Thrust to 'reach the 3 million' missing TB cases

World TB Day, 24th March
The theme for World TB Day 2014 is 'Reach the 3 million.' Of the nine million people who get sick with TB every year, one third or three million of them are ‘missed’ by health systems. Reaching them and then treating and curing them is an essential step towards achieving Zero TB Deaths and also to halve TB deaths by 2015.

The World Bank estimates that each dollar invested in TB yields US$ 30 in return, making it great value for money. We need to invest more to find and treat the missed 3 million.

A "3 Million" brochure issued jointly by the World Health Organization, the Stop TB Partnership and the Global Fund to Fight AIDS, TB and Malaria (The Global Fund), highlights the problem of the millions missing out on quality care and calls for everyone suffering from TB to have access to quality TB care including diagnosis, treatment, prevention and cure. Here are the main highlights of the brochure:

Every year 9 million people get sick with TB, but 3 million do not get the care they need and are missed out. This has devastating human, health and economic consequences. We have to find them; treat them; and cure them with urgent action and increased investment, ensuring that no one is left behind. ‘Missed’ is the gap between the estimated number of people who become ill with TB in a year and the number of people who are notified to national TB programmes. Many of those who are missed do not get the TB care that they need. Hence many of them will die, some will get better, while others will continue to infect others. The proportion of missed cases has been nearly the same for the past seven years and their number is accumulating every year.

Nearly half of the 3 million missed TB cases are in Asia, while South Asia and Africa account for nearly 66% of them. The majority of these people with TB first go to the private sector to access TB treatment, whose TB management practices are rarely aligned with national or international standards, and they generally do not notify people under their care to national health systems.

The main reasons for missing such a huge number are: weak recording/ reporting public systems and lack of mandatory case notification by health service providers; poor linkages with private health sector; limited awareness of why and where to seek care; financial barriers; little community engagement and outreach; poverty, marginalization and related stigma; and limited number of health facilities.

People with TB may not access care at all. Or they may access health services but not get diagnosed. Some people do get diagnosed but may not get started on proper treatment or get notified.

Integrate TB-HIV care
In 2012 only 50% of the estimated 1.1 million new cases of people with HIV-related TB were reached globally even though TB is the leading cause of death among people living with HIV. The dual stigma associated with TB and HIV, along with discrimination in health care settings, further limits access. Multi-sectoral engagement, integrated service delivery and the scale-up of rapid diagnostics in HIV care settings are critical to expand access to testing and full TB/HIV care.

Treat all those with multidrug-resistant TB (MDR-TB)
In 2012, globally only 94, 000 of the 450, 000 (just 25%) people estimated to have MDR-TB were diagnosed. The pace of expansion of MDR-TB diagnostic testing needs further acceleration. Financing of quality diagnostics and drugs need to be secured, along with a network of well-trained facility-based and community care providers. Stronger links between the public and private sectors will help limit the development of drug-resistance and enable improved access.

Some simple and effective solutions:
(i) Expanding access to care by: focussing on vulnerable communities; improving awareness to
reduce stigma; expanding community-based outreach; eliminating out-of-pocket expenses for receiving care; and increasing the number of public, private and voluntary quality TB care health facilities.
In Ethiopia a recent community outreach programme involved training, engaging stakeholders and communities and active case-finding by female Health Extension Workers (HEWs) who are lay workers with a small government salary to provide basic services to their communities. HEWs identified individuals with TB symptoms in their community and also collected sputum, prepared slides for microscopy and supervised treatment. TB case notification almost doubled and treatment success improved in just one year in an area of over 3 million people.

Myanmar has framed a national response plan to find its heavy burden of missed TB patients using evidence. The response builds on the ongoing roll-out of new rapid TB tests, and more effective use of chest X-ray for TB screening. It involves hospital out-patient departments, use of mobile X-ray units for screening in poor urban areas and selected remote rural areas.

(ii) Expanding screening and testing by: enabling healthcare providers to better identify patients with TB symptoms for further testing; performing systematic screening in high-risk groups; improving access to better screening and diagnostic tools, specimen transport and patient referral systems; and strengthening outreach to the contacts of persons with TB.

