Are we putting money where the mouth is to reach the missing millions?

Shobha Shukla, Bobby Ramakant *

Unless we find people with TB and put them on treatment, how will we be able to reduce avoidable human suffering, untimely deaths, and break the chain of infection transmission? Finding TB remains the critical entry point to TB care pathway.

Amidst the growing call for finding new tools to prevent, diagnose and treat TB, are we using the best of such tools we have today to the greatest possible extent? While we must fully fund and support TB science for better new tools, it is no less a compelling priority and a human rights imperative to ensure that all the new evidence-backed technologies we have today, are maximally deployed and utilised – everywhere. Scientific breakthroughs must be converted into public health advances, no excuse not to do so.

A day before the United Nations General Assembly High Level Meeting (UNHLM) on TB was held on 22 September 2023, we read a news from Papua New Guinea. The island nation has 70 WHO recommended molecular testing machines (Gene Xpert - which requires semi-centralised infrastructure) to diagnose TB in each of the 22 provinces or cities; but all are underused except one which is installed in its capital city at Port Moresby General Hospital. Despite 32% of those with TB could not be diagnosed in 2021, all but one of its molecular testing tools lie underused in the country in 2023.

Reasons cited for underuse of Gene Xpert molecular tests were: “sputum transportation challenges, road conditions, etc.” Real reason, which is not cited in the news, could be that Papua New Guinea has deployed Gene Xpert which is not laboratory independent and requires semi-centralised infrastructure in place.

One wonders that why was the existing WHO-recommended point-of-care, laboratory independent and decentralised molecular test (Truenat) not deployed in Papua New Guinea instead, to resolve issues such as, “sputum transportation challenges, road conditions, etc.”

Are we missing a chance to make a change?

Among the WHO recommended molecular tests, Truenat (made by Molbio Diagnostics in India) is the only laboratory independent, portable, and low maintenance platform solution that can replace microscopy for TB, and also perform multi-disease testing at the primary healthcare level. It works equally well in secondary or tertiary healthcare services too.

Why are we knowingly making a wrong choice?

Today, thanks to scientific advancements, we have a far better and proven choice to find and treat TB. So why are a large majority of people with TB still getting diagnosed using old archaic and inefficient tools (like sputum microscopy) and treated with drugs that are toxic, far less effective, and have a longer treatment duration? There is no reason why old tools, that are inefficient in preventing, diagnosing or treating TB, should not be done away with when we have better choices today.

Let’s do a reality check: In 2021, globally 39% of people with TB were not even diagnosed. During 2018-2021, a whooping 62% of those diagnosed with TB did not get a WHO recommended molecular test – instead they received the 140 years-old smear microscopy that underperforms to detect TB. Despite having the scientific evidence and WHO recommended molecular tests that have proven to work effectively, why have we not replaced all microscopy tests with the molecular tests by now?

Perhaps, this is a moment of truth - have we truly invested to ensure that a person with TB gets the best of standard WHO recommended diagnosis, treatment, care, and support? With the gaping chasm between what-we-know works and what-we-do, how do we hope to end TB in the next 27 months in India and 87 months worldwide?

Is it not time for people to demand that they be tested with WHO recommended molecular tests and treated with the one-month regimen for latent TB infection (TB preventive therapy), four-months regimen for drug-sensitive TB, and six-months regimen for drug-resistant TB?

Rocking chair?

Every motion does not result in moving forward. There is a price we pay if we do not use the best of existing diagnostic tools or treatments: the price is so heavy and so inhumane – and so avoidable – in form of more human suffering, untimely deaths, and more infection spread. This is so unacceptable.

Put money where the mouth is: Taking TB services to those unreached

The WHO, Stop TB Partnership, national TB programmes, affected communities, and partners have ably demonstrated that high TB burden countries can use innovative new tools to screen and diagnose TB and link the people with TB to treatment and care. With deployment of new innovative tools, not only these projects were able to find more people with TB but also put them on lifesaving treatments.

Having the best of molecular tests is not enough unless they are accessible and within reach of all those who may be at risk of TB. The national TB prevalence survey of the government of India (2019-2021) shows that half of those diagnosed for TB did not have typical TB symptoms, but showed an abnormality in the chest X-ray, which led to their TB diagnosis.

