Article By Shobha Shukla, Bobby Ramakant on the concluded 2nd United Nations General Assembly High-Level Meeting on TB on 22nd September 2023. With the promise to end TB globally by 2030, it is vital to ensure that we diagnose TB correctly, treat TB correctly and prevent TB correctly – early and accurately.
What is the important entry point into the TB care pathway?
Unless we find people
with TB and put them on treatment, how will we be able to reduce avoidable
human suffering, and untimely deaths, and break the chain of infection
transmission? Finding TB remains the critical entry point to the TB care pathway.
Amidst the growing call
for finding new tools to prevent, diagnose and treat TB, are we using the best
of such tools we have today to the greatest possible extent? While we must
fully fund and support TB science for better new tools, it is no less a
compelling priority and a human rights imperative to ensure that all the new
evidence-backed technologies we have today, are maximally deployed and utilised
– everywhere. Scientific breakthroughs must be converted into public health
advances, no excuse not to do so.
A day before the United
Nations General Assembly High-Level Meeting (UNHLM) on TB was held on 22
September 2023, we read a piece of news from Papua New Guinea. The island
nation has 70 WHO-recommended molecular testing machines (Gene
Xpert - which requires semi-centralised infrastructure) to diagnose TB in each
of the 22 provinces or cities, but all are underused except
one which is installed in its capital city at Port Moresby General Hospital.
Despite 32% of those with TB not being diagnosed in 2021, all but one of its molecular testing tools lie underused in the country
in 2023.
Reasons cited for the underuse of Gene Xpert molecular tests were: “sputum transportation challenges,
road conditions, etc.” The real reason, which is not cited in the news, could be
that Papua New Guinea has deployed Gene Xpert which is not laboratory-independent and requires centralized infrastructure in place.
One wonders that why was
the existing WHO-recommended point-of-care, laboratory independent and
decentralized molecular test (Truenat) not deployed in Papua New Guinea
instead, to resolve issues such as, “sputum transportation challenges, road
conditions, etc.”
Are we missing a chance
to make a change?
Among the WHO-recommended
molecular tests, Truenat (made by Molbio Diagnostics in India) is the only
laboratory-independent, portable, and low-maintenance platform solution that
can replace microscopy for TB, and also perform multi-disease testing at the
primary healthcare level. It works equally well in secondary or tertiary
healthcare services too.
"Nigeria is in support of this action-oriented political declaration, which commits 2 providing diagnosis & treatment 2 45 million people, including 4.5 million children & TPT 2 45 million people between d years 2023 & 2027. " - Tunji Alausa, Min of State @Fmohnigeria #UNGA78 pic.twitter.com/qqaPKkdtDE
— Debriche Health Development Centre (@DHDCNigeria) September 22, 2023
Why are we knowingly
making the wrong choice?
Today, thanks to
scientific advancements, we have a far better and more proven choice to find and
treat TB. So why are a large majority of people with TB still getting diagnosed
using old archaic and inefficient tools (like sputum microscopy) and treated
with drugs that are toxic, far less effective, and have a longer treatment
duration? There is no reason why old tools, that are inefficient in preventing,
diagnosing or treating TB, should not be done away with when we have better
choices today.
Let’s do a reality check:
In 2021, globally 39% of people with TB were not
even diagnosed. During 2018-2021, a whopping 62% of those
diagnosed with TB did not get a WHO-recommended molecular test – instead, they
received the 140-year-old smear microscopy that underperforms to
detect TB. Despite having scientific evidence and WHO-recommended molecular
tests that have proven to work effectively, why have we not replaced all
microscopy tests with molecular tests by now?
A new vaccine for tuberculosis can be a game-changer, says Dr.@TerezaKasaeva, Director of the Global Tuberculosis Programme at WHO.#EndTB #UNGA pic.twitter.com/wHo5NoIofr
— World Health Organization (WHO) (@WHO) September 22, 2023
Perhaps, this is a moment
of truth - have we truly invested to ensure that a person with TB gets the best
of standard WHO-recommended diagnosis, treatment, care, and support? With the
gaping chasm between what we know works and what we do, how do we hope to end
TB in the next 27 months in India and 87 months
worldwide?
Is it not time for people
to demand that they be tested with WHO-recommended molecular tests and treated
with a one-month regimen for latent TB infection (TB preventive therapy),
four-month regimen for drug-sensitive TB, and a six-month regimen for
drug-resistant TB?
Rocking chair?
Every motion does not
result in moving forward. There is a price we pay if we do not use the best of
existing diagnostic tools or treatments: the price is so heavy and so inhumane
– and so avoidable – in form of more human suffering, untimely deaths, and more
infection spread. This is so unacceptable.
Put money where the mouth
is: Taking TB services to those unreached
The WHO, Stop TB
Partnership, national TB programmes, affected communities, and partners have
ably demonstrated that high TB burden countries can use innovative new tools to
screen and diagnose TB and link the people with TB to treatment and care. With the deployment of new innovative tools, not only were these projects able to find
more people with TB but also put them on lifesaving treatments.
