Dr Michel Gasana & Dr Hugues Lago from the World Health Organization – Regional Office for Africa, spoke to Open Access Government about the status of tuberculosis prevention and the intention to end this epidemic in the region
In this interview with Open Access Government, Dr Michel Gasana & Dr Hugues Lago from the World Health Organization – Regional Office for Africa, reveal that tuberculosis (TB) is the thirteenth leading cause of death worldwide after COVID-19 and the leading cause from a single infectious agent, ranking above HIV/AIDS.
Find out in this interview why World TB Day is important annually as an opportunity to raise awareness about the burden of TB worldwide and the status of TB prevention and care efforts. Discover what priorities lie ahead concerning mobilising political and social commitment to further progress efforts to end TB.
Also, learn who is at the most risk of TB, what the global impact is, the symptoms and how it is treated. The discussion also picks up on how drug resistance emerges when anti-TB medicines are used inappropriately, through incorrect prescription by healthcare providers, poor-quality drugs and patients stopping treatment prematurely, for example. Finally, Dr Gasana explains how the WHO response to TB can be summarised, including a vision towards ending this epidemic.
Why is World TB Day important each year, as an opportunity to raise awareness about the burden of TB worldwide and the status of TB prevention and care efforts?
Each year, on 24th March, we commemorate World TB Day to raise public awareness about the devastating health, social and economic consequences of TB, which remains an epidemic in much of the world and to step up efforts to end this global epidemic.
Indeed, an estimated 10 million people fell ill with TB worldwide in 2020, among which, 5.6 million were men and 3.4 million women, with 1.1 million children, although the disease is preventable and curable. Of the estimated 10 million TB cases, 4.1 million, near half, were undiagnosed or not reported. It is urgent to mobilise international and national communities to find, treat and cure them.
TB is the second leading infectious killer after COVID-19 and the 13th leading cause of death worldwide. TB is now the leading cause of death from infectious diseases worldwide. It carries both deep economic and social consequences.
Besides, the African Region, home of seventeen (17) of the 30 TB high burden countries in the world, has made good progress in controlling TB, but it is not on track to reach the milestones of the End TB Strategy for 2025. The region has notified 1.4 million people with TB in 2020 and 44% of people with TB were undiagnosed or not reported. Drug-resistant TB remains a public health crisis with only one in three patients accessing treatment. Moreover, in Africa, 44% of the overall TB response remain unfunded and only 22% of existing resources come from domestic sources.
“Implementation at scale of the best available interventions for TB prevention, diagnosis and treatment, as well tracking the progress of the national response to TB should also be given priority.”
United Nations and countries made commitments to accelerate action to end TB and meet the milestones through WHO’s End TB Strategy, the political declaration of the United Nations (UN) high-level meeting on TB held in 2018 and the UN Sustainable Development Goals (SDGs).
What priorities lie ahead when it comes to mobilising political and social commitment to further progress in efforts to end TB?
Despite the toll of the disease, TB is not yet at the forefront of health priorities in countries. Engagement required from other development sectors to complement efforts made by the health sector is inadequate.
So, as recommended by the United Nations Secretary- General, in his 2020 progress report, to accelerate progress towards Ending TB targets, we must, first, fully activate high-level leadership to urgently reduce TB deaths and drive multisectoral action to end TB. Emphasis should be laid on promoting human rights and combatting stigma and discrimination, as well as ensuring the meaningful engagement of civil society, communities and people affected by TB. Also, we must urgently increase funding for essential TB services, including for the health workforce.
In addition, implementation at scale of the best available interventions for TB prevention, diagnosis and treatment, as well tracking the progress of the national response to TB should also be given priority.
The chances of the above happening require strong government leadership and strategic partnership to build a resilient health system, capable of carrying countries’ ambition to End TB by 2030, as part of the sustainable development goals. This is a commitment made by countries and governments that have to be made accountable for its achievement.
Tell us more about TB, the thirteenth leading cause of death worldwide and the leading cause from a single infectious agent, ranking above HIV/AIDS
As we said earlier, TB is the second leading infectious killer after COVID-19 and the 13th leading cause of death worldwide.
It was also the leading killer of people with HIV and a major cause of deaths related to antimicrobial resistance. In 2020, 1.5 million people died from TB, including 214,000 people with HIV.
TB is a bacterial disease caused by a microbe called TB bacillus or Mycobacterium tuberculosis. It is mainly transmitted via aerial routes from someone who has active TB (TB disease) and coughs. One person with TB, on average, throughout his or her disease, can transmit it to 15 people. Affecting lungs in the majority of cases, TB can also affect other organs, such as lymph nodes, meninges, peritoneum and bones.
As stated earlier, TB is a preventable and curable disease. Besides, 25% of people, globally, have TB bacillus in their body, in an inactive way. This is called latent TB infection. In the latter case, when the immune system is weakened for any reason, this might turn into TB disease. Therefore, people with latent TB infection are targeted with TB preventive treatment, widely available and effective.
Who is at the most risk from TB and what is the global impact?
