On our minds: All hands on deck to eliminate TB

On our minds: All hands on deck to eliminate TB

{Doctors visit patients in Rabia Balkhi hospital, Kabul Afghanistan. Photo Credit: Afghan Eyes/Jawad Jalali}Doctors visit patients in Rabia Balkhi hospital, Kabul Afghanistan. Photo Credit: Afghan Eyes/Jawad Jalali

COVID-19 will impact the prevention and treatment of many diseases, and there are particularly grim possibilities for tuberculosis (TB), which could set back our progress toward its elimination. Fortunately, our emphasis on strengthening local health systems is helping to build resilience against this kind of shock. We reached out to MSH technical experts leading three new global and national TB programs to learn what’s on their minds as their teams begin implementation under a COVID-19 reality. They all agree: COVID-19 reminds us why we cannot become complacent, and when it comes to the global fight to eliminate TB, it is no longer business as usual. Read what Ersin Topcuoglu, Daniel Gemechu, and Ehsanullah Darwish had to say about how we can fundamentally improve the way countries fight TB.

What is unique or new about how we are looking at TB elimination now? 

ET: As you may know, the global community is committed to ending TB by 2030 and has established ambitious targets for countries to achieve by 2022: to successfully treat 40 million people with TB and provide TB preventive therapy for at least 30 million people. We are already behind in meeting these targets, and COVID-19 is making our work even harder—destabilizing health systems, diverting funds, and threatening important gains made against the disease.  

It’s very clear that business as usual doesn’t work anymore. We cannot assume that National TB Programs, Ministries of Health, or even governments can achieve these targets alone. We need to be innovative; we need to change the game; we need to align and mobilize more resources and engage with more governmental and nongovernmental partners. Because TB control and elimination requires a multisectoral approach, the commitment to end TB should be shared across stakeholders, including public, private, and nongovernmental organizations. 

The new USAID Health Systems for Tuberculosis (HS4TB) project, led by MSH, is all about strengthening health care financing and governance for TB. This is a critical step in the journey to self-reliance, and that journey will be unique to each country. Our team is preparing to work in several priority countries to help scale up the political and financial commitment among key TB actors across every sector.


DG: MSH has been an important player in Ethiopia’s TB elimination efforts for the past 15 years, and we’ve seen big results. An 8% decline in TB incidence is seen year after year, thanks to high-impact interventions related to TB case finding and contact investigation, especially among key populations such as miners. Cross-cutting health systems strengthening activities have also contributed to the decrease, such as training health care workers at all levels, improving diagnostic capacity for TB, and improving drug and supply management to ensure access to quality treatment. But disruptions in TB detection and treatment due to the COVID-19 pandemic put many of these achievements at risk. We can’t afford to lose ground on drug resistance and must continue to build on our groundwork. I have seen that expanding our model of ambulatory care for multidrug-resistant TB (MDR-TB) services, renovating treatment-initiating centers for MDR-TB patients, and introducing a blended learning approach using video conferencing for training and case-based consultation for difficult cases is helping maintain and improve the quality of care for TB patients.  

Engaging communities and working with public- and private-sector partners has always been central to our success, and that’s really where we are focusing our energies moving forward under the USAID Eliminate TB Project: mobilizing domestic resources and building the capacity of government, civil society organizations, and private-sector partners at the local level to take ownership of national TB prevention and control activities to mitigate the impact of COVID-19 and demonstrate learning for government counterparts to sustain the efforts. 


ED: In past MSH TB projects in Afghanistan, we focused on implementing a proven, cost-effective TB treatment strategy in urban and rural settings. Our intervention was an extension of the classic direct observation therapy, short-course (DOTS) but with the added benefit of engaging private health sectors in TB referral and diagnostic networks and TB treatment. We also effectively implemented community-based DOTS in rural settings, when presumptive TB cases were referred from the community to diagnostic centers through community health workers and other community members.

Under the new integrated health project led by MSH, the USAID Assistance for Families and Indigent Afghans to Thrive (AFIAT) program, we will focus on active case finding in high-burden areas and support the integration of TB activities with maternal and child health interventions to minimize missed opportunities for identifying TB cases. We want to strengthen the way samples are transported for diagnosis and referral systems in rural areas, utilizing different community groups and the public and private sectors. We are exploring new ways to engage the community in TB detection and treatment, including the involvement of the educational directorate across multiple school districts and villages to create a coordination network among teachers trained in detecting TB signs and symptoms while providing sensitization to students and the wider community and connecting them to diagnostic centers. A similar approach will be rolled out that enlists support from religious leaders, who are trusted members of the community.


In the midst of fighting the COVID-19 pandemic, how do we seize opportunities to advance TB prevention, diagnosis, and treatment?

ET: The current pandemic may give public health leaders more of an impetus to ramp up efforts against TB, and we must be ready for that. COVID-19 has triggered a large range of innovations in a very short time. Innovative mobile technologies for screening, contact tracing, and mapping; community-based testing and diagnosis; remote, home-based treatment and care; and accelerated global research on infectious disease all provide great opportunities for our TB control and elimination efforts. 

As we adjust to new realities, we must maintain a focus on stewardship and good governance to ensure that gains are maintained and progress toward ending TB is accelerated. The first step is to create an enabling policy and legal environment so that more domestic funding can be leveraged. Then, we can ensure efficient and effective use of these funds for clinical and non-clinical priority services such as those that can help fight TB.  


DG: The fight against TB has moved to another level during the era of COVID-19, posing great challenges but also creating opportunities. With COVID-19, access to health services is compromised due to the risk of infection and disruption of services, including drugs and supplies, with limited focus on TB service provision. Mitigation strategies such as community-based DOTS, spacing clients’ visits to health facilities, and regular virtual discussion forums will help ensure service continuity.   

Particular to the USAID Eliminate TB project in Ethiopia, we are building the capacity of local organizations to take forward community-based TB services and facilitating domestic resource mobilization to ensure the journey to self-reliance. We will maximize and use the integrated TB and COVID-19 surveillance systems in the community, instituting infection prevention measures and introducing digital x-ray and artificial intelligence for screening for both diseases. Through the use of COVID-19 standard operating procedures, we can effectively implement TB interventions while ensuring staff safety. We are preparing to conduct a research study on TB elimination to create opportunities for government and local counterparts to learn from and sustain these efforts beyond the project. 


ED: Of course, COVID-19 affected TB case detection, which dropped from 72% in 2019 to 64% in 2020, according to WHO estimates. Integration is an effective approach to implement TB activities while COVID-19 continues spreading throughout the world. Since these two diseases have similar signs and symptoms, if we take the right measures we can leverage and advance the prevention, diagnosis, and treatment of TB and COVID-19. In Afghanistan, we are seeking to expand measures like increasing health education and triage in waiting areas at health facilities to improve community awareness, creating training or orientation activities for health facility staff to ensure concurrent screening of TB and COVID-19 and concurrent use of diagnostic tools such as the GeneXpert machines, and improving coordination and cooperation to boost referral systems and strengthen follow-up mechanisms for both diseases.