World TB Day: TB Eradication is at its tipping point

“Find. Treat. All. #EndTB”

24th March marks World TB Day, a day we commemorate the day Dr. Robert Koch identified the causative agent for TB i.e. Mycobacterium tuberculosis bacilli. This was a game changer as it opened way for the diagnosis and treatment of TB.

Tuberculosis (TB) is the ninth (9th) leading cause of death worldwide and the leading cause from a single infectious agent according to the WHO[1]. The bacteria that causes TB affects the lung tissues (pulmonary TB) causing impaired breathing, shortness of breath among other symptoms such as coughing, night sweats, fever, fatigue etc. Other tissues can also be affected e.g. the brain and in this case we term it military TB (MTB).

The global community mobilizes action and efforts to eradicate TB under the umbrella of different organizations such as the Global Fund, Stop TB Partnership, and WHO. On 24th March when the world marked World TB Day, the focus was on stepping up efforts towards commitments made by global leaders in 2018 to; scale up access to prevention and treatment, build accountability, ensure sufficient and sustainable financing, promote and end to stigma and discrimination and promote equitable, rights-based and people-centered TB response[2].

Daily, the world loses 4,000 people to TB and close to 30,000 people get infected. As grim as this may look, progress has been made considering 58 million lives have been saved since 2000.

In lead up to this years’ World TB Day, the WHO launched new recommendations for TB prevention[3] focusing on prophylactic treatment to stop onset of disease, avert suffering and save lives. This is on the backdrop of the fact that one quarter of the world population is infected with TB bacteria. These people are neither sick nor contagious but are at a greater risk of developing TB disease especially for those with a weakened immunity.

Kenya is among the 30 high TB burden countries as per WHO classification. This has seen some work being done to drive the agenda including a national prevalence survey in 2016/2017[4]. However, for such efforts to translate to outcomes, there is need for action. The survey found out that only 46% of people with TB will get diagnosed be put on treatment; men didn’t seek care even with suggestive symptoms which is attributed to negative health seeking behaviors, a prevalence peak among 25-34 year old age bracket suggestive of active transmission. It also found out that majority i.e. 83% of the study subjects who were diagnosed with TB were HIV negative contrary to public perception that HIV patients are more predisposed and bear the highest burden of the disease. It was also reported that the classical symptoms didn’t manifest in most the patients and thus was a drawback in terms of diagnosis where symptoms were a presumptive diagnostic criteria. Shortfalls in diagnostic capacity was also reported as a hindrance.

The theme for this year was as suited to the call which needs every person to play their part. “It’s Time” to act. The question then is what should be done?

Based on the findings of the survey and the current commitments that had been made by global leaders, we must act with speed in a structured and coordinated manner. Our focus should be on the end goal of TB eradication with all activities directed towards this. HIV/AIDs programs have been strengthened over years and this has granted HIV patients access to TB care because of the integrated structure. This leaves out the general public who are at risk as per the findings. It is therefore important to scale up screening for the general public to diagnose and treat positive cases. This will also help with tracing of contacts who form at risk group for preventive treatment as per the new WHO guidelines. Stop TB Partnership – Kenya, has been at the forefront of screening and advocacy for TB but this needs to be scaled a notch higher.

Reproductive, Maternal, Neonatal and Child Health (RMNCH) programs have for decades been at the forefront of action leveraging on capacity of community health workers (CHWs) and community organizations to improve service delivery, foster advocacy and drive the agenda for RMNCH. These have realized commendable results. Adopting such models backed with evidence of action is a sure way to scale action for TB. This would be through CHWs addressing stigma around TB, promoting health seeking behavior in the communities and linking suspected cases & close contacts with health facilities to start treatment. These can also serve as critical drivers in surveillance for TB considering case identification and reporting is a shortfall of the entire system.

Diagnosis is a critical component of TB treatment and management. However, because of the symptomatic criteria in diagnosis, low suspicion among clinicians in certain populations and lack of diagnostic capacity, most patients will stay undiagnosed. This not only impedes care for these people but also provides a reserve for the bacteria which is critical in transmission of TB, a finding from the study as well. There is need to build capacity in the clinical teams to be able to suspect, diagnose and treat TB patients. Where not possible there should be a robust referral system for cascaded care for these patients.

Globally, there has been a wave of advocacy for Public-Private Partnerships (PPPs) with sound arguments in certain spheres with equal proportion of maligned interests in the whole discussion. Backed with evidence the role of the private sector especially chemists and pharmacies in the healthcare sector cannot be overstated. In most instances, these serve as the first point of contact for most people with the healthcare system. With minor symptoms such as cough or fever, individuals will seek care from the pharmacy and because of low suspicion in certain cases, lack of structured diagnostic systems and referral mechanism these patients may not be diagnosed. This is a drawback to the overall efforts to eradicate TB. It’s therefore a sound investment to integrate such services into the overall healthcare system with backing from different stakeholders.

Other than these efforts, research and development must continue especially with the unprecedented wave of antimicrobial resistance (AMR). With an increase in number of patients with drug resistant (DR-TB) and multidrug resistant (MDR-TB) tuberculosis, there is need to develop new therapies or vaccines that would help in the fight. Efforts by Validate Network, are critical in such fronts with a need to scale these to local contexts to help collect evidence, develop a knowledge base and help in R&D efforts. These platforms not only provide young scientists opportunities to grow in their careers but a chance to impact the global health ecosystem positively.

We all have a role to play in eradicating TB. Failure to do our part is giving consent to the scourge and exposing ourselves and our loved ones to the very risk.

Additional resource: http://www.kelinkenya.org/wp-content/uploads/2018/04/TB-Data-Assesment.pdf

[1] The TB Burden in Kenya at a Glance: https://kanco.org/the-tb-burden-in-kenya-at-a-glance/ [2] World Tuberculosis Day 2020: https://www.who.int/news-room/events/detail/2020/03/24/default-calendar/world-tuberculosis-day-2020 [3] New WHO Recommendations to prevent tuberculosis aim to save millions of lives: https://www.who.int/news-room/detail/24-03-2020-new-who-recommendations-to-prevent-tuberculosis-aim-to-save-millions-of-lives [4] Kenya tuberculosis prevalence survey 2016: Challenges and opportunities of ending TB in Kenya: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6306266/