More than 95% of cases and deaths occur in developing countries. All countries are affected by TB, which primarily affects adults in their most productive years, with all age groups at risk.
Vulnerability to TB could be perceived in two ways: the exposure to the microbe and the probability of progression of the infection into TB disease.
Regarding exposure, people in poverty conditions, living in crowded and poorly ventilated places are most at risk of contracting TB. These are the vulnerable people, including children, refugees, miners and ex- miners, prisoners and drug users who have limited access to basic healthcare services. Also, homeless people and individuals living in densely populated communities are especially at increased risk of contracting TB.
As for progression into TB disease, any factor which could weaken the immune system may cause TB disease, especially among people with latent TB infection. These factors are HIV infection, undernutrition, tobacco use, alcohol abuse and diabetes mellitus.
People infected with HIV are 18 times more likely to develop active TB disease. People with malnutrition are three times more at risk. Globally in 2020, there were 1.9 million new cases of TB due to undernutrition.
Alcohol use disorders and smoking increase the risk of TB disease by a factor of 3.3 and 1.6, respectively.
Most TB patients are among the low-income portion of the community. The consequences of costs related to TB treatment and care on household income can lead to further impoverishment. One of the three goals of End TB strategies by 2030 includes reducing to zero the percentage of TB-affected families that face catastrophic costs which are considered as a proxy of poverty. In the African region, in 2020, ten countries carried out a TB cost survey, with an average of 49% of TB affected households experiencing catastrophic costs. Poverty alleviation should continue to be an integral component of global TB control interventions to address both the clinical and socio-economic aspects of the disease.
What are the symptoms of TB and how is it treated?
Presumptive pulmonary TB describes any patient with a cough for two weeks or more, with or without fever, night sweats, loss of appetite, weight loss (low child weight gain), sputum production, chest pain, fatigue and hemoptysis.
Warning! In a person infected with HIV, presumptive TB is when the person has one or more of the following signs or symptoms, regardless of their duration:
• Adult: cough, fever, weight loss or night sweats.
• Children: cough, fever, low weight gain, tubercular contact with a bacteriologically confirmed case of TB.
Most TB cases are cured with antibiotics. But it takes a long time: at least six to 12 months for sensitive TB. After taking drugs for a few weeks, the TB patient will feel better, and he or she is no longer infectious to others.
Tell us also about how drug resistance emerges when anti-TB medicines are used inappropriately, through incorrect prescription by healthcare providers, poor-quality drugs and patients stopping treatment prematurely, for example.
Allow me to recall a few principles of antibiotherapy. To fight strong bacteria, it is recommended to use more than one antibiotic of a different kind to target different sites into the microbe. The medicine should be prescribed at an adequate dose that can kill the bacteria, and the duration of the treatment is set in such a way that, in the end, we can confirm the body is cleared from the microbe. These measures are taken to treat the patient and to avoid the development of resistant strains.
TB drug resistance in many ways is a man-made problem. Drug resistance is the result of inadequate, incomplete or poor treatment quality that allows the selection of mutant resistant strains. People in close contact with a DR-TB patient have a high risk of becoming infected with the same strains of bacilli and developing DR-TB (primary resistance).
Causes are multiple and can be linked to either healthcare providers or patients. On one hand, the healthcare provider could be held responsible for, for instance: inappropriate treatment, meaning prescription of the wrong treatment, not complying with treatment guidelines and also inadequate monitoring of patients on treatment, including poor management of adverse drug reactions. In general, this results from a lack of training on the management of drug-resistant TB. On the other hand, on the patient side, reasons for the emergence of drug resistance could be related to non-compliance with treatment prescribed, non-completion of the full course of TB treatment, sometimes because of irregular supply of some of the medicines prescribed for the treatment.
How would you sum up the WHO response to TB?
WHO’s role is first promoting the needful leadership to end TB globally, in defining the global TB agenda through the development of the End TB strategy by 2030 and advocating for the United Nations, first-ever, High-Level Meeting on TB in 2018, preceded by the Moscow Ministerial Conference. Another major role of
WHO is normative, in all aspects of the TB response. WHO also leads work on strategic information, tracking and reporting globally annually on countries’ progress towards the targets of End TB Strategy. WHO advocates for increased investment in TB research to drive technological breakthroughs and rapid uptake of innovations, regarding, for instance, diagnostics, treatment and vaccines.
WHO is working with governments and other partners to support action needed and to strive towards ending the TB epidemic in our region by following up and remembering the promises made at various global and regional fora, to step up policy, political and programmatic actions towards ending the TB epidemic by 2030.
WHO is supporting countries to put in place/reinforce the Multisectoral Accountability Framework for TB in African Region to address the agreed milestones and targets that are not on track as well as the socio- economic determinants of TB.
WHO is working closely with countries, partners, civil society, non-governmental organisations to adopt and roll out and ensure universal access to the WHO recommended rapid molecular tests as first-line tests for diagnosis for all presumptive TB cases and other TB guidelines.
WHO is supporting countries to strengthen monitoring and evaluation systems to track progress towards ending the TB epidemic.
