Q&A: The need for flexibility and innovation in TB care — now more than ever

How has COVID-19 impacted people living with TB and why might now be the time to innovate for improved patient care? Photo by: Johnson & Johnson

In the midst of COVID-19, now is the time to innovate when it comes to improving access to treatment for people living with tuberculosis, says Saurabh Rane, an extensively drug-resistant, or XDR, TB survivor living in India and an advocate for TB elimination.

A combination of antibiotics can cure most TB patients in around six months, but current lockdowns and travel restrictions have limited access to TB diagnosis and care. This could contribute to what the Stop TB Partnership estimates could be an additional 6.3 million cases and a further 1.4 million deaths as a result of COVID-19 over the next five years.

As an illness that affects lung capacity, it’s also thought that people with TB who contract COVID-19 won’t respond as well to treatment. In 2018, TB killed 1.5 million people.

Multidrug-resistant TB and extensively drug-resistant TB

Of the estimated 10 million TB cases in 2018, about 500,000 developed a drug-resistant strain. MDR-TB means that the disease does not respond to the two most powerful TB medicines: isoniazid and rifampin.

XDR-TB means that aside from the resistance to isoniazid and rifampin, there is resistance to additional TB medicines. Around 8.5% of MDR-TB cases are considered XDR.

Rane said the pandemic has highlighted the rigidity of health systems and says now is the time to innovate and introduce more flexibility so that TB patients can get the care they need.

“Do what it takes, go online, help [people with TB] figure out when to book appointments, keep it flexible, and also be open to accepting new innovations because the truth is, we have to do what it takes right now to make sure that the patient gets what they need,” Rane said.

Speaking to Devex, he explained further how COVID-19 is impacting TB care, how innovative solutions can be brought to scale, and why Johnson & Johnson’s QuickFire Challenge focused on DR TB is giving him hope.

This conversation has been edited for length and clarity.

Would you say COVID-19 has presented a different set of challenges for a person living with DR-TB?

It has definitely caused a lot of destruction, primarily because people can't step out. When you're a DR-TB patient, there are routine tests [and] consultations that you have to get done. Now the health systems are so overwhelmed with everything, there's just no space for such patients. Not just that, even people who live in rural areas have to go to cities because of the local restrictions [and some] are not able to do that.

And the biggest component is injectables. You need a health care person to administer injectables for the DR-TB patients and that's extremely challenging — demonstrating the importance of transitioning to all-oral regimens recommended by the World Health Organization.

All of this is just the medical aspect of it. It's a whole different mental health ballgame. A lot of patients, because of the stigma, find their sense of freedom in stepping out of the home and engaging in outdoor activities. They're unable to do that right now because of COVID-19 and that's very suffocating mentally for a lot of patients.

How do you think these challenges can be overcome and what, if any, signs of progress are you seeing in your community and globally?

I think primarily the whole anxiety about not having answers to questions because of COVID-19 can be solved by communicating. A lot of these issues can be simply sorted out through communication. Just open up both channels, let people talk to the government stakeholders, let the government stakeholders understand people's issues and they can tackle them. Unless you know what the problem is, you can't solve it.

Secondly, just think about how you can take the services to the patients versus how it was happening before when the patient had to find his way to get the services.

Drug-Resistant Tuberculosis Lifeline QuickFire Challenge

Earlier this year, Johnson & Johnson’s Global Public Health team, together with Johnson & Johnson Innovation made a call for innovative proposals for creative, easy-to-implement ideas in helping to address continuity of DR-TB care for patients in high-burden countries during the pandemic. Five awardees received grant funding of $50,000 each and the opportunity to engage with experts at the Johnson & Johnson Family of Companies.

Awardees included:

India-based nonprofit, Doctors for You, which uses telemedicine and delivery services to continue providing critical DR-TB care services remotely.

The Philippines’ De La Salle Medical and Health Sciences Institute, where health workers developed a smartphone application to support treatment compliance by allowing caregivers to review patient dosage information.

Kenya-based Keheala, which uses behavioral economics and basic feature phones through digital adherence technology to support patients throughout their treatment process.

TBpeopleUkraine, which is scaling up the OneImpact application. This aims to empower the TB community by supporting adherence and implementing a patient-centered approach to treatment and care.

The ZMQ Global team in India, which has developed a mobile toolkit that uses video observed therapy to empower patients with adherence reporting and to connect them with remote health consultations and emergency care.

Do you think changes to the way care is delivered to DR-TB patients during COVID-19 could help act as a catalyst for improved access to care even after the pandemic?

Definitely. I think one thing the pandemic has shown us is how broken our public health systems are. I think solutions are here to stay because now everyone's realized that it doesn't have to be done in such a rigid way and we can be flexible with how we administer care.

I believe that now is the time to innovate and figure out how we can fight these issues, because the pandemic has accelerated the need. We were going to get to this some point in the future, but it looks like the pandemic forced us to take the shorter path. Hence, I feel like these solutions are going to be there for a longer time, even when the pandemic ends.

I also think it's time that we sort of decentralize the whole care delivery model. The more local it's going to be, the more empowering, the more in control the patients are. It has a shorter turnaround time for delivering the solutions that we need — and just having local peer support, someone that you can talk to or meet in person, someone who is right there around you, is a very tangible thing for patients. Building local systems, which can then talk to one centralized system and show us that, while the central government or the central agency has control over things that are going on on the ground, the local control enables people to deliver care much faster, raise issues much quicker, and also troubleshoot them at a very fast rate.

As a judge for Johnson & Johnson’s QuickFire Challenge, how positive are you that innovative solutions for increased access to DR-TB care will come about during this pandemic?

I was super excited and very happy to see all the entries that came in. [There were] so many innovative solutions. The enthusiasm and the will to push and find a way to help the patients was just amazing.

I am very positive about this because these innovators seem to have plans to get to the patients as quickly as possible. I think that’s what’s really exciting about this challenge.

What do you think it will take to bring such new innovation and approaches to scale?

The first thing would be for the large system to accept that change is good and that we have to make changes and these innovations are just small ways to showcase that.

Secondly, I understand that these experiments of these innovations should have some space in the larger system. If you can accept that, then make the system more flexible, give them the funding that they need, and actually invest in these things for scale-up. Again, if the pandemic has taught us one thing, it’s that we need to invest more in our public health systems. These innovations could definitely be a start and that's how we can get them to scale.

Read more about the innovations coming out of the QuickFire challenge.

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