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No longer business as usual: Out of the box solutions needed to end TB

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Shobha Shukla, Citizen News Service - CNS

In May 2014, the World Health Assembly approved the WHO's new post-2015 global TB strategy and targets for tuberculosis, which aims to achieve the targets for 2035-- 95% decline in TB deaths and 90% decline in TB incidence rate compared with 2015--less than 10 TB cases per 100, 000 population, and the elimination of catastrophic costs for TB-affected households. It is a 20 years approach but also includes the expectation to have by 2025 new revolutionary tools like shorter and better regimens for TB and MDR-TB.

Global TB Report of WHO 2014
(Image by WHO)
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So essentially it gives 10 years to research to produce a new vaccine, a new treatment regimen to facilitate achieve the targets for 2035. Meanwhile by decreasing poverty and implementing all that is available today, one can hope to achieve by 2025 a 75% reduction in TB deaths and a 50% reduction in TB incidence compared with 2015--less than 55 cases per 100,000 population.

In an interview with Citizen News Service (CNS), Dr Mario C Raviglione, Director of the Global Tuberculosis Programme at the World Health Organization (WHO), said that, "There new are many new things in this new strategy which are about thinking out of the box to accelerate the decline in TB incidence and help to achieve our milestones for 2025 and the targets for 2035 for ending the TB epidemic."

This new strategy is based upon 3 pillars: (i) 'integrated, patient-centred care and prevention'; (ii) 'bold policies and supportive systems'; and (iii) 'intensified research and innovation'.

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Dr Raviglione said that, "The emphasis under the first pillar is upon early case detection, community involvement to ensure treatment completion, and prophylaxis for treatment of latent TB".

"One out of the box measure to detect TB early on (so as to minimize transmission of the disease from infected persons to others) is for the NTPs to map the TB epidemic--understanding which geographic areas and which groups/communities are most affected by TB and vulnerable to not only other diseases like HIV, diabetes but also to smoking and alcohol. This would not only help in early case detection, but also enable to do corrective therapy in some cases and thus reduce the pool of people with latent TB infection".

According to Dr Raviglione TB treatment must be supervised and patient centric so that patients get all the necessary support to complete the medication through community and civil society engagement, as well as through educating the people about symptoms. Communities have to empower themselves to take care of their own health.

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He clarified that although prophylaxis is an old intervention, it is now being proposed on a much wider scale than before.

"Prophylaxis is a difficult intervention as it involves people who are not sick. New guidlelines on prophylaxis not only promote isoniazid for 6/9 months daily but also a new regimen of isoniazid + rifapentine to be given once a week for 12 weeks. The latter regimen is much more feasible and user friendly. But the cost of rifapentine is high and WHO is working on getting the price reduced so that more countries could adopt it".

The out of box proposal under the second pillar is to have a much broader commitment from individuals (like Ministers of Health) and departments other than the National TB Programme (NTP) Managers for TB control. Without proper and well laid out policies and systems in place to help them, NTP Managers alone will not be able to change the TB scenario. Without proper systems in place, just biomedical approaches are not going to work in TB care and control.

Taking the example of India, he said that, "The Indian government must ensure that the mandatory notification system works and all doctors, whether public or private, notify all TB cases to the NTP. There are other systemic issues also like lack of proper infection control methods in clinics/hospitals especially in HIV/ART centres where people wait long hours in unhygenic conditions along with people coughing, thus exposing PLHIV to TB infection. It is also important to ensure drug quality and rational use of drugs to avoid creation of resistance".

Dr Raviglione is of the opinion that it is not just enough to provide free access to TB diagnosis and treatment. It also needs to be ensured that during the treatment period, the poor patients have access to some social protection type of mechanism that gives them the wherewithal to remain on treatment till the end and complete it.

So according to him, "Another out of box step would be for governments to take social protection measures that may not necessarily be TB centric, yet complement TB care and control. It For this there have to be inter linkages between various departments. WHO would want the Ministers of Health and NTP Managers to enter into a policy dialogue with Ministries of Finance, Social Welfare,and others to manage some social protection schemes, like giving incentives, free food pouches, free transportation to TB clinics etc".

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He gave examples of Brazil and Thailand where such programmes are already in place. Brazil is pushing very strongly in this direction and has begun to extend such schemes to TB patients. In Thailand the Minister of Health and NTP Managers together knock at the door of other Ministries to explore opportunities that get TB inserted into social protection methods, so that patients can benefit.

"So in the second pillar we are asking NTP managers to embark on discussions with higher authorities and other ministries. Social determinants of TB like poverty, bad housing, poor nutrition can be corrected only when these different Ministries and NTP managers work together. If we can remove people from poverty, this will benefit eradication of TB. Even though the focus on diagnosis and treatment remains very important, but from a political perspective we have to work on other things too".

"Collaborating internationally is important. Researchers/institutions from the US or UK will need the cooperation and collaboration of countries like India to develop better diagnostics and regimens. Right now we have two new drugs--Bedaquiline and refapitine and a new diagnostic tool--the GeneXpert. We must help countries needing them to implement them. So it is an international global call to national people to find ways and means on how to better implement new diagnostics and regimens. We are also calling for universal drug susceptibility tests in all countries which will help in controlling drug resistant TB," he said.

These out-of-box solutions assume greater significance in the context of the Global TB Report 2014, published by the WHO on 22nd October 2014, which shows that, of the estimated 9 million people who developed TB in 2013 (including 1.1 million people living with HIV), 56% were in the South-East Asia and Western Pacific Regions. India and China alone accounted for 24% and 11% of the total cases respectively. The report concedes that even though an estimated 37 million lives were saved between 2000 and 2013, the death toll from the disease is still unacceptably high (1.5 million people died from TB in 2013) and an acceleration in current rates of decline is needed to meet all targets.

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