containment - lecture 6 - Innovating in response to tuberculosis - social science

tuberculosis

• hand in hand with HIV

• Drug resistant strains - only 1 in 9 patients with this strain is successfully treated

• it is curable → but care is too often of low quality

• long complex care pathways

• stigma and discrimination

• TB is the worlds deadliest infectious disease → 10.8 million fell ill in 2024. of these 400 000 got the drug resistant strain. 1.25 million died 

missing million

• every year 3.5 people are missed → remain undiagnosed and untreated (children, poor, malnourished) 

  • people with limited or no access to healthcare

  • people who are not aware treatment is available and accessible

  • people prevented from seeking care because of stigma (combined stigma with HIV and TB)

  • people with incorrect diagnosis or treatment

  • people who are being treated for TB without being notified to national TB programs.

diagnosing TB

• sputum microscopy (depends on the quality of the reader, often inaccurate, can not see which strain)

• chest Xray - see scarring of lungs, not clear if it is active disease

• culture based tests - not very accessible, available in big cities, take long to diagnose (gold standard for testing for drug resistant strains)

new tests;

• urinary LAM testing (can only diagnosis very advanced HIV and TB). this is a dipstick urine test 

• molecular tests - PCR

• gene expert, truenet → molecular tests (have changed the game quite a bit). 

TB vaccination

• BCG vaccine

  • over 100 years old

  • only this one vaccine

    • incomplete protection - works best in young children - not in adolescencce and adults (these groups often have tb)

covid and TB

• people did not want to go to the healthcare facilities - scared of covid

• significant amount of TB funding went to covid

help funding of TB

• often comes from the USA and Switzerland

• very political

• different countries have different guidelines for TB

  • WHO recommends the countries how to act

  • global TB report helps for these guidelines being made

  • GRADE approach → assemble group of global experts and these get scientific evidence. based on the evidence the guidelines are made. WHO give global recommendation.

US TB funding cuts

• WHO reports that there is dismantling of essential services in 30 highest TB burden countries

• break down drug supply chains

• lab services disrupted

• potentially >2 million deaths in the next 5 years if the funding is not restored

• before funding cuts → very hopeful to diminish TB

  • UN highlevel meeting (UNHLM). the heads of state meet and they intended to produce concrete commitments to action.

inequality, equality, equity and justice

• inequality → unequal access to opportunities

• equality → evenly distributed tools and assistance

• equity → custom tools that identify and address inequality - deficit model - adjustments for individuals

• justice → fixing the systems to offer equal access to both tools and opportunities.

equitable response to TB

• people most affected by TB face systemic disadvantages related to poverty, gender, age, socio-economic position, race, ethnicity, geographical location, migration.

• TB itself imposes catastrophic costs, food insecurity (drugs make you hungry), revenue loss and discrimination, all of which compound vulnerability.

• inequities in

  • testing

  • access to care

  • social protection

policy language on equity

• recent policy of TB focuses on equity

• recognizing unique challenges faced by vulnerable populations

• need to address the social determinants

• advocate for universal access to TB services

• suggest a multisectoral approach

however

• no clear definitions and accountabilities

• existing targets of succes remain centred on Dx and Rx

DOTS

• Backbone of TB treatment

• Directly Observe Therapy → directly observe the patient take the medicine

  • the antibiotics need to be taken 6-9 months and you can not abandon antibiotics.

  • after 2 months you start to feel better → idea is that people will stop taking the drugs then → Big problem

  • thus patients need to come to the hospital to take the drugs there.

• but DOTS providers started faking the numbers.

• DOTS really challenging for patients → missing work, daily seen at TB clinic

• healthcare workers also challenged. They had higher workload.

history of TB treatment

• sanatorium bed rest → thought TB was a hereditary disease

• in 1940 discovery of anti TB drugs → changed control efforts, bacterial cause for the disease, however, still hospitalization for over a year

• 1950s; madras study → looked at patients who were hospitalized and patients that didn’t. there wasn’t any difference between the groups. they did see that patients in hospital sometimes did not take the drugs

  • so the need for observation of treatment also in hospital

• earliest examples of direct observation therapy (DOT) → revolutionized global TB strategy.

• countries abandon hopitilization

• 10970s → further developmetn DOT

• 1963 → rifampicin (core TB drug) was made → seen as the magic bullet

• 1968 →m largest controlled trial of BCG → BCG is ineffective in controlling transmission (not effective in adults)

• confirmed view that TB is a managerial problem that can be solved with drugs.

• after thiss all efforts were concentrated on improving treatment.

• 1983 WHO introduces DOTS

• 1993 → WHO declares TB s global health emergency. and actively markets DOTS as the global TB strategy

how did countries adopt TB treatment strategies

• implemented through loans of the world and bilateral donors.

• get the loan but you have to implement DOTS.

• national policymakers could not make there own policies anymore.

• lot of critique on DOTS because at the core there is only the drugs. no attention to the socio cultural aspects or different needs of patients (maybe they can not come to hospital). concerns for dignity and autonomy.

• Evaluation of RNTCP by WHO & donors on DOTS: based on global targets (cure & detection rate), and NOT on contribution to health system strengthening

TB in India

• 1947 → nation wide disease control prphrammes

• 1961 → national TB programme 

• 1997 → revised national TB control programme with DOTS

  • international detour of ideas → main principles DOTS developed in India → world bank would give loans if this was implemented

  • DOTS was implemented worldwide but does this actually increase quality of access (care)

digital technology and TB treatment

• KNCV has ASCENT research project on digital adherence tech

• but they found no effect on unfavourable outcomes

gene xpert

• TB molecular diagnostics - PCR reaction

• would revolutionize TB control → silver bullit

• quick diagnosis of TB and DR-TB (drug resistant of rifampicin)

• cut diagnostic and treatment delays

• ability to run in primary care levels, easy to use.

• ability to diagnose in 90 minutes.

BUT

• rarely used as an initial diagnostic test

• expensive

• no real cut in delays of testing (can only test 4 people at a time)