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TB Preventive Treatment: The Need For Choice

Africa, Headlines, Health, Poverty & SDGs, TerraViva United Nations

Opinion

The progress made in HIV prevention is nothing short of a global success story. It is time that TB caught up to HIV. Medicine is simply too advanced for us to tolerate how one disease can be beaten back yet another continues to flourish. Credit: Jeffrey Moyo/IPS.

JOHANNESBURG, Jul 26 2023 (IPS) - Before COVID-19 came along, the two most lethal infectious diseases were HIV and tuberculosis (TB). Even though HIV still lingers, with 1.5 million people contracting the infection every year, epidemiologists point to the availability of many HIV prevention options as a primary reason for the decreasing caseload.

According to the World Health Organization (WHO), over the past two decades, new HIV infections decreased by 49%, HIV-related deaths decreased by 61% and an estimated 18.6 million lives were saved because of new treatments that minimise the infection and prevent its spread.

We have so many options for HIV prevention at our disposal, including the dapivirine vaginal ring, oral Pre-Exposure Prophylaxis (PrEP), harm reduction for people who use drugs, condoms for both men and women, voluntary medical male circumcision and the recently approved long-acting cabotegravir, with other options in development.

We have a suite of prevention tools because everyone is different, and people need to be able to choose their methods according to the way they live their lives. We observe a similar abundance of choice within family planning with oral pills, a variety of injectables, intra-uterine devices and condoms—we share this prevention method with HIV programs.

The urgency of the need is clear: an estimated 1.6 million people lost their lives to the disease in 2021, the second consecutive year the death toll went up after 14 years of progress. In Africa, an estimated 2.5 million people contracted the disease in 2021, one million of which were never diagnosed and treated We do not have this many options for TB prevention, but the world needs to adapt to embrace choice if we are to meet the globally agreed-upon goal of reducing TB deaths by 90% by 2030—referred to as the "End TB targets."

The urgency of the need is clear: an estimated 1.6 million people lost their lives to the disease in 2021, the second consecutive year the death toll went up after 14 years of progress. In Africa, an estimated 2.5 million people contracted the disease in 2021, one million of which were never diagnosed and treated.

Yet there are glimmers of good news. Despite the COVID-19 pandemic, estimates of TB incidence have slowly declined over the past few years in Angola, Ethiopia, Gabon, the Republic of Congo, Sierra Leone, South Africa, Tanzania and Zambia—all countries with high burdens of TB.

Of these countries, Zambia has also had success in finding and diagnosing an increasing number of these infections; the pandemic impacted the surveillance efforts of the other governments.

As for HIV, there is no effective vaccine to prevent TB in adults: the BCG vaccine only prevents severe TB in children. However, there are ways to prevent TB when someone is potentially exposed to an infected person. In the workplace or when a family member at home becomes sick, for example, prevention starts with masking, which was traditionally used in clinical care settings. The other ways work through prophylactic regimens. For TB, we initially only had isoniazid that could be taken for six, nine, 12 or 36 months depending on country guidelines, but now we have shorter regimens that allow for patient choice.

These options include regimens lasting one (1HP) and three months (3HP), with different combinations of the antibiotic drugs rifapentine and isoniazid, all with vitamin B6 supplements to help counter some of the side effects of treatment. There is also a three-month regimen of rifampicin and isoniazid (often given to children and adolescents) and a four-month regimen of rifampicin alone. Longer courses of isoniazid taken for 6–36 months also remain options, though most people are eligible to take a shorter rifapentine- or rifampicin-based regimen and should be given the choice to do so.

We need to do a better job of making sure that people at risk of TB have access to the full range of prevention options. A recent peer-reviewed study underlines this point, estimating that tracing the personal contacts of people diagnosed with TB and providing them with prevention treatment would save the lives of 700,000 children under the age of 15 and 150,000 adults by 2035.

Even the financial benefits of the prevention program, in terms of increased economic productivity, would outweigh the costs. Nobody questions the need to have options for HIV prevention or family planning, but questions arise when trying to roll out a one-month TB prevention regimen when there's already a three-month regimen available. We need them all. We also need to collect more data to differentiate which prevention regimens are best for each patient type to ensure success.

The WHO guidelines for preventive TB treatment create the possibility of choice among TB preventive treatments by not ranking the regimens by preference or effectiveness. But health care facilities and outreach programs need to embrace that range of options and make sure that a choice exists in practice. Supply chains may limit choice initially, but if there is no demand for more options from providers, there is no impetus to expand the supply chains.

The progress made in HIV prevention is nothing short of a global success story. It took a combination of scientific ingenuity and innovation, combined with an intensive dedication of resources that made a range of preventive options available around the world.

It is time that TB caught up to HIV. Medicine is simply too advanced for us to tolerate how one disease can be beaten back yet another continues to flourish.

Violet Chihota is an Adjunct Associate Professor and Chief Specialist Scientist at the Aurum Institute. She has been a researcher in global health for over 10 years, designing and managing the conduct of clinical research studies in South Africa, Zimbabwe, Botswana, Cameroon, Georgia, India and Malaysia.

