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Treatment gaps and poor governance hold back progress in reducing TB

Tuberculosis was declared a global public emergency of international concern 30 years ago, so why are 1.6m people still dying from the disease worldwide every year despite wide-scale preventative interventions? asks MedicalBrief.

TB continues to be the world’s leading cause of death despite treatment having been available since 1952, and the reduction in new infections is too slow to place the world on the path to ending the epidemic as a public health threat by 2030.

Writing in Spotlight, Gaurang Tanna and Yogan Pillay say in South Africa, in 2021, fewer than half of the estimated 328 000 people with TB were successfully treated. Almost 120 000 people with TB had not been diagnosed and/or initiated on treatment and more than 70 000 of those on treatment did not complete the full six-month course.

The World Health Organisation estimates that 55 000 people died from TB in South Africa in the same year, another 172 000 were diagnosed with the disease, and some 304 000 people fell ill with it during that time.

Experts warn that if efforts to end the killer epidemic are not stepped up, the battle will never be won, with a new report saying that efforts to end TB as the nation’s leading cause of death will be in vain if policy implementation and governance of programmes are not improved.

The latest State of TB in SA report by the TB Accountability Consortium, comprising policymakers, scientists and civil society bodies, says that while the country’s TB response is guided by well-constructed policies that often put it ahead of its counterparts, putting into practice these guidelines is problematic and blurred.

In the second edition of the report titled “Tackling governance gaps to improve care” released last week, the authors rang alarm bells, saying SA’s national strategic plan not only lacks transparency, but the TB database and strategy meant to end the scourge work incoherently.

These challenges are also likely to slow down the country’s recovery plans from the Covid-19 pandemic, which saw TB cases rising and thousands of sufferers undiagnosed, reports TimesLIVE.

“An overwhelming positive within the TB community is that there has been a concerted effort to make the recovery plan a priority. But there are many challenges, for starters, a lack of transparency around the national strategic plan,” said Sihle Mahonga Ndawonde, the consortium’s project officer.

“This makes it difficult for people to ask questions around the implementation of these plans and to hold to account those who are responsible for that.

“Equally challenging is that the data surrounding the national TB strategy are siloed. While there are various data sets providing parts of the puzzle around the TB cascade, each set works independently – there are no points of alignment.”

The report says even though the incoherence in the approach is felt at a national level, the biggest challenge lies at provincial level, which manages the bulk of TB services.

These gaps are most evident in KwaZulu-Natal and the Western Cape, which remain high TB burden provinces where the TB prevalence sits well above the national 615 cases for every 100 000 people.

“The disconnect between the national and provincial levels means there is no clarity on how the National TB Recovery Plan is implemented,” the report says.

SA has the eighth highest TB incidence globally at a rate of 537 per 100 000 population a year. The WHO 2022 global TB report between 2020 and 2021 showed a 4.5% increase in the number of people who fell ill from TB and a 3.6% increase in the number of new TB cases, including drug-resistant TB cases.

The consortium noted that “our report also shows a lack of consistent community involvement”.

“Collectively these issues all compromise the management of the response. The result is that the policy framework is not met with effective implementation, adequate support and strong oversight, so there is accountability.  The focus on governance is a critical one.”

With more than 400 hospitals and 3 800 clinics countrywide, the assumption is that accessing healthcare in the public health system should be easy, observed Ndawonde in the Daily Maverick.

But it’s not, particularly true for people needing treatment for the disease, he said.

“Either they don’t have money for transport to the healthcare facility, or they can’t afford the time off work.

“When they do manage to get a day off or find transport money, inefficiencies in the system can mean they’re often not even seen by a doctor or nurse, meaning they have to return the next day.”

Numerous studies support these claims. One co-ordinated by the Human Sciences Research Council found that more than two-thirds of people in South Africa with TB do not seek treatment. Some said they were still planning to do so; others said their symptoms were not serious and the balance had no money for transport.

The challenge with people not testing is the nature of the disease and how it has been spread. Mostly affecting the poorest citizens, TB is airborne and spreads in overcrowded, poorly ventilated areas.

