TB and women: a call to action

The Lancet, 2010

Pulmonary Research and Respiratory Medicine - Open Journal, 2017

Tuberculosis still remains an important global health disease, killing many people annually. Yet it is a preventable cause of death. Maternal mortality rates due to tuberculosis and HIV/AIDS in Sub-Saharan Africa make up a significant proportion of maternal deaths. It remains a disease of poverty, overcrowding and underdevelopment. Pregnancy increases maternal and fatal mortality in AIDS-infected women. In pregnancy it can be a challenging diagnosis to make, delaying treatment that could lead to adverse outcomes. Clinicians working in high prevalence areas of tuberculosis and those looking after immunocompromised patients should maintain a high index of suspicion. Developing countries must be helped to develop by the world financial institutions with debt reduction. The Sustainable Development Goal aims to end tuberculosis related deaths, transmission and catastrophic costs by 2030. Tuberculosis is a preventable death, the world must act together to prevent unnecessary deaths.

Multidisciplinary Respiratory Medicine, 2010

Paediatrics and International Child Health, 2015

2020

INSTITUTIONAL AFFILIATIONS: BM University of Sydney and The Children’s Hospital at Westmead, Sydney, Australia Email: [email protected] FA The Indus Hospital, Karachi, Pakistan. Email: [email protected] AG Center for Clinical Global Health Education, Division of Infectious Diseases, Department of Medicine, Johns Hopkins University, Baltimore, USA. [email protected] MB Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA. Email: [email protected] KS Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; Email: [email protected] EN The National Institutes of Medical Research, Dar es Salaam, Tanzania. Email: [email protected] AH Desmond Tutu TB Research Centre, Stellenbosch University, Cape Town, South Africa. Email: [email protected] MC Department of Medicine, Therapeutics, Dermatology and Psychiatry, Kenyatta University, Nairobi, Ke...