In Afghanistan, the staff of 47 health facilities was trained in screening, to ensure good sputum collection. Through improved screening of people attending health facilities, in one year over 70% more cases were found than in the year before and almost one million people were screened.

South Africa is currently the largest user of Xpert MTB/RIF in the world which has resulted in a dramatic increase in the numbers of people diagnosed and put on treatment for MDR-TB. Moldova too has been able to identify twice as many people with TB by Xpert than by smear microscopy.

(iii) Improving information flow for quality care by: strengthening TB recording and reporting
systems; implementing mandatory TB case notification systems; and expanding linkages that enable all those who can screen, test, diagnose or treat TB to effectively communicate and serve patients.

Pakistan’s multi-pronged approach includes not only investing in public- private mix but also in private-private mix through the promotion of social franchising and social business models. Currently, every fourth case is notified by engaging the private sector. An initiative provides a mix of an incentive-based system to community lay workers who act as screeners using mobile phones in a large number of small general practitioner facilities and a large hospital. It also involves mass media campaigns, and a sputum transport network. In one year, case notifications from the reporting unit in Karachi doubled. In the second year the same approach was expanded to a second area of the city with equally impressive results.

In Philippines, streamlining hospital TB clinics in Manila has increased case notifications by over 13,000. The model is now being replicated and scaled up nationwide.

In India, national and regional task forces set up to involve all public and private medical college hospitals, with related financial aid for operating hospital-based TB clinics, have helped contribute up to 15% of national case reporting from these facilities.

In China, strengthening of surveillance systems has improved notifications. Its National TB Programme provides services principally through a network of TB dispensaries. Yet, a large number of people with TB symptoms seek care from hospitals, which do not always enable continuity of care during the full TB treatment. In 2004, the government established a national web-based system for mandatory reporting of 37 infectious diseases, including TB, within 24 hours of diagnosis. With this stimulus, hospitals now contribute nearly 40% of TB notifications in China.

Small interventions that have had big impacts
In Karachi, Pakistan, community health workers are using electronic scorecards on mobile phones to identify people that need a TB test. At a low cost, they identified six times the number of cases of childhood TB compared to previous years.

In the remote villages of Lesotho, health workers on horseback reach out to communities which previously had little or no access to healthcare. The health workers pick up samples from villagers and take them to laboratories for analysis. The test results are reported via text messages and people with TB are provided with life-saving drugs.

In Mbeya, Tanzania, a mobile laboratory offers a rapid diagnostic test for TB and HIV testing in rural areas. The van serves as a test centre during the day and a mobile cinema at night. Zimbabwe and Cambodia have also adopted this approach.

In London, UK, where TB rates are among the highest in Western Europe, a cost effective outreach programme using mobile digital X-ray units helps homeless people, drug/alcohol users, vulnerable migrants, and people who have been in prison, to access TB care. The team includes former TB patients, health and social workers.”

Dr Mario Raviglione, WHO Director of the Global TB Programme said, “We hope our focus this year on the people ill with TB who are missed helps drive practical action in the field.  We cannot miss the opportunity now with new TB strategy, new diagnostics, and more partners engaged in universal health coverage and TB efforts, to reach all people and communities – they have a right to access quality diagnosis and care.”

“It is easy to reach people like me with TB services, but to reach those most vulnerable, most at risk, those that are poor, weak, scared, stigmatized, and alone – for this, you need additional efforts, you need innovative thinking and, beyond anything else, you need to care. I am happy we are having this conversation on reaching, treating and curing everyone with TB at a global level. This is what it is all about,” said Dr Lucica Ditiu, Executive Secretary of the Stop TB Partnership.

“Our partners are driving a more targeted approach, and we fully support that,” said Mark Dybul, the Executive Director of the Global Fund. “People in countries with these missing cases can take advantage of the flexibility and agility of the new funding model to reach more people affected by TB.”

On this World TB Day 2014, let there be a global effort to find, treat and cure all those ill with TB and accelerate progress towards zero TB deaths, infections, suffering and stigma.

Citizen News Service - CNS
March 2014

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