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TB reclaims title of deadliest infectious disease. That's an 'outrage' says WHO

The ancient scourge of tuberculosis for years was the deadliest infectious disease. Then SARS-CoV-2 came along and grabbed the notorious title of #1 killer: In 2020, COVID-19 was responsible for 3.5 million deaths worldwide vs 1.5 million for TB.The 2024 Global Tuberculosis Report, published last week by the World Health Organization, puts TB back in the top slot with 1.25 million deaths in 2023 compared to 320,000 COVID-19 deaths. There's also been an increase of hundreds of thousands of new TB cases in 2023 compared to the year prior.

The 1.25 million TB deaths in 2023 is down from 2022’s number of 1.32 million (which that year was second to the COVID toll). But it's still indefensibly high, say public health leaders.

“The fact that TB still kills and sickens so many people is an outrage, when we have the tools to prevent it, detect it and treat it,” said Tedros Adhanom Ghebreyesus, WHO director-general, in a statement issued on October 29.

According to the report, approximately 8.2 million people were newly diagnosed with TB in 2023 — the highest number since WHO began global TB monitoring in 1995 and a “notable increase” from 7.5 million people newly diagnosed in 2022.

TB sleuths are trying to figure out the reasons behind the increase. Anand Date, global TB branch chief at the Centers for Disease Control and Prevention, says population growth may account for the increase in cases last year -- and that it may take until the 2024 to find out if that is so or if the leap in 2023 reflects an undercount of annual TB totals during the pandemic.

“Disruptions to TB programs during the height of the pandemic led to more people going undiagnosed and untreated for TB. [And] guidance to shelter in place may have also limited the spread of TB, says Yogan Pillay, who heads efforts to improve TB program delivery at the Bill and Melinda Gates Foundation (which is a funder of NPR and this blog).

COVID-19 did trigger a new setback in the effort to control TB. But most of the reasons the infection persists are frustratingly well-known, says Lucica Ditiu, executive director of the Stop TB Partnership. There's too little money for research, treatment. and patient care needs. And there's stigma that can keep the most common victims of TB, impoverished people including migrants and sex workers, from seeking help or being offered treatment.

In addition, health conditions like malnutrition, diabetes and smoking that can exacerbate TB and keep medications from being fully effective, says Luke Davis, a TB and HIV specialist at the Yale School of Public Health. “TB is unusual,” says Davis, in that most people who are exposed to the bacteria won’t progress to infectious TB. Only about 10% do, and they are usually among the world’s poorest people often with poor health to begin with, which exacerbates their condition.”

So what's the solution?

And that brings us to the Tedros point. The world knows how to vanquish TB — but is not doing a good job.

Money reigns as perhaps the biggest obstacle to conquering tuberculosis. A spokesperson for WHO tells NPR: “Compared with global funding targets for TB set at the 2023 U.N. high-level meeting on TB, there are large funding shortfalls for TB research as well as prevention, detection and treatment services. To close these gaps, more funding is needed from both domestic sources in the countries most impacted by TB and from international donors.”

Global funding for TB prevention and care decreased in 2023 from $6 billion in the three previous years to $5.7 billion and remains far below the yearly target of $22 billion, according to WHO.

What would more money bring? WHO cites expanded rapid diagnostic testing as critical. Then treatment can start sooner. And people wouldn’t have to travel long distances to a clinic then wait for days for the results.

Increased funding would also help reimburse families for lost wages and food and travel expenses incurred as they go for treatment. Those costs keep some patients and their families from seeking care.

The WHO report and other investigations also say that countries burdened by TB also have to step up and spend more money on prevention, diagnosis and treatment. A report by MSF/Doctors Without Borders published last month, for example, found that, only 5 out of 14 countries have adapted their guidelines — based on WHO recommendations -- to initiate TB treatment in children when symptoms strongly indicate TB disease, even if bacteriological tests are negative.