Meanwhile, and additionally worrying, write Francine Ntoumi, Alimuddin Zumla and Tom Nyirenda in The Conversation, TB in children isn’t being controlled – and yet it’s key to fighting the disease for everyone else

“When TB it was declared a global public emergency in 1993, at the time, the focus was on adult TB. Childhood TB was not thought to be important, and establishing evidence of the scale of the problem wasn’t available.”

But over the ensuing decade, thousands of African children have died of TB and TB/HIV co-infection.

“It took visionary leadership from African scientists and pathologists to conduct a large, landmark autopsy study in 2002 on 164 children who had died of respiratory illness in Lusaka, Zambia,” they said.

The study found that 25% of deaths were due to TB. It was only then that the WHO recognised that TB in children was a neglected disease.

Despite that, serious investment into early diagnosis, treatment and prevention of childhood TB have not been forthcoming. Systemic health services challenges and lack of adequate knowledge around the disease also hamper improvements.

“Based on our combined four decades in TB research we believe the burden of childhood TB can be one of the indications of a failing TB control programme in any setting.”

In 2021, of the estimated 10.6m people who fell ill with TB worldwide, 1.2m were children. Of the 1.6m who died that year, 240 000 were children. Almost all were undiagnosed before death.

This reflects the dire need to prioritise childhood TB. Its early detection and treatment must be part of the global strategy to end TB.

Key challenges in childhood TB

TB in children can easily be missed, because the symptoms are similar to other childhood illnesses – so diagnosis and treatment are delayed.

Diagnosing TB in children is difficult for various reasons. The most vulnerable present with non-specific symptoms. Chest X-rays are the textbook way to diagnose TB, but these are not always available in rural settings. Although there have been numerous studies evaluating new tests and algorithms, the ideal test for childhood TB has not yet been found because it must be easy to use at points of healthcare, affordable, with simple non-invasive sample collection.

TB vaccination

The age-old Bacille Calmette-Guerin (BCG) vaccine remains the only licensed vaccine, and provides only some protection in early childhood. But it’s not effective in preventing active disease in older children and adults.

“In many developing countries BCG vaccination for children after birth is mandatory. But vaccine coverage varies across countries. For national TB control programmes to work there must ensure high vaccination coverage.”

New vaccine development for TB has not been a priority. There are 16 candidate vaccines that have reached proof of concept stage based on recent efforts. But more investment for facilitating their evaluation in clinical trials is required.

Funding to meet global targets

Adequate funding is required to fight childhood TB. The global targets set in 2018 aimed to treat 40m people with TB disease between 2018–2022. This target included 3.5m children with drug-sensitive TB and 115 000 children with drug-resistant TB.

But progress in many areas of TB control has stalled – or been reversed. This has mainly been due to the pandemic. This calls for renewed efforts to fund TB control adequately again.

Compounding matters, health workers, including in Africa, have limited knowledge and practice in managing childhood TB. It’s essential to improve understanding of childhood TB from training institutions and clinics – all the way down to the community.

New technologies in testing and diagnosing childhood TB

Most children with TB present with negative results on microscopy of their respiratory fluids while radiographs are unreliable as they are rarely definitive. GeneXpert is currently the most widely used tool for diagnostic accuracy of TB. But affordability and maintenance mean it’s not practical to roll it out in settings that have few resources.

“The best option, in our view, is metagenomic next-generation sequencing. This enables broad identification of pathogens and antimicrobial resistant genes directly from clinical samples within 24 hours. But these technologies are not readily available in low-middle income countries where the TB burden is the highest.

“Some children with respiratory symptoms may have mixed infections. Accurate diagnosis of multiple infections in a child will lead to proper management, with reduction in mortality due to untreated infections, including TB.”

Tech steps in

The National Department of Health has opted for a simplified technological solution to increase awareness and diagnosis of TB – but in such a way that the poorest residents can still benefit, points out Ndawonde.

The TB Health Check app allows users to check their symptoms without having to go to a clinic for tests.

“They just need a mobile phone. They don’t even need data. The service is free and users access it via USSD codes or WhatsApp, making it the most cost-effective way of establishing whether a TB test is needed.”

But there’s a problem.

While the app system has been launched at national level, there are questions about how it is being rolled out at provincial level. What awareness is being created about the app in communities that are at the highest risk of TB?

