Although the world has made unprecedented gains in combating tuberculosis (TB) in the past two decades, access, quality and equity in TB care remain a big challenge. The added burden of COVID-19 is threatening to reverse these gains. Early on, lockdown and movement restrictions led to a decline in clinic visits due to fear of contracting COVID-19. Now, overburdened healthcare systems continue to cause TB patients or those who are likely to have TB to hold back from seeking appropriate health care. This is particularly detrimental to TB patients who must seek and receive regular and regimented treatment for six months to a year to be cured. Recent data from high TB burden countries have shown severe declines in TB case notifications. Models developed by the STOP TB partnership are predicting there will be an extra 6.3 million TB cases and 1.4 million deaths occurring in the next five years.
The theme of this year’s World TB Day is ‘The clock is ticking.’ As we get closer to 2022 – the deadline for achieving the UN General Assembly High-Level Meeting targets – tremendous effort is required to close the TB treatment and prevention gap. Numerous interventions to end TB have been tested and shown success in the past few decades, but their scale up has been challenging. The time is now for national TB programs in high burden countries to urgently expand efforts and commit to carry out a mix of cost-effective, sustainable interventions.
Here are two recommendations for critical interventions to implement immediately:
1. Leverage community-based models
The World Health Organization (WHO) End TB strategy recommends the use of community-based interventions in the detection and management of TB. Evidence from many countries has shown that community-based case finding and direct observed treatment (DOT) increase TB detection and treatment success rates, while reducing levels of treatment interruption.
Prior to COVID-19, many high burden settings considered these to be useful strategies for TB patients who may otherwise delay seeking care due to stigma, lack of access to services, or negative perceptions of the quality of health care at facilities. COVID-19 has underscored the importance of patient-centered care models. National health programs that use community-based approaches have shown tremendous success in coverage and outcomes, such as Namibia. In 2020, Namibia’s Ministry of Health and Social Services increased community-based interventions quickly to provide care for TB patients notwithstanding the challenges of accessing care during the COVID-19 pandemic. According to the Namibian model, each TB patient is linked to a community health worker based in their community. The community health worker collects TB treatment on behalf of the patient from the health facility and can provide information, support, and healthcare screening for TB and other illnesses. The Namibian government has committed to continuing widescale community-based service delivery for TB post COVID-19, which is critical to meet national targets and global goals.
2. Adopt digital technologies
In recent years, the drive to move DOT for TB patients from the clinic into the hands of patients themselves has led to the development and testing of new digital technologies. Video observed treatment (VOT) for TB and monitoring devices for medication support are the most popular. VOT is an application that can be accessed through a digital device – such as a smartphone – and allows TB patients to record themselves swallowing their daily TB medication and transmit the video in live or asynchronous mode to a health worker. In 2017, the WHO endorsed VOT as an alternative strategy to DOT but the scale up of this intervention has been limited despite evidence from low- and middle-income countries that the intervention is cost efficient, feasible, and acceptable.
Since smart phone penetration and digital literacy rates are increasing worldwide, encouraging the use of VOT may improve access to TB monitoring and treatment for a larger group of people relatively quickly and easily. Synchronous and asynchronous video treatment options provide additional flexibility in resource-limited settings where internet services are constrained or interrupted. A 2020 study in Moldova demonstrated that VOT decreased nonadherence by four days per two-week period, reducing this from 5.24 days for DOT to 1.29 days for VOT. Treatment under VOT also costed patients 504 Moldovan Leu (approximately $28) less. In the U.S., the cost savings can be as high as $140,000.
Belarus is one of a handful of countries that started using VOT widely after a conducting a pilot in 2015 which demonstrated high levels of adherence to treatment and good treatment outcomes among a diverse group of TB patients. In 2019, the government introduced a new clinical protocol on diagnosis and treatment of TB that recommends TB health facilities provide either a smartphone or a smartphone application to implement VOT after a patient’s consent is obtained. According to Dr. Nino Berdzuli, Director of the Division of Country Health Programmes for WHO Europe, “Belarus is part of the WHO Europe’s innovative regional initiative on fully introducing oral, short-term video observed treatment of TB. This regional initiative covers 14 countries of the WHO European Region and is focused on producing quality evidence for future recommendations on TB.”
The Race to 2022
National TB programs ought to use a mix of interventions to ramp up TB efforts and meet 2022 targets. The WHO, the Global Fund to Fight AIDS, Tuberculosis and Malaria, bilateral donors, and implementing partners have a role to play in mobilizing resources, providing technical assistance when needed, and facilitating learning across countries to ensure global targets are met.
Community-based interventions are resource-intensive and thus best scaled for TB patients in harder-to-reach or underserved communities. To address cost implications, we recommend leveraging existing community resources by joining forces with other national programs such as those serving HIV/AIDS. VOT, on the other hand, is best carried out in urban and semi-urban settings among TB patients who are digitally literate and have access to mobile phones and reliable internet services. Applying the interventions as intended, close monitoring of TB outcomes, and continued investment in drug supplies and diagnostic capacity are key to achieving success.
National TB programs – alongside their global partners – need to ensure the needs and recommendations of TB patients and other relevant stakeholders are incorporated into the design and scale up of these interventions. The clock is ticking and opportunities to reach TB targets are being missed due to COVID-19 and other bottlenecks in the health system. Taking a two-pronged approach by immediately implementing community-based interventions and affordable, accessible digital technologies like VOT will get us closer to winning the fight against TB.
Posts on the blog represent the views of the authors and do not necessarily represent the views of Chemonics.
