Endorse the global call: Find all TB to stop TB

(click here to endorse the global call) Unless we stop missing TB cases, we cannot end TB. One of the key actions enshrined in the WHO Director General’s flagship initiative to Find.Treat.All (first launched in 2018) is to replace microscopy with upfront rapid molecular diagnostic test by 2027, because microscopy underperforms in diagnosing TB, and thereby misses TB cases. More importantly, the WHO initiative backed by the Stop TB Partnership and The Global Fund, calls for a people-centred and rights-based TB response, through community-led and gender-transformative interventions.

But the progress is way off the mark. Almost 7 out of every 10 people with presumptive TB worldwide were not diagnosed by a molecular test in 2021, and TB response is far from being people centred even today.

Early and accurate TB diagnosis is not only a critical gateway to TB care pathway, but also a public health and human rights imperative. It helps stop the spread of TB infection as well as reduces unnecessary human suffering and risk of untimely deaths due to TB.

Bringing “lab to the people” (and not people to the lab) is the first vital step towards finding TB. If we fail to do this, we will keep missing TB cases despite having the best of tools in the labs.

Additionally, we must ensure that the full cascade of TB care services is people centred.

Call to find all TB to stop TB, has 1 key ask and 2 actions:
  • Key ask: Stop missing TB cases
  • Key actions
    • 100% replacement of smear microscopy with WHO recommended molecular tests as soon as possible, along with a paradigm shift from a lab-centric to a fundamentally people-centric model to find TB, leaving no one behind
    • Find the missing millions! Screen everyone (and not just those with TB symptoms) with WHO recommended screening tools and confirm those with presumptive TB using molecular tests

Why we need this call to find all TB to stop TB?

Diagnosis is the entry point to TB care pathway. If we are to end TB, we must find TB early and accurately – and leave no one behind.

· Firstly, 4 out of every 10 estimated people with TB worldwide are missed (or we do not know what TB care they receive if at all).

· Secondly, only 38% of the remaining 6 out of every 10 people with TB globally get a WHO recommended molecular test.

o This is a hugely missed opportunity as a lot of them get tested using smear microscopy that underperforms in TB diagnosis, and many of them are not even bacteriologically confirmed for TB.

o We will miss (or misdiagnose) cases if we use underperforming tests or do not confirm them bacteriologically (as far as possible).

o If we take the best of TB screening and diagnostic tools from the lab to the people, we can find all TB.

o Ensuring TB response is people-centred is pivotal for the full implementation of the WHO’s Find.Treat.All.

Verbal screening for 4 symptoms of TB is not enough because a significant number of TB patients are asymptomatic. The WHO definition of active TB case-finding is “provider-initiated screening and testing in communities by mobile teams, often using mobile X-ray and rapid molecular tests.” Screening everyone (and not just those with symptoms) have proven to reduce TB rates significantly (such as in parts of Vietnam recently TB rates declined by 68%, and earlier in countries like Australia). Screening everyone with WHO recommended TB screening tools and confirming them on molecular tests should be the mainstay.

Test and treat must be the norm, and not the other way round, as happens often especially when health systems are weak or fragile.

Everyone who get diagnosed with TB must be offered a drug susceptibility testing (DST) so that treatment with effective medicines (and latest WHO recommended 1/4/6 regimens) can be initiated on the same day ideally. The 1/4/6 regimens refer to: 1 month regimen for latent TB infection, 4 months regimen for drug sensitive TB, and 6 months regimen for drug resistant TB. Care and support during the anti-TB therapy plays a key role in helping people complete the treatment successfully. Infection control and all other evidence-based approaches and tools that have worked to address TB must be optimally deployed (such as, food security, and/or collaborative activities related to TB-tobacco, TB-HIV, TB-alcohol, TB-diabetes, among others).

If we act upon the key ask, imagine the difference it will make when no TB case is missed, and all people with TB are brought in the care fold in a rights-based manner. A people-centric approach to find all TB, treat all TB, and prevent all TB is critical to end TB.

Let’s make this difference, everywhere!