Hi Dr Sunil

The main reason why tuberculosis has not yet been eradicated is that of having a long treatment that despite being "strictly supervised" is often not complied with or because of its adverse effects, it is not complete, this coupled with the idiosyncrasy of People, who are usually of low socioeconomic status, do not help self-care and self-treatment of themselves.

Hi,

World TB Day 24/3

We have to ensure medication compliance with TB drugs. Many times patients stop taking their drugs, therefore causing a therapy failure. Drug resistance is also an issue.

Danielle, Precisely, that is why active case finding may help.

To "end TB",the world needs badly those items:

Point of care test,

Ultra-short effective anti TB regimen,and

Effective pre-and post-exposure vaccines.

Asfaw, Thanks.

Active surveillance will be more or less effective depending on the context and the actual capacity of the health system to respond. For example, in a country with a meager rate of transmission, install a robust system of active surveillance focused on high-risk populations, and manage cases of LTBI (late infections of tuberculosis) for treatment.

I firmly believe that it is possible to eliminate TB as a health problem. However, it depends on critical factors such as an effective surveillance system (sensitive enough to detect the case that may perpetuate transmission); a care system operationally ready to treat, investigate and execute prophylaxis actions in contacts; and have a population sufficiently informed about the risks and the different options available to reduce them.

Thanks Angela. Probably what we need is robust surveillance with an ability to pick infection as early as possible- through screening.

Active case finding is key.

Early diagnosis and completion of treatment by the patients are also key in TB eradication. Probably drastic measures like DOT and quarantine during the intensive phase of TB treatment could also bear valuable fruits in curbing poor adherence and spread of the bacteria.

TB is often asymptomatic disease (latent) and some of these progress into active disease. When active, some of these patients delay visiting a doctor or dont seek healthcare at all. This is why massive screening of the entire population (as done in Europe in the 60ies) would work, if your aim is complete eradication - to detect latent cases and treat them. After this, compliance to assigned therapy becomes also important, of course.

A recent news article illustrates how governments play an important role, and without good public health programs, the struggle gets very difficult:

https://www.nytimes.com/2018/03/20/world/americas/venezuela-tuberculosis.html

Sorry there was a misspelling in my response. I meant Latent TB Infection as the descriptor of LTBI.

I think, all of us are almost on the same page: Robust Surveillance, early case detection and Compliance to Treatment.

As a public health policy initiative, I suspect our capacity to carry out mass screening (it has its own limitations). What i feel might work is high risk screening.

Your take on this?

Yes active case finding is one key intervention in controlling TB but you will agree with me that our case detection strategies have been more of pssive than active partly due to resource constraints. But in addition there must be a strong focus on TB prevention which includes actions geared towards limiting the impact of TB risk factors such as HIV/AIDS, diabetes, smoking, malnutrition, alcoholism and crowded living conditions.

True Mavis, active case finding is resource limited. Probably a two step screening process (self assessment based on a risk score , with second investigation step) will reduce the cost.

The world is now a global village, TB action plan to end spread must be global in outlook and application. One active TB case in Europe does not make Africa free and vice versa. It is a global challenge and must be technically seen as such by global partners. Poverty in Africa and Asian countries must be tackled. Government in the Africa and Asia countries must show more commitment. Local research must be encouraged and surveillance must be multi-faceted, to ensure compliance to treatment.

I think, I have opened up a hot debate, let us try to identify three key reserarchable areas to End TB in Asia and Africa, resourc poor settings.

please share

Prof. Raina Sir,

Active surveillance as you have mentioned is the need of the hour. The areas what i think important is: Prison, mentally handicapped home, orphan home, old age home, urban slums, vagabond (most important source, since they remain undetected and not accessible also) etc. etc. Increased adherence is necessary, but these above mentioned sites should also be routinely visited for TB screening.

True Dr. Indranil. But probably we need to move beyond the so called high risk groups and think of find ways of reaching to a larger population base using existing health care models.

Absolutely sir

It has been interesting reading the many answers to the question of whether "End TB" is possible without Active Case Finding and the second question on the important components of a way to end TB worldwide.

