacterium that is much larger than a cold or flu virus and is thus more difficult to transmit. Still, TB is quite widespread with one third of the world’s population carrying inactive TB in their lungs. Tuberculosis is often transmitted in confined spaces where people live in crowded, unventilated conditions such as in prisons, but in the vast majority of those who are infected the disease is inactive. However, TB can be transmitted within the family and is especially dangerous for infants below the age of three whose immune systems are not fully developed and the elderly whose immune systems have declined.  

            Today, active TB is preventable and, in most cases, curable, except in some cases of multi-drug resistant (MDR) TB that is worryingly on the increase. Worldwide 95% of TB infections are latent or inactive, held in check by the immune system. When the immune system declines due to infection with HIV, other immune suppressive diseases, co-infections, or old age; TB acts as an opportunistic disease and can become active and transmissible again. Anyone who suspects they may have developed the active stage of the disease, which is often indicated by a persistent, otherwise unexplained cough should take a TB test. If they have developed active TB, they should seek immediate medical help at a government clinic. This is not only to protect their own life and health, but also to protect the health of their family, loved ones, and those with whom they closely live and work.

Besides a persistent cough lasting more than three weeks, the signs of active tuberculosis include coughing blood, chest pains or painful breathing, fever, night sweats, fatigue and unexpected weight loss. 

Since the advent of HIV, TB has become a fellow traveler. Almost half of active TB cases are related to immune suppression caused by HIV, and approximately a quarter of AIDS deaths are related to TB co-infection. That makes TB the number one co-factor in AIDS related deaths, especially in Southern Africa where the two diseases frequently co-exist.          

While your correspondent has attended over fifty AIDS conferences over the last twenty-seven years, this was his first TB conference, so he had a lot to learn. Besides HIV, numerous other health conditions increase the likelihood of stimulating a latent TB infection into becoming active and potentially dangerous to those in close contact. These include diabetes, smoking tobacco, silicosis lung disease that is suffered by many miners, pneumonia, and co-infection with other viruses including hepatitis, influenza, and cytomegalovirus (CMV). They also include severe kidney disease, cancer, malnutrition and living in overcrowded conditions. Essentially any conditions that lowers immunity, causes inflammation, or put additional stress on lung tissue can potentially trigger a latent infection into becoming active.

Tuberculosis has plagued mankind at least as far back in history as ancient Egypt, five thousand years ago, because signs of it have been found in Egyptian mummies. It has probably been in humans since man first domesticated cattle that carry a closely related lung disease. Through the first half of the last century TB was mostly untreatable and patients had to be isolated in sanatoriums for the protection of the public. However medical breakthroughs with antibiotics in the late 1940s finally produced combination therapies that cured the disease. However, due to various factors, some tuberculosis bacteria gradually mutated into drug resistant strains. Today world health experts are facing the major challenge of resistant and multi-drug resistant MDR-TB.

For whatever reason, almost no new effective antibiotic drugs have been developed to treat TB in the last thirty years. With the increase in MDR-TB, that raises a serious threat to world health. Thus the 49^th Union World Conference on Lung Health met one month after the United Nations convened a special high-level meeting to raise the priority in the worldwide fight against TB. Among other things, the UN meeting called for spending thirteen billion dollars a year by 2022 for treatment and care of TB patients and two billion dollars a year on research. The goal is to provide care for forty million patients worldwide by 2022 and provide preventative treatment to thirty million people by that year.

  Although overall TB is declining by 2% annually, it is increasing dramatically in some countries such as Russia. Southern Africa including South Africa, Lesotho and Swaziland suffer some of the highest rates of TB in the world, primarily because of the high rate of HIV infection in the region, but also because working as a miner is a major risk factor for silicosis, TB, and other lung diseases.