And increased funding would speed up the pace of research says the CDC’s Date. Funding for TB research has stagnated at around $1 billion per year, constraining progress, according to WHO. The target at the U.N. meeting: $5 billion per year by 2027. “The world also has the most promising R&D pipeline of new TB tools in decades,” says Pillay. “What’s needed now is greater investment to deliver on the promise of that pipeline and ensure patients and those at risk of TB have affordable and equitable access to these tools when they are available.”

Vaccines in the works

Pillay says there are more than a dozen TB vaccine candidates in clinical trials, including one whose late stage (stage 3) clinical trial is sponsored by the Gates Medical Research Institute. The trial began recruiting patients last March. That vaccine candidate is called M72/AS01E and if proven effective would be the first new TB vaccine in 100 years. The lone TB vaccine available now is not predictably effective in adults, and can cause a false positive result on TB skin tests.

But even an effective vaccine won’t do that much good if there aren’t funds to purchase it for countries impacted by TB. Janeen Madan Keller, deputy director of the Global Health Policy Program at the Center for Global Development, based in Washington, D.C., says that while Gavi, The Vaccine Alliance, pays for [a variety of] vaccines in some of the poorest countries such as Afghanistan, Burundi and the Democratic Republic of the Congo, some countries with high rates of TB are middle income countries, like Indonesia, and no longer eligible for support. Ahead of a TB vaccine’s approval, says Keller, there needs to be a better match of policy and funding.

“Often it seems that when we find a way to help vanquish TB,” says Lucica Ditiu, “we also find another barrier.”

Fran Kritz is a health policy reporter based in Washington, D.C., and a regular contributor to NPR. She also reports for the Washington Post and Verywell Health. Find her on X: @fkritz




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Safe street advocates don’t feel safe amid many car-related pedestrian deaths

By Keyshawn Davis

One October morning in 2019, 12-year-old Alena Wong got on her bike and headed to class at California Middle School. 

She followed her usual route. But as she crossed Sutterville and Mead Avenue, a high school senior driving a car struck her. The vehicle hit the back of her bike, she slid up the hood of the car and flew 10 feet in the air.

Wong sustained numerous injuries from the accident, including a broken femur, humerus, tibia, mandible, three of her teeth were broken into her jawline and she got a traumatic brain injury. 

Her father, Kevin Wong, said he found out Alena was involved in a collision and rushed to her location, at which point the police and paramedics had also arrived and were attending to her. He said Alena was taken to UC Davis Medical Center after the accident. 

“The driver was a senior at McClatchy,” Kevin Wong said. “He was actually on his way to school. He wasn’t breaking the law, he wasn't speeding. He was just driving in traffic and didn't see her. The sun was in his eyes.”

Alena Wong spent three and a half weeks in the hospital. She couldn’t remember much because of her traumatic brain injury, but as time went by she said her memory started to come back.

“My mom says I would ask, ‘Why am I here? What are we doing here?’ She'd answer me, 10 minutes later, I'd have to ask the same question because I just didn't remember,” Alena said. “She'd read the same chapter of a book to me every day until finally, I said, ‘we already read that. Why are you reading that?’”

Alena made a full recovery during her time at UC Davis Medical, her father said. During her time there, she underwent multiple surgeries plus physical and occupational therapy. By the time she left the hospital she was in a wheelchair and had to use crutches.

Although Wong survived her collision in the streets of Sacramento, that isn’t the case for many others. There have been 162 motor vehicle crash-related deaths this year, according to the Sacramento County coroner's office. Out of the 162 deaths, 16 were cyclists and 44 were pedestrians.

Sacramento Vice Mayor Caity Maple proposed a state of emergency at a City Council meeting in September as a result of the third fatal collision that occurred that month. 

“I’m devastated to see yet another person critically injured after being struck by a vehicle on Sacramento’s roads,” Maple said in September on social media. “Even beyond our City’s commitments to eliminate traffic deaths through Vision Zero, we need to take immediate and urgent action.”

Maple and her team have since been working on the proposal, which would require the city manager to identify funds for a public awareness campaign to educate drivers, cyclists, and pedestrians about traffic safety. It would also mobilize the Sacramento Police Department to ramp up enforcement of traffic laws on city streets. 

