Author: David Collins, Management Sciences for Health (MSH), Systems for Improving Access to Pharmaceuticals and Services (SIAPS)
The Philippines is one of the 22 high-burden countries but has had much success in treating TB over the last few years. However, stock-outs of some medicines and loss to follow-up remain problems. These result in treatment interruption which has an impact on the wellbeing of patients and their families, on the health system and on society and the economy in general. The study involved the collection of data on stock-outs and loss to follow-up for 2014 and on the impact of the resulting treatment interruption. The results were modeled in a new spreadsheet-based tool.
The key findings are that
Possible stock-outs of DS-TB medicines in 2014 for 2,663 patients for one month could have resulted in an additional economic cost of as much as USD 21.2 million as well as 329 new drug-resistant cases and 588 deaths;
Loss to follow-up of 8,870 DS-TB patients for 3 months in 2014 could have resulted in an additional economic cost of as much as USD 72.2 million as well as 1,132 new drug-resistant cases and 1,958 deaths; and
Loss to follow-up of 777 MDR-TB patients for 5 months in 2014 could have resulted in additional economic costs of USD 12.9 million as well as 474 new MDR-TB cases and 233 related deaths and 349 new XDR-TB cases.
These represent a significant economic burden for the country and it is likely that the cost of addressing these problems would be much less than this burden. Investment in improving patient management and interventions to ensure the availability of good quality medicines and interventions to encourage and assist patient compliance will bring important and substantial health and economic benefits.
I was exposed to the plight of children with tuberculosis early in my 32 years of experience as a physician. I was a medical intern in a provincial hospital in Peru’s jungle region. I noticed Adrian, a severely malnourished 3-year-old child in the corner of the ward, feverish and breathing with great difficulty. His condition didn’t respond to pneumonia treatment, and a chest X-ray revealed liquid surrounding the right lung. My attending physician concluded that Adrian had severe malnutrition and pneumonia and decided to continue his antibiotic treatment.
Adrian died on the third day of my watch. An autopsy revealed the little boy had been afflicted with TB. That was likely why he died, not malnutrition or pneumonia. We later found out that Adrian was living with an uncle who had recently died “coughing blood.” My attending physician confessed that he had been so focused on managing the presumed pneumonia that he didn’t think about TB as an alternative diagnosis.
As a doctor, you don’t forget a death under your care and that is why the 47th Union World Conference on Lung Health that gets under way in Liverpool in the United Kingdom this week will be so vital. Pediatric tuberculosis will be an important and complex issue on the agenda. The conference follows the World Health Organization’s latest report on TB, which showed that the TB epidemic is larger than previously estimated. Fortunately, effective treatments and innovative practices abound.
According to the WHO, TB killed 170,000 children in 2015. That’s almost 10 percent of TB’s total death toll. In the same time period, 10.4 million people are estimated to have fallen ill with TB, of which 1 million were children. In settings with a high burden of TB, around 10 to 20 percent of all TB cases are expected to occur in children. Such settings are countries that also have high rates of mortality in children who are younger than 5, thus making it more likely for sick and malnourished children to also be infected with TB.
It is difficult to diagnose children with TB: Around 20 to 30 percent of TB in children lack a typical pulmonary manifestation; it can affect the lymph nodes, the meninges of the brain, or be disseminated throughout the body. TB can also accompany children with malnutrition, pneumonia, and HIV, thus “hiding” a tuberculosis diagnosis.
All too often, maternal, newborn and child health — or MNCH — providers fail to ask about household TB contacts as part of the medical assessment of a sick child, such as adults who are diagnosed with TB or who are coughing for more than 15 days.
To make matters worse, in cases when we do suspect TB may be the problem, we often don’t know what to do — should we refer the patients elsewhere, or try to treat it ourselves? Part of the problem is that MNCH practitioners are seldom trained and encouraged to think of TB as a childhood disease, and what to do when confronted with a potential case. Moreover, MNCH and TB practitioners usually have none or limited collaboration for patient consultation and referral.
4 ways to capitalize on existing MNCH services
I am — and believe we should all be — more optimistic about the future. Examples of good policies and field implementation exist throughout the world. Of course, challenges still remain on both, especially in the countries where the TB burden is the largest. But there are enough positive examples to learn from using “south-south” exchanges. As a global community of MNCH and TB practitioners, we need to facilitate a speedy learning of these best practices.
Here are a few ways that TB programs can capitalize on existing MNCH services.