At The Hague conference The Union for Lung Health announced a goal of reducing TB deaths by 90% by 2030. This is impossible given the current rate of progress. There have been virtually no new drugs to treat TB for the last thirty years and multidrug resistant TB is on the rise. Although a number of new drugs are in the pipeline, when these new drugs may become available, how much they may cost, and what side effects they may have are all questions. The Union of Lung Health acknowledges that innovative new ideas are needed to achieve their goal.   

Your correspondent distributed a paper at the conference titled, “The Tuberculosis, HIV, Selenium Deficiency Positive Feedback Loop” that explains that both TB and HIV attack the body’s selenium supply and as a result, cause immune deficiency. Selenium supplements are an easy and affordable addition to TB and HIV therapies that increase CD4 white blood cell count due to selenium’s effect on the thymus gland where CD4 cells are produced. Higher selenium levels in the body help prevent inactive TB from becoming active.

While most conference delegates from Africa and Asia were happy to hear the positive news about selenium, many academic researchers from Western countries tried to dismiss the use of selenium against TB despite scientific evidence to support its use. These academic naysayers have adopted an ideology that only pharmaceutical drugs can possibly treat a disease. Of course, medical researchers have a conflict of interest on this issue since they benefit from drug companies funding their research.

There were two schools of thought at the conference concerning the use of selenium to boost the immune system against HIV and TB. One group endorsed a people centered approach to TB treatment supporting any fact-based initiative to improve patient’s health that actually works. The other group supported a pharmaceutical company first approach contending that only new drugs can help against TB - that is, keep the immune system out of the equation. But any objective, knowledgeable scientist readily will admit that the immune system is more powerful than any single drug.

Tuberculosis is three times higher in people with the lowest quarter level of selenium compared to the highest quarter level of selenium, and is thirteen times as likely in people with less than 135 CD4 count compared to a healthy CD four count – and selenium is proven to increase CD4 count. Thus in theory – but not yet proven - using selenium to increase CD4 count could result in up to a 60% reduction in TB worldwide. That would go a long way to achieving The Union’s goal of a 90% reduction in TB by 2030. New drug therapies finally coming on line also will be essential to achieving that goal, so an emphasis on new drug development is essential as well. It will take a duel track approach to achieve the goal of a 90% reduction within eighteen years.

What good are “new innovative ideas” such as immunotherapy with selenium if they are not rigorously tested and put into practice? In order to do that your correspondent is helping organize two small pilot studies of selenium against TB, the results of which should be presented at the next African regional conference on TB scheduled for Harare, Zimbabwe in 2019.

While the world conference primarily focused on tuberculosis, there were also a few sessions on asthma and the dangers of smoking tobacco. Interestingly, according to the Lancet medical journal, selenium is helpful in both treating asthma and in reducing lung cancer by up to 43%. Selenium also works as an anti-inflammatory and as a broad spectrum antiviral so it reduces most of the contributing cofactors in developing active tuberculosis. It helps to both prevent and treat pneumonia, another mycobacteria that, like TB, also lives latently in the lungs.

While tuberculosis has been around for millennia, HIV is a much more recent development. Yet TB has taken a back seat to the fight against HIV/AIDS with HIV taking five times the international funding compared to the fight against TB. Deaths from TB, the biggest killer disease of the last three centuries, have again surpassed the number of deaths from HIV. This imbalance should again shift more attention and funding towards the fight against lung disease.

The good news is tuberculosis is curable. It can be stopped. One of the biggest problems, as with HIV, is just locating the people who have active TB. If you think you or someone you care about may have TB, please visit your local government clinic to check it out. The life you save may be your own.   

Most TB cases are non-symptomatic so most people who are infected have no idea they are. If you have prolonged coughing for several weeks or any of the other early warning signs of TB, protect your health and the health of your family by promptly getting a TB checkup.

Working together we can bring the challenge of TB under control and eventually end the worldwide pandemic of tuberculosis. This will happen only if every person acts responsibly and contributes to this effort.

            So please act responsibly to protect your health and join the fight to conquer tuberculosis. If you have any symptoms, get a checkup today. Your family, community, and country will thank you.