Overcoming challenges to a TB epidemic

By Sophie Cousins 07 November 2016

Anti-tuberculosis medication issued by health workers at a TB screening in Haiti. Photo by: Pan American Health Organization / CC BY-ND

The World Health Organization’s 2016 global tuberculosis report found the burden of the disease is greater than previously thought, calling into question ambitious global goals to end the epidemic by 2035.

There were 10.4 million TB cases worldwide last year, up from the 9.6 million previously estimated. The disease also kills 1.8 million people each year, not the 1.5 million that was previously thought and cases of drug-resistant TB, which are more difficult and expensive to treat, have risen to half a million a year.

While there have been advances in helping to tackle the disease, including two new drugs to treat resistance, bedaquiline and delamanid — the first in almost half a century — and new diagnostic tools, TB research and development remains severely underfunded, according to the report.

Additionally, investments in low- and middle-income countries for TB care and prevention fell almost $2 billion short this year of the $8.3 billion needed. It’s predicted this annual gap will widen to $6 billion in 2020 if funding levels don’t increase, the WHO report found.

Innovative financing

Unlike diseases such as AIDS and malaria, the majority of TB cases are not confined to the world’s poorest countries meaning there is less funding available from wealthy nations, which donate money through international financing organizations such as The Global Fund to Fight AIDS, Tuberculosis and Malaria.

Experts acknowledge there needs to be an innovative financing revolution to get anywhere close to the money required to fight the disease.

The situation is “quite serious,” said Rob Dintruff, a global health lecturer at Northwestern University, at the World Conference on Lung Health last month in Liverpool, U.K. “It will take funding and innovation to have the impact we want to have in this area.”

“Current treatment programs rely on international funding, but funding has to be consistent with what a country can absorb,” he said. “Some countries’ ability to use funds properly has been impeded.”

Philanthropic endeavors, he said, were problematic because the process was slower and funding didn’t go far enough.

Another issue, he added, was the transition of emerging economies that have a high burden of multiple drug-resistant TB — patients resistant to at least two of the most powerful first-line anti-TB drugs — to middle-income countries, which meant they lost their financing from the Global Fund, including countries such as Albania and Turkmenistan.

While most low-income, high-burden countries receive funding for MDR-TB treatment from the Global Fund, treatment can cost more than 200 times more than regular TB drugs, placing additional burden on countries’ economies and health systems.

Digital health technology

Recognizing the shortfall in money, experts have focused on developing and implementing a range of innovative solutions using technology to improve treatment adherence to DOTS (Directly Observed Treatment, Short Course).

Completion of treatment is a major barrier to eliminating the disease because of its long duration, side effects and cost, if not covered by the public health system.

Dr. Richard Garfein, professor of global public health at the University of California, has been working on developing mobile phone-based interventions to improve patient adherence.

Traditionally, health care providers directly observe patients taking their anti-TB medication — a costly approach with many barriers including a lack of human resources, stigma and transportation costs — but Video Directly Observed Therapy, or VDOT, is providing an alternative option.

With VDOT, patients are observed for treatment adherence via videos they record and send via mobile phones to their nurses.

“DOTS is a good thing. We’re not trying to switch to something different, we’re trying to add flexibility,” Garfein said.

Research in the U.S. has found compliance rates between 95 and 97 percent among those using VDOT, along with high patient satisfaction rates.

However, challenges remain including the issue of privacy and network coverage.

Garfein said the ultimate goal was for VDOT to be implemented in high-burden, low-resource settings. Currently its use has been tested in the U.S., Mexico and Kenya.

“How will VDOT perform? Can it be used for other diseases other than TB? These are important questions that we need to answer,” he said.

Another cheap technology being used to improve adherence and retention is the 99DOTS solution being scaled up across India, led by Bruce Thomas, founder and managing director of The Arcady Group, a company that helps organizations address global health issues.

Given the rise in patients seeking care in the private sector and increasingly self-administering their medications without observation, the team at 99DOTS designed an envelope where medication is packed together with dosage instructions and when a dose is a taken, a hidden telephone number is revealed.

After taking the medication, patients make a free call to the number, reassuring health care workers the dose has been taken. Adherence records are then made available to all staff involved in the treatment program and automatic alerts and reminders to non-adherent patients and supervisors are also sent out.

As of October, more than 400,000 99DOTS envelopes had been produced and shipped to every state in India, with the help of the government and the WHO.

Latent infection screening

New mathematical modeling has found that just under a quarter of the world’s population has latent TB infection, or LTBI.

Given that 1 in 7 of the world’s population is on the move, experts agree investment in new tools to improve diagnosis and treatment of those with LTBI at risk of progressing to the disease is required if the Global Goals have any chance of being achieved.

However, while the WHO has a conditional recommendation to screen for latent infection in immigrants arriving from high-burden countries, there is no standard practice, with decisions made on a country-by-country basis.

The lack of standard practice is complicated by the movement of refugees from countries like Syria and Iraq, which have historically had a low TB prevalence.

“They come from low-burden countries, or at least they were low-burden before the war, [but] nobody knows what the situation is now,” said Dr. Alberto Matteelli, co-director of the WHO’s collaborating center for TB/HIV activities. “Asylum-seekers coming from a war zone are not normal migrants. Their itinerary of migration is very long, complex, full of deprivation, so it’s usually much more at risk of activation of latent infection compared to other journeys of other immigrants.”

But implementing an effective screening and treatment program presents myriad challenges, including cost-effectiveness, health system preparedness, human resources and stigma.

Given the lack of clarity on the issue, Matteelli said the European Union had given a mandate to the European Center for Disease Prevention and Control to prepare a guidance document, set for publication in 2017.

What TB interventions are working and how can barriers to successful rollout and upscale be overcome in practice? Have your say by leaving a comment below.

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About the author

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Sophie Cousins

Sophie Cousins is a health writer based in India. She was previously based between Lebanon and Iraq focusing on refugee health and conflict. She is particularly interested in infectious diseases and rural health in South Asia. She writes for international medical journals, including The Lancet, and for international news websites such as Al-Jazeera English.


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