March 23, 2023 — Tuberculosis (TB) is the second deadliest infectious disease in the world—second only to COVID-19. The World Health Organization estimates that 10.6 million people became infected with TB in 2021, and 1.6 million died of the disease. TB is both curable and preventable.
To mark World Tuberculosis Day, two specialists on Credence’s Global Health Training, Advisory, and Support Contract (GHTASC) shared where they see challenges and opportunities for progress as they work with the global health community to reach those infected with TB, improve health outcomes, and save lives.
Ali Kwizera is a tuberculosis country diagnostics network advisor supporting the Office of Infectious Disease within the USAID Bureau for Global Health. Ali supported laboratory diagnostics networks for over 10 years for USAID and CDC-funded HIV/AIDS and TB prevention and treatment programs in Africa before joining GHTASC on the TB case finding team.
Sarah Cook-Scalise is a tuberculosis diagnostics advisor on GHTASC and supports the TB case finding team. She has spent more than 15 years working on tuberculosis and the treatment of drug-resistant tuberculosis. Her current focus is on how to make diagnosis and treatment more accessible and patient friendly.
What makes tuberculosis such a challenging disease to diagnose and treat?
Sarah: TB still carries some stigma. Patients don’t always come in for testing right away, and often unknowingly transmit the disease within their communities until they get very sick. It can also take a long time to get test results back. Sometimes, by the time we have a positive diagnosis, the health system has lost track of the patient. They are back to living their lives, working, trying to care for their families.
Ali: Many infectious diseases, including COVID-19 and HIV, have rapid diagnostic test kits (RDTs) available or self-tests that can be done at home. For TB, there are no at-home tests or RDTs. The patients must be identified through active case finding efforts and then screened and diagnosed. And the signs and symptoms are easy to miss for those with latent TB infection.
Sarah: Treatment for tuberculosis is also challenging. It requires several different drugs—many of them with serious side effects—and a minimum of four to six months of sustained treatment. But once an individual starts to feel better because their TB is improving, they may decide to stop treatment. This is one of the ways the disease grows resistant to the drugs used to treat it.
COVID replaced TB as the deadliest infectious disease, but it also affected efforts to diagnose and treat cases of tuberculosis. Where did you see the greatest impacts?
Ali: COVID-19 affected many healthcare programs, but it had a huge effect on TB. Because of the lockdown, it was not easy to identify TB cases, diagnose them, and initiate treatment. This led to a decline in TB case notifications. During that period, most programs were so focused on COVID-19– both health care personnel and the testing resources – that many other types of care suffered.
Sarah: Existing TB patients were also not able to finish their treatment or receive their medication during lockdowns. People were sometimes in lockdown at home with their families, which increased community-level spread in areas that had previously been successfully treating patients. As a result, we saw an increase in TB deaths for the first time in years. It has been really hard to see those setbacks.
Ali: Recently, I was interviewing some TB patients in Tanzania about the economic burden of coming in for treatment during the lockdowns and stretches without work. People were finding it hard to get their treatment, and to come to the facility for their monthly refills. That affected treatment monitoring, continuum of care, and treatment completion.
Sarah: We also saw supply chain issues affect drug availability. A patient could be on a drug for three months and then not have it for two weeks. That can be long enough for resistance to build.
Where is your work focused now? Where are you seeing reasons for optimism?
Sarah: There is some good news for sure. First, we are seeing the potential of a shorter treatment regimen—four months rather than six for drug-sensitive patients. And six rather than 9-18 months for drug-resistant patients. If we can have a patient cured of their very drug-resistant tuberculosis—a disease that may kill them—much faster, that means they are back to living a fuller life. They are also more likely to complete their treatment.
On the diagnostic front, there are still a lot of challenges, but we can more quickly and accurately diagnose and assess drug resistant strains. This means we can get more people on the right medications in the first place. If we can get people feeling better and give them more quality years, that’s a win.
Ali: One of the goals for USAID is to work with partners worldwide to reach every person with TB. We are working towards that goal every day. We support high TB burden countries by using the most accurate new rapid molecular diagnostic tools and using case data combined with geographic information systems (GIS) mapping to help distribute or redistribute TB diagnostic services. Placing testing and care resources close to those who need them greatly improves accessibility, availability, and utilization.