Ryan Brown, the chief of staff for Vice Mayor Maple, told CapRadio that the proposal is expected to be further discussed at the Nov. 12 Law and Legislation Committee meeting. 

“Our next steps include a series of meetings with key advocates and stakeholders (including experts in the field) who are helping make our proposal as strong as possible,” he added.

Advocates push for safety changes 

In 2021, Sacramento had the highest amount of total traffic fatalities and injuries compared to 15 other California cities with a similar population size, like San Francisco and Stockton, according to data from the California Office of Traffic Safety. The city was also in the top five California cities with the highest amount of pedestrian fatalities and injuries.

Sacramento Area Bike Advocates is a nonprofit that advocates for safe streets and bicycling infrastructure for the city. Executive Director Debra Banks said if the city had good bicycling infrastructure, it would help reduce collisions.

Banks said she’s “fearless” when she rides her bike and isn’t afraid of riding into traffic, but there are people she knows who avoid cycling altogether. 

“Those are the people that we'd love to make them feel safer, so that they would feel comfortable to ride their bike,” she said.

Banks said she was also once a victim of “vehicular violence.” Almost 10 years ago, she was hit by a 3,000-pound vehicle and was severely injured. But her experience spurred her toward activism.

“The person has paid the consequences [and] ended up going to jail. But that didn't make our streets safer,” Banks said. “It just took one person off our streets. The best way that we can make our streets safer is by changing the design of the street.”

She added she’d like to see road improvements like narrowing streets and increasing bike lanes, which makes cyclists feel safer and slow traffic.

In 2017, the city of Sacramento adopted a resolution called Vision Zero. This traffic safety policy doesn’t refer to car collisions as accidents; rather, it views them as preventable incidents that should be systematically addressed.

The Vision Zero Action Plan was adopted in 2018 with the goal to have zero traffic collision deaths in Sacramento by 2027. Banks said the city isn’t close to hitting that target. 

But Banks added she’s thrilled that there is momentum amongst the elected city council members to make changes with the state of emergency proposal. 

“That's great, but there has to be funding,” Banks said. “If there's no funding, then everything sounds great. We can draw up plans, we can sign a declaration, but without funding those streets aren't going to change because street design costs money, costs a lot of money, and Sacramento is low on funds for that.”

Slow Down Sacramento is a grassroots organization focused on increasing awareness of slowing vehicular traffic speeds. According to Executive Director Isaac Gonzalez, SDS advocates for changes to road infrastructure that make it less conducive for people to drive recklessly or at high speeds.

“The thing that we advocate for the most is changes to the built environment, because we know that through changes to the built environment, we get the results that we want,” Gonzalez said. “So narrowing lanes, decreasing the amount of opportunities for people to drive fast, making the lanes narrower, adding protected bike lanes, stop signs, that just make vehicles slow down.” 

Gonzalez said there have been “far too many people dying” on city streets, and said anyone who isn’t in a car is considered a vulnerable road user. 

“We know that crashes are going to happen. We know there's going to be collisions,” he said. “That's an eventuality with traffic, but the greatest thing that impacts whether or not that will be a fatal injury is speed.”

According to the Safe Transportation Research Center at UC Berkeley, speeding related fatalities increased in California by 16.5% between 2020 and 2021. Sacramento was in the top five counties in California for speed related fatalities and serious injuries in 2021. 

Gonzalez said as vehicle speeds go up, collisions are more likely to result in fatalities.

“If we could decrease those average vehicle speeds down to 25 miles per hour, or even 20, which would be better, we can really decrease the likelihood of a crash resulting in a fatality demonstratively,” Gonzalez said. 

City infrastructure is changing, but advocates say it could be done faster

The City of Sacramento has recently made a few changes to its streets, most notably with the Central City Mobility Project. The project includes protected bikeways and lane reductions. It has converted 5th Street from a one-way street to a two-way street as part of the project.

“That’s a new conversion. It's brand new, and it's fantastic,” Banks said. “Personally, as a cyclist and as an advocate, I would love to see every single road in the grid be turned back into a two way street.”