The Lancet

this decline reflects a substantial progress in the number of patients diagnosed and treated. Moreove, it aslo occurred as poverty-related drivers of TB decreased and economies grew. As evidence of this Ethiopia, Viet Nam, Zimbabwe and Côte d'Ivoire all achieved annual average rates of decline in TB mortality of more than 6% between 2000 and 2017 (Table 1). This progress aside, however, TB mortality rates, especially among people living with HIV and in children are still substantial. 5,6 Furthermore, rates of TB mortality have declined much more slowly than for most other infectious diseases (Appendix Table xx), and the declines are far less in lowand lower-middle income countries compared with elsewhere (Table 2). Three-quarters of all TB deaths occur within just eight countries (Appendix Figure xx). In many parts of sub-Saharan Africa and Southeast Asia, TB remains a leading cause of years-of-life lost. Moreover, TB ranks as the 9 th leading cause of death and the 12 th leading cause of years-of-life lost worldwide. 7 TB incidence: An estimated 10 million people (90 percent adults, 58 percent male) became ill with TB in 2017. Eight countries in Southeast Asia and Africa (India, Indonesia, China, the Philippines, Pakistan, South Africa, Bangladesh and Nigeria) accounted for two-thirds of all new cases worldwide. Overall, TB incidence has fallen approximately 1.4% per year since 2000 and 2% per year since 2015-far less than the rate needed to achieve WHO End TB targets 5 (an annual incidence rate decline of 4-5% by 2020 and 10% by 2025 to achieve the milestone case reductions) and less than declining trends in mortality. The overall slow decline in TB burden suggests that TB programs, while reducing deaths, are insufficient to overcome poverty-related drivers that substantially impact the epidemic. 8 Modeling suggests that to avert transmission, individuals at risk must be identified and provided effective preventive therapy, and individuals with less infectious, early TB must be diagnosed and provided immediate treatment. 9,10 TB Prevalence: Between 2000 and 2016, 32 national TB prevalence surveys were performed in 26 countries. 5 These studies consistently found a higher prevalence of TB than previous estimates based on less precise information such as case notifications. The upwardly revised incidence estimates highlighted large numbers of undiagnosed or unreported TB cases in many countries. Prevalence surveys also revealed that people with TB often sought care for TB symptoms that health care workers failed to identify. Other individuals did not recognize the seriousness of their symptoms and had not sought care. All prevalence surveys in the last decade have found a higher burden of TB among men, with male:female ratios ranging from 1.2 (in Ethiopia) to 4.6 (in Viet Nam). 5 The higher global disease burden in men-estimated to be 1.8 times higher than in women 5-combined with larger detection and THE LANCET COMMISSION ON TUBERCULOSIS 5 reporting gaps highlight gender differences in accessing care that may be related to both financial barriers and stigma. 11 The differences also suggest that male-friendly strategies to improve access to and use of health services are required. Why haven't we made more progress over the last quarter century? The lack of progress against TB over the last 25 years has resulted from a mix of political, societal, scientific, and strategic shortcomings. These include health system frailties; lack of investment in control efforts, and in research towards developing new medical tools; reliance on simplified, one-size-fits-all approaches that fail to meet the different needs of individual patients; biological factors, such as HIV coinfection and the spread of drug resistance; and the huge and persistent reservoir of latent TB infection are all to blame. Moreover, TB is also 'a disease of the shadows,' disproportionately affecting those communities with the least powerful constituencies to effect change. Lack of investment and political will-Deaths from TB fell rapidly in western Europe and the United States as living standards improved. The combination of a decline in TB cases in high-income countries and the lack of a powerful civil society voice in high-burden countries has undermined efforts to garner the same political support or domestic investment as for other diseases. Failure to appreciate the profound negative economic impact of the epidemic and advocate for increased donor financing in highburden, low-income countries has hampered efforts. In many of the highest burden countries, chronic under-funding and lack of political will have profoundly disabled TB programs, and also explain why, 40 years after the Alma Ata Declaration, 13 half the world's population still lacks access to comprehensive health care services. Under-investment in TB research and development-Funding for TB R&D has been stagnant for many years, despite that TB remains a major global health threat. 3 A reflection of this under-investment is the continued reliance upon tools such as smear microscopy and the BCG vaccine developed nearly a century ago. 14 While global funding for TB research received more funding in 2018 than ever before ($772 million), the pace at which scientific discovery progresses has been greatly hindered by lack of sufficient funding dedicated to research priorities that have been defined ad nauseam. 15-17 THE LANCET COMMISSION ON TUBERCULOSIS 6 Broken care cascades and poor quality of care-Turning the tide on TB requires early, accurate case detection together with the rapid initiation of and adherence to effective treatment that prevents Mtb transmission, especially in high-burden countries. To achieve this, national TB programs in such settings must first invest to ensure that all patients with TB seeking care have access to TB diagnostics and treatments. Unfortunately,TB care is frequently delivered with little attention to patient needs and preferences, poorly coordinated with other services, and undermined by lack of access to essential services. 18 A recent assessment of patient pathways in 13 countries accounting for 92% of the world's missed TB cases revealed that even among people who actively sought care, fewer than one-third sought care at a facility that had the capacity to diagnose and/or treat people with TB. 18-21 Referral systems to access diagnostic technologies also were limited. These findings confirm those of numerous other studies from various settings demonstrating the many programmatic and financial barriers 22,23 that prevent people with TB from accessing healthcare. 24 Furthermore, they highlight how it is critical to align the availability of services to where people seek care. Not only is access highly variable, so too is the quality of TB care in many high-burden countries. Although the DOTS strategy emphasized the importance of quality-assured drugs and diagnostics, it neglected to ensure prioritizing the quality of TB care. The Lancet Global Health Commission on High-Quality Health Systems (HQSS) recently highlighted that the vast majority of TB deaths result from poor quality care.. 25. As Figure 1 demonstrates, the care quality is undermined by chronic under-funding, limited access to new tools, and inadequate implementation of policies. Numerous studies have highlighted substantial gaps in the TB care continuum for all forms of TB cases: active disease, DR-TB, latent infection, and childhood TB. 26-30 For patients with multidrug-resistant TB (MDR-TB), only 14% completed treatment, and 11% remained disease-free at one year. A similar study in South Africa found that only 82% of 532,005 TB cases were diagnosed, and less than 54% of drugsusceptible TB cases completed treatment. 29 Of those with rifampicin-resistant TB, only 22% completed treatment (Appendix Figure xx). Simulated patient studies in three countries show that most primary care providers are unable to diagnose TB and referral linkages to the National TB Program (NTP) are weak. In India, China and Kenya, only 28% to 45% of simulation patients were correctly managed by primary care providers. 31-33 Simply put, the current global capacity to diagnose, link to care, treat, and cure TB patients is woefully inadequate for the massive burden of disease that exists. The public health implications, as well as the THE LANCET COMMISSION ON TUBERCULOSIS 7 poor clinical and financial implications 34 for patients, are self-evident. Substantially reducing TB mortality and incidence will require significantly increasing both the coverage and the quality of TB services across the entire care continuum. Failures to optimize private sector engagement Of the 3.6 million unreognized or "missing" TB patients in 2017, 63% of them are in six countries where primary care is dominated by private providers and >67% of initial care-seeking is in the private sector (Table 3). However, in these countries, private provider notifications are just 18% of total TB notifications and 9% of estimated TB incidence. Based on data from TB prevalence surveys and private sector drug sales, 35 a considerable proportion of TB patients are treated in the private sector, with largely unknown levels of quality and patient outcomes.. Given the dominance of private health care in countries with the largest share of "missing" TB patients, to meet national and indeed global TB goals, private providers must be engaged to provide high-quality, patient-centered care on a scale equal to their role in primary care. Modeling studies also suggest that untreated or poorly-treated patients in the private sector are a major source of Mtb transmission. 36 This is due to delay in diagnosis and treatment initiation among private patients, as well as recurrent TB among private patients who were inadequately treated. Therefore, improving the diagnosis and treatment of patients seeking care in private facilities is an opportunity to rapidly reduce TB...