1. Improve the identification of children infected or diseased with TB who are in contact with an index TB patient. Active case finding is one of the most efficient ways to control TB transmission among children and adults because new infections usually occur around existing patients. The experience of MNCH programs with community health workers and volunteers, home visits, and outreach activities could decisively enhance active case finding.
2. Call on existing community- and facility-based MNCH providers. These providers can administer TB prophylaxis (to children exposed to TB patients) or TB treatment (to those diagnosed with TB), as it is currently happening in Brazil, Ethiopia and Afghanistan.
3. Utilize community-based peer support groups. Given that both TB prophylaxis and treatment last six months and require continuous family and community support to complete, TB providers can adapt the existing experience of community-based peer support groups, which have increased the attendance of pregnant women to antenatal care and skilled birth delivery. Thus, like-minded community groups can support the adherence of TB patients to their six-month drug regimen, as has happened with the Cured TB Patients Councils in Afghanistan.
4. Engage existing community-based MNCH organizations. These include women’s groups, safe motherhood action groups, youth and adolescent peer groups, and others. They can disseminate appropriate messages and raise awareness of childhood TB and its relationship to malnutrition, pneumonia and HIV infection. We can apply tools such as the Community Action Cycle to build local capacity to explore root causes, identify and prioritize local health challenges, and work to plan actions.
The big picture
Childhood TB is gaining significant policy attention at the global and national levels. Key policies took center stage at a recent webinar moderated by UNICEF, Save the Children and Management Sciences for Health: the 2013 WHO guidelines for managing children with TB and the increasing number of national guidelines for TB control, which include separate chapters for the identification and case management of TB in children.
The discussion also highlighted successful examples of the field implementation of these international and national policies — fortunately showing increased cooperation between TB and MNCH practitioners.
Here are some success stories that give me hope:
• In Uganda, the TB program uses the existing MNCH-focused village health team members to improve the detection of household contacts who might have TB.
• In Ethiopia, a similar program resulted in 90 percent of registered household contacts being screened for TB, with about 11 percent being children under 5.
• In Afghanistan, when women aren’t allowed to leave their homes, community health workers collect sputum samples from children at home and bring them to the health facility for testing. And the country’s national MNCH and TB programs trained midwives and other health professionals on childhood TB detection.
• In Malawi, the novel inclusion of a single question on household TB exposure as part of the diagnosis of sick children led to the identification of children at risk for TB. They were then referred to a health facility for a final diagnosis, but many of them never reached the facility mainly because of lack of transport or financial means.
And now years after Adrian’s death, Peru is a world example of how TB can be effectively controlled. If the global health community can identify and collectively address TB with today’s innovations and collaborations, we can prevent these tragic childhood deaths.
Dr. Luis Tam is the global technical lead for maternal, newborn and child health at Management Sciences for Health, a global health NGO. With 32 years of global public health practice, he regards childhood TB as one of the most important technical topics yet to be addressed in the implementation of the global maternal, newborn, and child agenda.
Developed by USAID’s Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, e-TB Manager enables providers to manage susceptible tuberculosis, MDR tuberculosis, tuberculosis-HIV, and paediatric tuberculosis cases from diagnosis to treatment outcome through WHO guidelines. It allows communicable disease teams at all levels, from health-care providers to government officials, to access individual and consolidated data for evaluating system performance across facilities and regions. Each user account is assigned a certain view by the National TB Program authority depending on the health system level of use. Usually a select handful of staff from the central level will have access to the entire country’s patient data. These are assigned “administrator view.” The vast majority of users in the country can see patient data only for those patients that they are serving, be it at a large city hospital or in a district health facility. Depending on the size of the country, certain doctors or nurses are designated “administrator view” for their responsible state or province.
We recently conducted an 18-point anonymous e-TB Manager user satisfaction survey in nine countries that covered more than 2000 users working in some 1500 health facilities (infographic). We had a high response rate of 76% and received more than 600 user comments. These were channelled back to respective country national decision makers to help with continuous quality improvement, thereby meeting some of the Principles for Digital Development. We also conducted in-depth interviews with key leaders and implementers and learned how e-TB Manager facilitated national, regional, and local health workers’ abilities to track and manage tuberculosis cases. Our findings have key implications for digital health technologies in general.
Niranjan Konduri is a Principal Technical Advisor of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) programme, funded by the US Agency for International Development (USAID) and implemented by Management Sciences for Health.