Banks added that SABA takes people on social rides around the city to teach cyclists about infrastructure. She said the process of learning how to navigate through the streets safely helps build confidence. 

She said many of these injuries happen at intersections: “People are doing right turns on red and if you're in a protected bike lane and it ends just as a car is coming up, they may not see you until the very last minute,” Banks said.

Gonzalez said SDS is advocating for the city to utilize quick-build tactical urbanism, which involves making rapid changes to a roadway immediately after a collision occurs. He added that these changes aren’t permanent — road workers can move pieces around to experiment with what works and what doesn't.

“When a crash happens in the city of Sacramento that results in a fatality, typically, nothing changes the next day,” he said. “Nothing may change for a very long time unless neighbors and advocates really press the city to do something.”

He said those changes could sometimes take a decade or more to happen. 

“We want the city to look at every instance of serious injury or death as it is an immediate, urgent remedy that must be required,” Gonzalez said. “We want the next day for cones and signage to go up, for temporary traffic calming measures to be implemented, and then, if successful, put in permanently. That's called tactical urbanism.”

The city of Hoboken, New Jersey has reached its own Vision Zero Action Plan goals after adopting this style of tactical urbanism. Starting in 2021, Hoboken immediately made changes to roads after serious crashes that resulted in injury or death. It hasn’t seen a traffic-related fatality on its roads since.

Over the last year, Hoboken has added multi-way stops at 14 intersections, six of which were identified as high-crash intersections. It’s also installed 418 delineators, which can help navigate drivers through hazardous conditions. An estimated 61 crosswalks were re-striped with high visibility markings, and 27 curb ramps were upgraded. 

In 2019, the New Jersey Department of Transportation awarded Hoboken over $730,000 for transportation funding, which the city used towards its Vision Zero infrastructure and safety upgrades. 

Gonzalez said he wants Sacramento to view this issue with the same urgency as Hoboken, and added it’s a solution the city can do for a lower price than permanent fixes. 

“I could go to a store today and buy the things needed to change traffic patterns on some of our hotspots and get the driver behavior that we want to see,” Gonzalez said. “But it takes policy, and it's not currently the policy in the city of Sacramento, so that's what we want to see.”

After Alena Wong’s accident in 2019, the city took some small measures to ensure that more people wouldn’t get hurt at the intersection. 

Kevin Wong, Alena’s father, said then-council member Steve Hansen’s office was working on installing a traffic light there, but it didn’t end up happening.

“They're telling us that maybe they can get something done, but ultimately, there wasn't any funding for that to get done. So nothing has been done since then,” he said.

Wong said he met with District 7 council member Rick Jennings earlier this year, who said it's his top priority to make the intersection where Alena was struck by a car safer. 

“They did say that they do want to put a mini roundabout, which is something that we have been advocating for,” Wong said.

Six months after Alena’s accident, she was able to start running and biking again. 

“She was eager to do so, in fact,” Kevin Wong said. “After leaving the hospital, physically she was able to make, I'll call it a 95% recovery. She has ongoing dental trauma.” 

Nearly five years later, Alena still rides her bike to and from school everyday.

“I remember while I was in the hospital, mainly my mindset was that I just needed to get back to where I was before, and having that one goal made it a lot easier to just push towards it,” she said. “Once it all slowed down and I looked back at it, I realized how hard it must have been.”

She said she’s realized recently that she’s glad it happened when she was 12 as opposed to the age of 40 because she can learn with her injuries, rather than have lived most of her life and then have to start a new one.

“I think that it's made a lot of who I am, like, how determined I was to get better again,” Wong said. “That's a lot of my personality now. I honestly don't know who I would be without having had that.”

Kevin said he and his wife were comforted by the fact that Alena wasn't afraid to face the fears that other people might have after her accident.

He added the family has made a habit of speaking at city council meetings, transportation-adjacent committee meetings, and various neighborhood association meetings to continue to advocate for traffic safety in Sacramento.  





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