 

Tuberculosis On The Rise For First Time In Decades After COVID-19 Interrupted Public Health Interventions And Increased Inequality

by Carlos Franco-Paredes, The Conversation

Updated on Jul 19, 2023, 5:00 a.M. ET

Before SARS-CoV-2, the virus that causes COVID-19, spread across the world in 2020, tuberculosis was responsible for more deaths globally than any other infectious disease. But thanks to targeted public health efforts in the U.S. And globally, tuberculosis cases had been steadily falling for decades.

I am an infectious disease clinician and public health practitioner who has been caring for underserved communities in the United States for more than two decades.

During the pandemic, it at first appeared that, as with many other common illnesses like the flu, COVID-19 prevention efforts reduced tuberculosis cases, too. But tuberculosis numbers have quickly climbed back up to pre-pandemic levels, marking the first time in decades that cases and deaths have risen globally.

The pandemic not only interrupted important health interventions for tuberculosis, it also caused a decrease in social and economic opportunities for marginalized people around the globe. Together, these effects appear to have put a serious dent in the fight against tuberculosis.

Tuberculosis before and during COVID-19

Tuberculosis is a contagious bacterial infection of the lungs that is normally spread through the air. Most tuberculosis infections are asymptomatic and not contagious.

About 5% to 10% of infected individuals develop active tuberculosis, which is characterized by cough, fever, decreased appetite, and weight loss. If left untreated, tuberculosis is a very contagious and dangerous disease that can result in death.

Total estimated tuberculosis infections globally have been falling for years. The lowest number, 10.1 million cases, occurred in 2020, according to the World Health Organization; 2021 saw a significant increase in infections, to 10.5 million, the first rise in more than a decade. Global tuberculosis deaths followed a similar pattern, reaching a low point of an estimated 1.4 million deaths in 2019, then rising to 1.5 million in 2020 and 1.6 million in 2021.

The number of confirmed cases of tuberculosis — infections detected through direct testing — tells a different part of the story. As testing efforts have improved, confirmed cases have been rising globally to a peak in 2019. As the coronavirus disrupted lives in 2020, confirmed cases of tuberculosis fell significantly before quickly rising again in 2021.

A similar pattern played out in the U.S. There was a sharp drop in confirmed cases in 2020 — mostly driven by lack of testing — followed by a sharp rise back to pre-pandemic levels.

Tuberculosis is a social disease

Tuberculosis is a preventable disease, thanks to effective vaccines, testing and treatments. But millions of people around the world still suffer from this disease, not because of a lack of medical knowledge, but because of persistent social inequities.

Unequal access to economic opportunities, limited health care, poor sanitation, crowded living conditions, malnutrition, and illnesses such as diabetes or HIV are all associated with increased risk of tuberculosis.

In the U.S. In 2021, racial and ethnic minority groups accounted for more than 85% of tuberculosis cases, with 71% of cases occurring in persons born outside the U.S.

Increased inequality causing more tuberculosis

Even as the world witnessed a rapid decline in confirmed cases in 2020, experts were worried that interruption of prevention and treatment efforts might result in a rise in tuberculosis.

These fears were warranted. Many health experts, along with the U.S. Centers for Disease Control and Prevention, have confirmed the pandemic disrupted access to tuberculosis testing and diagnosis. It is likely that many cases were missed because of the interruption of tuberculosis control activities, since funding, resources and staff were reassigned to assist in COVID-19 control efforts. Additionally, during health encounters, similarities in symptoms between COVID-19 and tuberculosis may have led to missed diagnoses.

The drop in confirmed cases seems to be, in large part, driven by a lack of testing. The rapid increase since the pandemic, and especially the rise in deaths, confirms that progress made in tuberculosis control over the last 20 years has stalled, slowed, or reversed. These two troubling trends are also almost certainly connected to the increase in inequality brought about by the pandemic.

The existence of multigenerational households, overcrowding in low-income neighborhoods, lack of paid sick leave, inability to shield from the pandemic, use of public transportation and lack of health insurance all converged to heighten the risk of both COVID-19 and tuberculosis among the most vulnerable people.

Of course, the pandemic is not the only factor that has increased human hardship — and therefore, tuberculosis — in recent years. For example, Ukraine now has one of the world's highest tuberculosis disease burdens as a result of Russia's invasion and the resulting harm to Ukraine's medical, social, and economic systems. Ongoing conflicts in other parts of the world, energy shortages and the effects of climate change and associated impacts on food security are expected to worsen the broader social and political determinants of tuberculosis.

There are many neglected diseases of poverty, and tuberculosis is a great example of how social forces produce human disease. With an estimated one-third of the world's population at risk for tuberculosis today, fostering social justice interventions to reduce health inequities is a critically important step to relieving the global medical burden of this relentless disease.

Carlos Franco-Paredes is an associate faculty member of the Mycobacteria Research Laboratories at Colorado State University.

This article is republished from The Conversation. Read the original article here.

Unraveling The Consequences: COVID-19's Devastating Effect On The TB Care Cascade

In a recent pre-print posted to the medRxiv* server, researchers conducted a systematic review to evaluate the impact of coronavirus disease 2019 on the tuberculosis care cascade. They screened 27 studies across North America, South America, Asia, Africa, and Europe.