If we are to end TB, we must ensure that all people are screened for TB and not just those who are symptomatic.

In the 1970s, richer nations like Australia had screened everyone (not just those with TB symptoms) and provided TB treatment to those found positive. Eventually Australia could bring TB rates so low that TB was considered eliminated in the nation. It is important to note that back then Australia did not have the latest TB diagnostic tools we have today.

More recently, a few years back in some parts of Vietnam, all people were screened using modern diagnostic tools for TB, molecular tests were provided to those with presumptive TB, and those found with the disease were linked to treatment and care. As a result of this, TB rates dropped by 68% in a period of 4 years, said Dr Nguyen Binh Hoa, deputy manager of Vietnam’s National TB Programme.

The best time for a paradigm shift was years back. Next best time is now. Science-based active TB case finding needs to be a norm and not confined to pilots anymore. We have to walk the talk on active case finding by using the best of screening tools recommended by the WHO (and not merely through verbal questioning for TB symptoms), and follow those with presumptive TB by offering a molecular test on their doorstep, and treatment, care and support to those found positive for TB.

TB lab on wheels

Dr Arvind Mathur, WHO Representative to Timor-Leste shared how an innovative approach – “TB Laboratory on Wheels” – one stop mobile diagnostic van – is being used to find the missing people with TB.

TB Lab on wheels has taken TB diagnostics closer to the communities. It is equipped with digital x-ray, WHO recommended molecular test Truenat, and electronic medical record facility synchronized with Artificial Intelligence (AI) for reading the digital X-ray films. This van is helping to screen TB among different populations including high risk people and in villages and hamlets.

“We were looking at how to increase case detection rate, how to go about screening large populations for TB in a short span of time. This molecular diagnostic tool (Truenat) is much more easily accessible, requires low maintenance, and gives quicker results. On one side we have digital x-ray with AI that can provide us a very formal confirmation to some extent about where the problem is, and then at the same time we could run the molecular test (Truenat) to confirm diagnosis of TB, within the same settings and look into drug resistance in relation to the next step to be taken,” said Dr Mathur to CNS (Citizen News Service).

The impact: “In a short span of time, around 7000 individuals have been screened with more than 600 people identified with presumptive TB. A 32% increase in detection has been observed as a result of using this technology,” confirmed Dr Mathur.

TB lab on wheels approach is being adopted by many other countries (and customised to their contexts) such as Cameroon and Bangladesh, among others. Now, the big van is just a big car with a mounted Truenat molecular test and other best of TB screening tools.

TB lab on utility boat goes from islet to islet in the Philippines

Dr Samantha Tinsay, Municipal Health Officer, Bantayan Municipality in Cebu, Philippines shared how Truenat molecular test machines, along with Fujifilm portable x-ray, were kept in a plastic tub and taken in a utility boat from islet to islet to screen and diagnose people with TB. “Case detection went up by over 317% and screening of presumptive TB went up by 1293%,” said Dr Tinsay.

It is not difficult to imagine the huge positive public health outcomes if what Dr Mathur and Dr Tinsay have done in a limited manner was done on a larger scale in all high TB burden countries. What is holding us back from doing so? We can tailor the approach to find TB and treat TB in local contexts but if we continue to do ‘business as usual’, we will miss this opportunity to make a real difference by using the right tools at the right place and time.

Finding the missing millions timely with appropriate tools

With TB elimination targets far off the track, the sense of urgency and purpose should drive us to turbocharge deployment of the best of tools we have to find and treat TB. We also need to turbocharge the efforts to find better new tools to prevent, find and treat TB too. This is not an “either/or” situation, but it is about doing both with compelling commitment and urgency.

Finding new tools is one part of the relay race, deploying them and ensuring full uptake of the services is another. Full scale deployment and uptake of new innovative tools to find and treat TB globally will also pave the way for better rollout of new tools that are in the research pipeline (if and when they come in future).

The 2nd UNHLM on TB (although attended by only one head of nation, Zimbabwe, among others) ended with an important political declaration. Next UNHLM will be in 2028. But answer to the question “will we walk the talk on the promise to end TB” will be written by us – especially donors and governments – if we can eliminate the divide between what-we-know-works and what-we-do.

It is high time to make the right turn to end TB, so do we believe.