Disability

Efforts to properly and adequately secure health for those with disabilities is a global work in progress.

The 2022 Global Report on Health Equity for Persons with Disabilities [1] is a great step forward. Next steps could include:

1.  Planning
• Plans for follow-up reports, updates and standardization work (metrics, etc) could be detailed. Short- and long-term points, meetings, and responsibilities of individual groups could be detailed.
2. Strong analysis
• Application of the definition of disabilities as “those who have long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on an equal basis with others” could be analyzed sharper. This definition could be examined In the context of the cited estimate that 80% of persons with disabilities live in low- and middle-income countries where health services are limited [2]. Stronger analysis would improve global picture accuracy and focus.  
• Tiers related to outcomes, health quality of life and policy implementation by country could be developed in similar fashion to income tiers. This could help with organization and a united path forward. 
3. Representation 
• Survey and response could include patient disability and patient advocacy organizations. For example, global spinal cord injury, global vision and global autism organizations could ask patients and caregivers needs questions directly. Asking communities what they do not have to help keep them healthy, as well as what is preventing them from obtaining what they need (ie money, transportation, stigma, independent decision-making, unavailable resources in the country) is a solid approach.
4.  Hand-off improvements
• World health makes many recommendations for many health issues, and the recommendations are broadly directed to government, leadership, policymakers and rights groups. A specific handoff with set expectations could be established for disabilities and health. When WHO makes specific recommendations regarding epilepsy [3], decisions, implementation and funding would be automatically picked up by the team. When disabilities related to specific disorders receive significant attention, and solutions are presented, there should be a coordinated hand-off. 
5.   Implementation
• Literature reviews with international focus should be examined, compiled and used as a foundation for future portfolio planning.e
• Recommendations should be decided on and concerns should be taken seriously. For example, healthcare worker training, communication and time allocation barriers [4] related to primary care and intellectual disability should prompt discussions of medicine redesign.

The United States continues with integrated approaches to disability and healthcare. Social services, disability experts and public insurance are major coordinators in this approach. Despite efforts, healthcare for those with disabilities is insufficient and health outcomes are inferior. A few focal points could include:

1. Transparent actions
• Public health efforts to link disability alongside known health outcomes needs to improve. For example, the CDC’s Disability and Health offers many topics yet navigates us to the condition [5]. It would be helpful to know the data around disparities, the interventions, and the ongoing solutions. It would be helpful to hear if insurance coverage for adaptable gym equipment or insurance coverage for electric toothbrushes and prescription toothpaste is in the works. It would also be helpful to know if fresh fruit and vegetable adaptation tools, like kitchen appliances to help with soft diets, will be funded. 
• Public health efforts to address specific unhealthy behaviors within the disability community should be recognized, appreciated and funded. Work with smoking reduction [6] is a great example. 
• Public health efforts to align with world health on disability and health [7] should be encouraged and continued.  US public health work with the disability community [8] could be a model, or could adapt, alongside international health teams.
2. Strong analysis
• Financial literature around healthcare and disability is great [9]. Future analyses could consider inclusion of durable medical equipment specifics and/or access to holistic care (ie mental health, physical therapy, social services, meditation, complementary and alternative medicine, chiropractic medicine).
3. Representation
• The disability community should be part of public health design routinely, automatically and representatively.
• The disability community should be asked some basics, and those basics should be responded to. What can be done for better home care and home delivery? What can be done for independence with healthcare?
• The disability community should be routinely asked what should be considered as essential equipment for healthcare, including adapted bathing and personal hygiene tools.
• Response should be measured and, if applicable, reimbursed accordingly. It is patronizing to have conversations without response, and this community’s input should valued.  Failure to do so could be matched with reimbursement consequence.
4. Implementation
1. Health equity recommendations from medical experts [10] should be advanced with assigned responsibility from public and private healthcare partners.
2. Solutions should be shaped by anticipatory design. For example, training and education of healthcare workers continues to be a named solution for disability health equity. Yet there is no simultaneous work to link resources in a provider-friendly manner, improve electronic medical records, or create efficiency with medical billing. Solutions should be implemented wisely. 
5.  Expert guidance.
• The National Council On Disability should be listened to [11]. Private and public healthcare should be addressing policy requests without delay, then advocating and working toward policy implementation. These requests include:

