SYDNEY – When Merinda Sebayang was undergoing treatment for multidrug-resistant TB in Indonesia – a nation with the third highest tuberculosis burden in the world after India and China – she would wonder about the tens of thousands of people living in poverty who couldn’t afford enough food for TB treatment to work, she said here on Tuesday. Those are the people, Stop TB Director Dr. Lucica Ditiu said, who “are not easy or comfortable for policymakers to look at.” Issues of poverty, stigma and discrimination against people infected with TB who have “very little voice or presence and come from the global south and not the north,” said Ditiu, contribute to the spread of drug-resistant forms of TB and pose serious threats to global health security, she and other international public health advocates and researchers said.
In a session devoted to the impacts of drug-resistant TB on collective global security against infectious disease threats, including antimicrobial resistance, experts said the struggle patients go through to access TB services “contributes massively to the AMR burden” and subsequently to weakened health security globally.
“Most patients go to up to six providers before being diagnosed,” Dr. Catharina Boehme of FIND said, which contributes to catastrophic costs for patients on top of further spread of disease.
To successfully combat the threat drug-resistant TB poses to global health security, tuberculosis responses need to put people at the center and tailor interventions to affected peoples’ rights and needs – this includes forgoing the traditional Directly Observed Treatment Short-course protocol which places undue burden on patients and is underpinned by passive case finding, Steve Graham of the Burnet Institute said. Passive case finding – in which the onus is on patients to present themselves to health centers for care and treatment – misses patients who don’t display typical symptoms and in places with weak health systems, and challenges patients to navigate the cascade of care, Graham said.
In comparison, active case finding in which health workers go into communities to systematically find active TB disease increases case detection by more than two-fold and increases bacteriologically-confirmed case finding by six-fold, Graham said.
“Population-wide active case finding is an issue of going back to the future,” he said, recalling that during the 1960s Australia was able to steeply reduce TB rates by requiring people to complete chest x-rays or be subject to a fine.
In addition to patient-centered TB programs, Ditiu said, Ministries of Finance need to be better engaged alongside Ministries of Health to increase resources not only for care and treatment but for research and development of new tools. “It’s a crime to have hope for bringing new treatments or compounds through the pipeline to see the light of day, then to not have enough money to see it through or not enough to scale up access,” Ditiu said.
Scaling up tuberculosis services will have a high up-front cost, Dr. Suman Majumdar of the Burnet Institute said, “but in the long term if the focus is on reducing transmission and disease, we’ll save money.” Currently, drug-resistant forms of TB cost the global economy up to $78 billion in losses, he said.
“We haven’t done anything to address drug resistance, TB in children, extra-pulmonary TB, and almost nothing in preventive therapy,” Ditiu said. “We are in a marathon where we’ve started way behind everyone else, and have to catch up to the front.”
Rabita Aziz is senior global health policy specialist at the Infectious Diseases Society of America, which produces this blog.