Provincial hurdles

Ndawonde said lack of provincial co-ordination means that people who most need information about the TB Health Check app are not receiving it. For the app to be successful, it requires the involvement of communities in community-led governance programmes.

“Community champions, with support from hospital boards and clinic committees, could spread the messages about the TB Health Check app and get residents to check their statuses at home.

“They could also report on challenges and glitches – and come back to the national Department of Health, holding it accountable by asking how many people who used the app actually went on to be tested and treated.”

Other hurdles and obstacles also need to be tackled.

Tanna and Pillay conceded that the limitations associated with current drugs, diagnostics, and vaccines can’t be excluded.

“However, it is encouraging to witness the recent investments in TB research and development (R&D) in new tools that could fundamentally change how we detect, treat, and prevent TB, thus dramatically transforming the TB fight. For the first time in history, funding for TB R&D reached $1bn worldwide in 2021, marking a significant milestone. However, this investment still falls significantly short of what’s needed to achieve the United Nations’ Sustainable Development Goal of ending TB by 2030.”

SA at the centre

They told Spotlight that South Africa plays a central role in TB R&D and the country is benefiting from these efforts.

“A new TB preventive therapy treatment is being introduced: Xpert MTBRif, a molecular diagnostic test that is being scaled up globally, and has been available for almost a decade as a first-line TB test in South Africa.”

National guidelines are being amended to provide BPAL (bedaquiline, pretomanid, and linezolid), which is a shorter, six-month, all-oral regimen, as the new standard of care for DR-TB. The M72/AS01E TB vaccine is advancing to a phase III trial in South Africa, with promising preliminary results.

“This development, in particular, is significant given that the only currently used TB vaccine, BCG, is more than a century old and not very effective.”

‘A watershed year’

This year is a watershed year globally and in South Africa. After the 2018 UN General Assembly High-Level Meeting on TB, 2023 will be the first time the global health community and governments will gather to review progress and make new commitments to work toward TB elimination.

In South Africa, the launch of the fifth National Strategic Plan (NSP) for HIV, TB and STIs titled “The People’s NSP”, for the period 2023-2028 provides renewed hope.

The writers appealed for partnerships to “bridge the gaps and explore stronger public-private partnerships to ramp up investment to ensure better access to quality TB prevention, diagnosis, and care services”.

“We call on all provinces to strengthen implementation of services, monitor and evaluate their plans, and to take corrective action to ensure that targets are met. We look to all healthcare workers to provide quality testing and treatment to people with TB, free of stigma and discrimination.”

And Nyirena, Ntoumi and Zumla urge funders and donors to provide enough resources to enable global targets to be met.

“And enough money is required to mitigate the impact of emergencies such as the Covid-19 pandemic and economic downturns.”

State of TB report

*Tom Nyirenda is Extraordinary Senior Lecture in the Department of Global Health , Stellenbosch University, Ntoumi is Research Group Leader, Institute for Tropical Medicine, University of Tübingen, Zumla is Professor of Infectious Diseases and International Health, UCL.

*Sihle Mahonga Ndawonde is project officer for the TB Accountability Consortium, an initiative of the Rural Health Advocacy Project.

*Tanna is Senior Programme Officer, TB, South Africa at the Bill & Melinda Gates Foundation (BMGF) and Pillay is a Professor at the Division of Public Health and Health Systems, Stellenbosch University and a former Deputy Director-General at the National Health Department.


Spotlight article – Opinion: Yes! We can end TB in South Africa (Creative Commons Licence)


The Conversation article – TB in children isn’t being controlled – it’s key to fighting the disease for everyone else (Creative Commons Licence)


TimesLIVE article – Tackle gaps to improve TB care, warn experts ahead of World TB Day (Open access)


Daily Maverick article – TB programmes are all very well, but better governance will make them effective (Open access)


See more from MedicalBrief archives:


Digital X-rays increase TB detection in asymptomatic South Africans


R8.8bn donated to South Africa’s Aids, TB and malaria programmes


Community care model improves uptake of TB therapy – KZN study


What next for TB treatment after disappointing results for shortened regime?


New TB detection technology speeds up case finding







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