1.       Designating people with disabilities as a Special Medically Underserved Population (SMUP) under the Public Health Services Act;

2.       Designating people with disabilities as a Health Disparity Population under the Minority Health and Health Disparities Research and Education Act;

3.       Requiring comprehensive disability clinical-care curricula in all US medical, nursing and other healthcare professional schools and requiring disability competency education and training of medical, nursing and other healthcare professionals;

4.       Requiring the use of accessible medical and diagnostic equipment

5.       Improving data collection concerning healthcare for people with disabilities across the lifespan.

 

US military, VA and veteran organizations can and should champion disability health equity. Disability and health equity is an enormous topic with many layers. Military and VA health partnerships can help lead the way to improvement. Some actions could include:

1. Implementation science
• Advancing health equity between military and civilian disabled populations as well as for everyone with a disability are both achievable. Research reviews, reimbursement for evidence-based practice, consensus on recommendations, and implementation science can pave the way
2. Research and data improvement
•  Stand-alone research, like an article on SCI and obesity [12], should have an automatic pathway through to decision-making, additional data funding or implementation of interventions.
• Literature reviews [13] should identify gaps for future research portfolio work.
• Satisfaction research should include best methodology to account for disability and health [14].
• Sources and surveys on military family satisfaction and needs [15-17] could be streamlined, removing redundancy or masking of any issue.
• Clarification between military family special needs and disability should be given consideration.
3.  Inclusion 
• Disability health efforts should account for disability comprehensively: military families with special needs [18], veterans and caregivers, active-duty members and spouses, and all other individuals involved with the military. 
• Conversations on data transparency and inclusion of the military should occur. Continued civilian population focus [19] is inefficient and suboptimal. Identification of the civilian veteran as the sole military indicator is also suboptimal, such as the American Community Survey used in disability reference [20].  Both 1) federal reimbursement of work that excludes military stats and 2) access and ease of de-identified active-duty disability data should be a civilian-military conversation.
• The National Council on Disability should always have a seat at the table and should always make room for VA and military disability health leadership at their table.
• Policy changes in civilian healthcare should occur equally in the military.

 

 

References

1. https://www.who.int/activities/global-report-on-health-equity-for-persons-with-disabilities

2. https://www.who.int/news/item/02-12-2022-health-inequities-lead-to-early-death-in-many-persons-with-disabilities

3. https://www.who.int/news/item/12-12-2022-new-who-brief-sets-out-actions-needed-to-improve-lives-of-people-with-epilepsy

4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7465578/

5. https://www.cdc.gov/ncbddd/disabilityandhealth/relatedconditions.html

6. https://www.cdc.gov/ncbddd/disabilityandhealth/smoking-in-adults.html

7. https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html

8. https://www.cdc.gov/grand-rounds/pp/2019/20191015-intellectual-disabilities-H.pdf

9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798675/

10. https://www.healthaffairs.org/content/forefront/advancing-health-equity-people-intellectual-and-developmental-disabilities

11. https://ncd.gov/sites/default/files/NCD_Health_Equity_Framework.pdf

12. https://www.tandfonline.com/doi/abs/10.1179/2045772311Y.0000000001

13. https://www.ncbi.nlm.nih.gov/books/NBK481384/?report=reader

14. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6800461/?report=reader

15. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2019.00274

16. https://bluestarfam.org/wp-content/uploads/2022/03/BSF_MFLS_Results2021_ComprehensiveReport_03_14.pdf   

17. https://link.springer.com/article/10.1007/s10826-021-02161-5?utm_source=xmol&utm_medium=affiliate&utm_content=meta&utm_campaign=DDCN_1_GL01_metadata

18. https://www.nichd.nih.gov/sites/default/files/about/meetings/2014/Documents/military_families_summary.pdf

19. https://files.eric.ed.gov/fulltext/ED620438.pdf

20. https://www.healthaffairs.org/doi/10.1377/hlthaff.2022.00499

 

Injury and Violence

Global health has done tremendous work addressing the public health components of injury and violence. 

