The Stop TB Partnership and Médecins Sans Frontières (MSF) have released a new report that shows critical delays in updating national policies to reflect the latest international guidance in key areas of tuberculosis (TB) care.
The 2020 Step Up For TB report reviews the national TB policies of 37 high burden countries with regards to TB care, focusing on policies and practices related to four key areas: diagnosis, treatment (including models of care), prevention, and medicines procurement policies.
Despite chronic underfunding for TB R&D (research and development), over the last decade there have been a number of key developments in TB care, from new drugs and regimens for drug-resistant TB and for TB preventive therapy (TPT), to advances in TB diagnostics that allow for faster detection and diagnosis of drug resistance.
However, for these advances to really matter, they must lead to real-live improvements for people with or at risk of TB. This means that national guidelines need to be updated to account for new innovations in TB care and prevention, leading to a better standard of care.
The impact that the COVID-19 pandemic is having on the world’s health systems reveals the important synergies across all diseases when it comes to access and quality of care. Dr Grania Brigden, The Union’s Director of TB responded to the report, saying, “If the world´s governments had taken the decisive steps toward stopping the household transmission of TB as they had promised to do at the United Nations two years ago, we could have been better prepared to deal with COVID-19.”
“What we are seeing today, in terms of the numbers of people dying from TB and from COVID-19, or being coinfected, is the consequence of broken promises and broken public health. It should be a wake-up call to government to invest in the health of its citizens or otherwise face up to future pandemics feeding off preventable, treatable and curable epidemics like tuberculosis.”
Thanks in large part to advocacy from affected communities, TB care is slowly moving towards a more person-centred approach. All-oral treatment regimens are now recommended for the treatment of drug-resistant TB (DR-TB). Shorter treatment regimens are also recommended, which are easier for people to take closer to home and remove the need for long hospital stays.
Despite these recommendations, 7 of the 37 (19%) countries surveyed still require hospitalisation for all people with DR-TB. However, the report highlighted that 41% of countries had policies to initiate DR-TB treatment at primary healthcare facilities, with 75% having national policies enabling DR-TB treatment follow-up at primary healthcare facilities. This transition to moving treatment out of hospitals and into communities must continue as clinically needless routine hospitalisation becomes a thing of the past.
Newly available all-oral regimens are proving to be a more effective and tolerable form of treatment for people with DR-TB, and it is encouraging to see that 22 of 36 (61%) countries have national policies that include a new, shorter all-oral regimen either for routine use or for operational research. These new all-oral regimens have not been in use for long; governments must invest in operational research that will help health authorities better understand how to best use them in real-life clinical situations.
The report also reviews national policies on TB prevention: only half of the countries surveyed have national policies reflecting international guidance for providing TPT to people over 5 years of age who live with someone diagnosed with TB. In 2018, the UN General Assembly endorsed a target to provide TPT to 29 million people in this age group by 2022. Globally, countries are less than 1% of the way toward meeting this target, and, as the report suggests, policy inertia is playing a big role.
Countries are making much better headway on TB prevention for people living with HIV (PLHIV). A full 100% of the countries surveyed had national policies reflecting the latest international guidance for making TPT available for people living with PLHIV—a tremendous advance. Last month the World Health Organization (WHO) reported that countries were 88% of the way toward meeting the target or reaching 6 million PLHIV with TPT by 2022, as established by the UN General Assembly in 2018. This progress shows that national policy is critical for driving action to achieve global targets.
Policy change requires stronger support for national TB programmes—particularly stronger support from their own governments; political will is essential to eliminating TB. Finally, policy change is not the final or only piece required in countries. Policy implementation should be monitored regularly, ensuring that policies lead to real-world improvements in care in line with internationally agreed targets.