Most of the challenges to ending TB have been highlighted above, however a few more include tackling the MDR-TB cases, dependence on donor-funding for poor countries and the political will of governments especially in Africa in terms of funding even the already existing programmes. We all agree that TB is poverty driven and so needs both health and social interventions to end it. Hence there is need for universal access to quality TB care and improvement in TB prevention strategies especially active case detection. If Universal Health Coverage (UHC) is pursued and achieved, for instance, TB-affected families facing catastrophic spending due to TB will be covered.

WHO document on how to achieve this goal of "Ending TB" by 2035 (with targets between 2020 and 2035) outlines the Principles and Pillars of the Strategy for achieving the goal.

The importance of continuing research for new drugs with less side effects and shorter duration of therapy cannot be overemphasised. Point of care tests are required for early and quick diagnosis. Developments of effective vaccine for pre- and post-exposure. Other research areas will incude development of risk scores for quick screening at point of care which will apply to whole populations not just high risk groups.

The truth is that TB will be very difficult to end without active case finding, passive case finding is not enough. However active case finding needs to be supported by other interventions especially in low socio-economic countries grappling with poverty.

Brilliantly summed up Margaret. I think by now most of us have come to the understanding that point of care diagnostics and treatment will be a key factor in ending TB. I my opinion this will be both cost effective and easily implementable. Drug/ Vaccine research will take some time. Therefore funding for an effective public health implementation policy at point of care level is the need.

I am currently identifying the components of a TB risk score, suggestions are welcome.

Yet, "Find a TB new case" programme will help, find a new case and reduce the spread should be the target group 1, No 2, "Take you drug -sure" group and " MDR case management group " these groups will join the WHO, CDC policy group to combert the disease. United Nation will fund these groups in all the nations. I am ready to work in any

of the groups! what of you?

To combat I mean

Thanks Christian Azubike Enwuru, thanks for sharing important information. I think a policy initiative focus on;

Reach, teach and treat every case of Tuberculosis will help end TB.

The goal of ending TB is too much ambition in our context of lack of political will especially in a setting of free market economy where everything is about money.

However, it is true that there is enough evidence that active TB case findings can go along way to reduce new TB infections. Though case findings has it's own limitations especially in settings of of low level of human resource for health, poor Lab and imaging investigations and unavailability /inconsistent supply of anti_TB to treat cases. Without improvement on those bottlenecks in TB case findings elimination is but a dream.

Thanks Ouma for sharing your thoughts.Given the fact that "cost" is an important determinant for initiating screening, we need to develop a cost -effective tool for this. Request your feedback on important risk factors for TB in your setting.

Dear Kumar, regarding risk factors for TB disease my my Uganda, the following stands out more prominently:

1. Poverty

2. HIV

3. Malnutrition

These three factors work in synergy. The poor, malnourished HIV positive individuals are the most at risk population for TB disease thought the three factors can also act independently.

But also at national level, there is low level financial resources allocated to fight TB. The implication is that there are few supplies and medicine needed for effective TB management in order to reduce risk of transmission to others. Likewise, TB contact tracing not possible and patients on anti-TB get loss to follow due to poor funding.

Thanks

Early diagnosis and completion of treatment by the patients are also key in TB eradication.

In addition to what others have written, one of the biggest challenges to the control of TB are issues related to the communities and the TB patients especially adherence to medications. Uganda recently introduced food as part of TB medications and a strategy is to promote adherence of TB patients to TB medications. This has worked to a great extent but there are still challenges with MDR patients who do not follow medical instructions

TB and HIV co-infection have had a very high negative impact on the end TB programs. Its only recently that most people can now access ARVs. The TB-HIV co-infection has and will continue to be a double tragedy to these patients. In addition, there is an emergence of Extra-pulmonary TB which affects a sizeable number of people with no capacity to receive timely diagnosis and treatment. More efforts should be added towards improving screening processes, investigation modalities, treatment adherence and food enablers and case follow-up

Thanks David. I understand that there is a paradox in TB today. We plan elimination of TB using modalities that focus on control. There has to be a strategic shift in TB care.