Having the best of
molecular tests is not enough unless they are accessible and within reach of
all those who may be at risk of TB. The national TB prevalence survey of the
government of India (2019-2021) shows that half of those diagnosed for TB did not
have typical TB symptoms, but showed an abnormality in the chest X-ray, which
led to their TB diagnosis.
If we are to end TB, we
must ensure that all people are screened for TB and not just those who are
symptomatic.
UN High Level Meeting on TB 2023 |
In the 1970s, richer nations like Australia had screened everyone (not just those with
TB symptoms) and provided TB treatment to those found positive. Eventually
Australia could bring TB rates so low that TB was considered eliminated in the
nation. It is important to note that back then Australia did not have the
latest TB diagnostic tools we have today.
Now that @UN Member States have renewed commitments to #EndTB, we must convert words into genuine action.
— WHO/Europe (@WHO_Europe) September 22, 2023
We’ve got new diagnostics, shorter oral treatment regimens, accelerated efforts on a TB vaccine.
Our work is urgent!@NinaBerdzuli, @WHOPoland Representative at #UNGA pic.twitter.com/7mWyPxn6oK
More recently, a few
years back in some parts of Vietnam, all people were screened using modern
diagnostic tools for TB, molecular tests were provided to those with
presumptive TB, and those found with the disease were linked to treatment and
care. As a result of this, TB rates dropped by 68% in a period
of 4 years, said Dr Nguyen Binh Hoa, deputy manager of
Vietnam’s National TB Programme.
TB lab on wheels
Dr Arvind Mathur, WHO
Representative to Timor-Leste shared how an innovative approach – “TB
Laboratory on Wheels” – one stop mobile diagnostic van – is being used to find
the missing people with TB.
TB Lab on wheels has
taken TB diagnostics closer to the communities. It is equipped with digital
x-ray, WHO recommended molecular test Truenat, and electronic medical record
facility synchronized with Artificial Intelligence (AI) for reading the digital
X-ray films. This van is helping to screen TB among different populations
including high risk people and in villages and hamlets.
“We were looking at how to increase case detection
rate, how to go about screening large populations for TB in a short span of
time. This molecular diagnostic tool (Truenat) is much more easily accessible,
requires low maintenance, and gives quicker results. On one side we have
digital x-ray with AI that can provide us a very formal confirmation to some
extent about where the problem is, and then at the same time we could run the
molecular test (Truenat) to confirm diagnosis of TB, within the same settings
and look into drug resistance in relation to the next step to be taken,” said
Dr Mathur to CNS (Citizen News Service).
The impact: “In a short
span of time, around 7000 individuals have been screened with more than 600 people identified with presumptive TB. A 32% increase in
detection has been observed as a result of using this technology,” confirmed Dr
Mathur.
TB lab on wheels approach
is being adopted by many other countries (and customised to their contexts)
such as Cameroon and Bangladesh, among others. Now, the big van is just a big
car with a mounted Truenat molecular test and other best of TB screening tools.
TB lab on a utility boat
goes from islet to islet in the Philippines
Dr Samantha Tinsay,
Municipal Health Officer, Bantayan Municipality in Cebu, Philippines shared how
Truenat molecular test machines, along with Fujifilm portable x-ray, were kept
in a plastic tub and taken in a utility boat from islet to islet to screen and
diagnose people with TB. “Case detection went up by over 317% and
screening of presumptive TB went up by 1293%,” said Dr Tinsay.
It is not difficult to
imagine the huge positive public health outcomes if what Dr. Mathur and Dr
Tinsay have done in a limited manner was done on a larger scale in all high TB
burden countries. What is holding us back from doing so? We can tailor the approach
to find TB and treat TB in local contexts but if we continue to do ‘business as
usual’, we will miss this opportunity to make a real difference by using the
right tools at the right place and time.
Finding the missing
millions timely with appropriate tools
With TB elimination
targets far off the track, the sense of urgency and purpose should drive us to
turbocharge the deployment of the best tools we have to find and treat TB. We
also need to turbocharge the efforts to find better new tools to prevent, find
and treat TB too. This is not an “either/or” situation, but it is about doing
both with compelling commitment and urgency.
Finding new tools is one
part of the relay race, deploying them and ensuring full uptake of the services
is another. Full-scale deployment and uptake of new innovative tools to find
and treat TB globally will also pave the way for better rollout of new tools
that are in the research pipeline (if and when they come in future).
The 2nd UNHLM on TB
(although attended by only one head of nation, Zimbabwe, among others) ended
with an important political declaration. The next UNHLM will be in 2028. But the answer to the question “will we walk the talk on the promise to end TB”
will be written by us – especially donors and governments – if we can eliminate
the divide between what we know works and what we do.
It is high time to make
the right turn to end TB, so do we believe.
(Shobha Shukla and Bobby Ramakant are part of the
editorial team of CNS (Citizen News Service). Both are on the governing board
of the Asia Pacific Media Alliance for Health and Development (APCAT Media) and PRB
Public Health Reporting Corps.)
Shared under Creative Commons (CC)