Please join Management Sciences for Health (MSH) during the 47th Union World Conference on Lung Health in Liverpool, UK.Since 1971, we at Management Sciences for Health (MSH) have worked at all levels of the health system—with policymakers, health professionals, and communities—in more than 150 countries to improve the quality, availability, and affordability of health services. In response to the HIV and TB epidemics, we build the capacity of our public and private sector partners to prevent TB and HIV and improve diagnosis and management of co-infected patients.Through collaboration with our country partners and national TB and AIDS control programs in 20 nations throughout Africa, Asia, Europe, Latin America, and the Caribbean, we work to increase access to quality services and medicines. Some of our key interventions include developing policy guidelines to ensure TB and HIV patients receive the care they need, implementing standard operating procedures to guide health service delivery processes, and training and supervising local health workers to improve clinical care and management of patients co-infected with TB and HIV.
Follow live updates on this blog and on Twitter with hashtag #unionconf and #healthsystem.
MSH staff are preparing for our largest ever presence at The Union Comference; 50 posters and 13 oral presentations, plus speaking at 7 symposiums and 2 workshops, all highlighting the important and vital global work surrounding tuberculosis (TB) and lung health. In over 30 countries, MSH is working with international, national and local partners to strengthen the capacity of health systems, national TB programs, and health managers to improve the lives of those affected by TB and prevent the spread of disease.
We also will have a booth (#34) in the technical exhibition area. (See event highlights below.)
A Movie Demystifying TB
Hosted by Management Sciences for Health
Friday, October 28 | 5:30 – 7:00 p.m. ACC Liverpool | Session Room 1A
How do you connect with the public about tuberculosis in a new way? How do you tell a compelling public health story in a world cluttered with health messages? The Leadership Management and Governance (LMG) Project implemented by MSH together with Discovery Learning Alliance (DLA), Howard Hughes Medical Institute (HHMI), and Wellcome Trust share their innovative initiative “The Lucky Specials,” a feature film aimed at changing how communities and individuals understand and respond to TB.
Workshop: Lessons learned from increasing access to Bedaquiline and Delamanid for management of drug resistance TB
The purpose of this session will be to present and share preliminary lessons learned from selected countries that have accessed Bedaquiline and Delamanid through the GDF. This information is relevant as countries plan to introduce Bedaquiline and Delamanid.
Thursday, October 27
10:30-12:00 | Session Room 8, ACC Liverpool
Symposium: Active TB drug safety monitoring and management: a transformative approach to limit treatment-related patient harm
Reporting adverse events (AEs) from real-life clinical practice contributes to evidence for decision making that impacts prescribing practices and improves treatment safety. In 2015, the World Health Organization launched the active drug safety monitoring management (aDSM) strategy. The strategy aims to promote the safe use of new TB medicines and novel regimens and develop a robust safety database to proactively protect public health. Chair: Antonia Kwiecien (MSH, PHT)
• Improving TB patient safety and management: the Georgia experience Nino Lomtadze, SIAPS Consultant, Georgia
Friday, October 28
10:30-12:00 | Session Room 4, ACC Liverpool
Symposium: Challenging Tuberculosis in Urban Settings and Big Cities in African, Euro-Asian and Latin American countries
The world’s total urban population reached an estimated 3.8 billion in 2013, and is projected to swell to nearly 6.3 billion by 2050. In 2015, the urban population represented over half of the global population compared to about a third in 1960. During the last two decades, TB incidence has increased in urban settings and big cities as a result of several social and demographic factors, including poor TB control efforts and the rise and concentration of high-risk groups.
Chair: Pedro Suarez (MSH, HPG, Arlington, USA)
• 10:45-11:00: Addressing the TB control issue in fragile states: urban DOTS experience in Kabul, Afghanistan Mohammad Rashidi Challenge TB, MSH, Afghanistan
Saturday, October 29
10:30-12:00 | Session Room 4, ACC Liverpool
Symposium: TB elimination initiative in countries of Latin America Region
There is heterogeneity in the distribution of tuberculosis (TB) incidence rates among countries of the Americas, from over 200 cases to less than 10 cases per 100,000 population. A group of low-incidence countries in the Latin America (LA) Region was constituted in 2000, including Chile, Costa Rica, Cuba, Uruguay and Venezuela as observer. In 2010, the united States, Canada and Puerto Rico were invited to join. The group aims to adapt TB control measures to these contexts, exchange North-South and South-South experiences, and develop a TB elimination plan aligned with WHO’s framework for TB elimination in low-incidence countries.