The study found a significant decrease in tuberculosis screening, hospital enrolment, and treatment success, as well as substantial increases in diagnosis duration during the pandemic compared to the year preceding its onset.

Study: Impact of COVID-19 on the cascade of care for tuberculosis: A systematic review. Image Credit: HelenaNechaeva/Shutterstock.Com

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Tuberculosis during the pandemic

Tuberculosis (TB) is one of the most ubiquitous and deadly diseases globally, responsible for an estimated 1.8 billion asymptomatic carriers, 10.6 million symptomatic patients, and 1.5 million casualties in 2018.

It mainly impacts low-to-middle-income (LMIC) countries, including China, India, Indonesia, Pakistan, Nigeria, the Philippines, South Africa, and Bangladesh. TB primarily infects the lungs and is characterized by cough, severe weight loss, night sweats, and high fever.

To combat the global TB burden, the 67th World Health Assembly (2014) signed the End TB strategy, aimed at reducing TB mortality by 90% and TB incidence by 80% by 2030. While numerous countries undertook steps to meet End TB goals, the onset of the coronavirus disease 2019 (COVID-19) has severely hampered their efforts. These impacts have hitherto not been quantified within a scientific framework.

One of the most characteristic government responses to the COVID-19 pandemic was the implementation of policies that imposed lockdowns and movement restrictions. Many countries shifted medical priorities towards combating the pandemic, often at the expense of other disease interventions.

In LMICs, COVID-19 is thought to have impacted entire health systems, severely impacting care cascades in diseases such as TB and AIDS, which require constant contact between patients and medical professionals at all infection stages.

The TB care cascade, comprising screening, diagnosis, treatment (onset and subsequent completion), and post-treatment patient monitoring, was adapted from HIV interventions to ensure positive medical outcomes and prevent relapses in TB patients. High TB burden countries, including India and South Africa, have even incorporated the TB care cascade into their national strategic policies.

However, the onset of COVID-19 is thought to have caused global disruptions in these policies, primarily due to patient movement restrictions and the re-deployment of medical caregivers and their allied health professionals to the care of pandemic patients.

While previous research has attempted to document the impacts of the COVID-19 outbreak on TB care cascade components, their results remain contradictory and inconclusive. Scientist postulate that this might be due to the country-specific differences in COVID-19 impacts and responses.

Repercussions of COVID-19 on TB care – a review

In the present pre-print, researchers conducted a systematic review to quantify the impacts of the pandemic on delaying or even reversing the global effort toward the End TB strategy.

Their methodology was modeled after the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines and began by screening Scopus, PubMed, CINAHL, COCHRANE, and Ebscohost for previous literature on TB care before and during the pandemic.

Criteria for study inclusion comprised research wherein quantitative changes in TB screen, diagnosis, and treatment were reported for at least one year preceding the pandemic and one year during COVID-19. Reviews, case studies, qualitative publications, and letters to the editor were excluded.

Of the 7,855 records originally found, screening cascades of duplicate removal, title, and abstract screening, and finally, full-text screening yielded 27 publications used in the review.

Two researchers then independently extracted data about changes in the number of patients processed through the TB care cascade and included characterization of the loss to follow-up, potential patients not evaluated, and TB-related or suspected deaths during the pandemic.

Study findings

The 27 studies included in the pre-print review covered seven countries from Africa, 15 from Asia, two from South America, two from North America, and 46 from Europe. Results from the study suggest that the pandemic contributed to significant decreases in TB screening, diagnosis, treatment enrolment, and retention.

Tuberculosis screening decreased by almost 50% in some nations, with multidrug-resistant TB (MDR-TB) reducing by 15%–17%. 

"It is worth noting that decreases in TB and MDR TB screening could have multiple adverse effects on the health system due to lengthened case detection gap, diagnostic delay, and decreased linkage to care. This may result in increasing TB prevalence, community transmission and incidence."

This study found that clinical TB diagnoses decreased by up to 46% and case notifications by more than 63% during the pandemic. The pandemic caused treatment delays of more than five days, which, when clubbed with reduced treatment success rates (17%), might have had severe repercussions on TB-related morbidity and mortality.

The study has notable limitations – results could not be compared to prior research, as no other reviews or meta-analyses on the implications of COVID-19 on TB care cascades exist. Contextual differences in reviewed studies, some of which have very small sample sizes, prevented statistical meta-analysis from being conducted.

Finally, many studies failed to report temporal population sizes, preventing analysis from standardizing results between nations.

Conclusions

In the present pre-print, researchers utilized PRISMA methodologies to attempt to quantify the impact of the COVID-19 pandemic on the TB care cascade.

Their results suggest significant delays in TB treatment and reductions in all aspects of the cascade (screening, patient enrolment, post-treatment follow-up), which seemingly halted or even reversed global progress toward the World Health Assembly's End TB plan.

"…findings suggest a need for policies to protect the existing healthcare systems for TB and other communicable, (and, by extension, non-communicable) diseases in future health emergencies."

*Important notice: medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

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