Tuberculosis (TB) has now overtaken HIV as the world’s leading cause of mortality. There were about 10.4 million TB cases in 2016, despite the fact that TB is an old and often curable disease whose incidence declined in industrialized countries long before the introduction of the TB vaccine and anti-TB drugs. TB continues to disproportionately affect low-income countries. For those of us who work in public health, this is tragic — we ought to be moving forward at a much faster pace to end TB for good.
There is notable progress in the fight against TB. Treatment success rates actually improved from 70 percent in 2000 to 83 percent in 2015, while TB mortality reduced from 28 percent to 20 percent during the same period. However, these gains from several decades of investment in TB control are at risk for one primary reason: We are unable to detect all of the world’s TB cases. Of the 10.4 million cases of TB, only 6.3 million were found and the patients put on treatment. This means about four million cases were “missing” — undiagnosed and thus not treated. To have any hope of eliminating TB, we must act, and act now, to find these missing cases.
Address two pervasive bottlenecks
- Move beyond a vertical TB service delivery system. For too long, TB service delivery has been vertical and isolated — not integrated into the rest of the health system. Without integration, millions of people will continue to pass through the health service system without being screened for TB and therefore, these cases will remain missing. For example, a full package of TB and HIV services at one location, managed by one health care worker or team, also known as the one-stop shop approach, has shown an increased initiation of antiretroviral therapy and improved TB treatment outcomes.
- End the stigma and fear. The stigma attached to TB is as old as the disease itself, but is not irrational. The mode of transmission of the disease used to require that those affected be isolated while infected and contagious; the treatment involved lengthy hospital stays, with loss of income for adults. As a consequence, many people continue to adopt a posture of denial and delay care or seek lower quality care through the private sector or traditional healers. To find and treat undiagnosed TB patients, we need to do more to educate and inform them about the realities of the disease and its treatment: TB can be cured without a hospital stay and with little to no impact on jobs or family members.
What else can be done?
It will take time to integrate TB services into the health system and end widespread stigma and fear associated with the disease. While we are working on those goals, we should also focus on:
- Better understanding the epidemic. This can be achieved through mapping and size estimation of outbreaks followed by microplanning at district and community levels with vulnerable populations.
- Meeting patients where they are. An integrated, differentiated model of service delivery should be the goal. This must include linking both the public and private sectors and working with traditional health practitioners and faith-based providers.
- Putting data at the center of TB control programs. Ensure that data analysis is constant and feeds back into the program at site level. This is a tried and true method for improvement.
Reaching the millions of missing TB patients and reaching the goal of zero new TB infections is possible. More than half a century ago, humanity conquered TB in high-income communities. While research will continue to advance TB vaccines, diagnostics and drugs for treatment, we must pursue what we know is needed: Innovative models of service delivery and stronger community approaches to break the stigma and improve heath-seeking behaviors. We know that, through experience, this is possible. We have seen HIV transition from a vertical disease control program to an integrated chronic care model, with a continuum between the health facility and community. It is time to do the same for TB.