THE PROFESSIONAL MEDICAL JOURNAL, 2017

To describe the profile and outcome of tuberculosis in a secondary care center in a low socioeconomic area in Karachi. Study Design: Descriptive cross-sectional study. Setting: Sir Syed Hospital, Karachi after ethical approval. Period: All cases diagnosed and treated as tuberculosis from January till December 2013 were included. Material and Methods: Data from the medical records on demographics, signs and symptoms, laboratory investigations, and outcome status were recorded. All the data was entered in SPSS version 20. Quantitative variables were analyzed for mean ± SD. Results of categorical variables were obtained in numbers and percentages. Results: Among 214 patients who received antituberculous treatment during the period of study, 44% were male and 66% were females. Mean age was 32.6 ± 16.6 years. Contact tracing was done in 2% of patients. Most of the patients 80.8% came to the center on their own initiative. Around 68% of the patients had pulmonary tuberculosis. Sputum smear was done in 49.5% of patients out of whom 52% were Smear positive. CBC was the most common investigation ordered in these patients (78%). ESR was done in 69% of the patients. Extra pulmonary tuberculosis was diagnosed in 32% of patients and the diagnosis was made mostly on basis of clinical data. Tuberculous pleural effusion and tuberculous lymphadenitis were the most common extra-pulmonary sites involved. Around 67% patients completed treatment and 29% defaulted. None of the patients who defaulted were traced to find reason for default. Conclusion: Tuberculosis is epidemic in Pakistan. The National TB Program is contributing a lot towards control of the epidemic but some changes, better training and stricter monitoring is required in order for it to achieve optimal coverage and utilization.

Asian Pacific Journal of Tropical Disease, 2015