Injury and violence reports and data breakdown are well organized, understandable and clear [1]. Thank you.  

• Injury and violence mitigation and treatment data could be clearer. Access to treatment and indicators for quality of care could be priority, particularly when disability and death are tracked. Additionally, evidence-based practice should be assessed and measured, particularly for trauma care and first response. This would encourage reviews, consensus and minimum expectations for debated issues [2] as well. 
• Data that addresses exclusions in global health could be accounted for. In example, drug overdose and gun violence are components to injury and violence public health work in the United States. Both adverse childhood experiences (ACEs) and traumatic brain injury (TBI) are also singled out in various country reports, yet not highlighted in this global report.  A category such as ‘other causes’ in the global health report, at minimum, could allow for country-specific components. Opportunities for standardization are evident and should be taken.
• The WHO response section is meaningful and impactful, thank you. Other WHO and UN reports have multi-agency policy crosswalks; perhaps policy crosswalks could be applied to injury and violence reports as well. 
• Violence mitigation interventions could also be catalogued and analyzed. This work could be clearer, with potential for research and intervention funding after analysis of evidence in various articles [3].
• Global health work could partner to organize the research portfolio, so that major research within countries [4-7], or on behalf of global health interventions [8,9], does not go without follow-up. Piecemeal is inefficient and can be wasteful. 
• Epidemiology liaisons could be offered at the design phase of the research to improve the quality of the research as well as build for the future. 
• Consensus on reporting and quality guidelines in the context of injury and prevention research, such as CONSORT [10] or GRADE, could steer funding. 
• Injury prevention work conducted under partnerships outside of global health, including through UN or charitable organizations, should not negate the need for collaboration and standardization of measures and interventions. Partnerships should also not negate the need for improvements in healthcare delivery that simultaneously assist research design.
• Occupational injury work should continue. Public health and public policy ties to global trade could also be sharpened.
• There is a lot to injury and a lot to violence. Perhaps these should be separated in health topics, with new definitions to tie the common and overlapping issues. 

The US continues to struggle with injury and violence, yet public health attention remains vigilant  [11,12]. 

• The US should continue to lead injury and violence prevention efforts. While other countries tackle processes the US already has in place, such as safe packaging and labeling, the US has opportunity to tackle its own pressing issues. 
• Expert recommendations [13] should be graded, tiered and implemented. 
• Major causes of injury that require multi-agency collaboration and policy implementation, such as transportation safety, should be funded for the long-term. Road safety could involve national campaigns, improved clarity to how state and local health departments track and intervene, multi-agency collaborations and accountability to state metrics.
• Healthcare involvement in violence prevention and management should continue to organize. AHRQ, patient safety and occupational safety work all address patient violence. The tools, screening, management, referrals and follow up should be clearer from aspects of operations, outpatient, reimbursement and insurance. The point of entry into non-emergency healthcare should see standards to injury and violence prevention, just as emergent healthcare should.
• Isolated military injury and violence work should be connected to greater public health. How the military funds violence and injury research, and opportunities for collaborative private-public sector approach, should advance. How military statistics are accounted for in local health department reports should be clear and should improve, especially those in which data is dependent on military courts, military emergency treatment billing or military bases. When local public health departments and state public health departments do not account for vehicle injury, substance abuse injury or interpersonal violence involving members of the military within military jurisdictions, local and state public health are not accounting for the entirety of the population.
• Multi-disciplinary expertise, including psychiatry, social services and advocacy organizations, should help shape a national strategic gameplan. If these task forces target specific populations, such as children or veterans, then leadership from those groups could be tapped for the national roundtable or research strategy work.
• Formal definitions and standards on allostatic load and cumulative effects would benefit all involved with injury and violence prevention. Aggregating and analyzing research in both military [14-17]  and civilian [18-21] populations could help organize a path forward. Methodology and definitions on cumulative effects and allostatic load needn’t be so disorganized. 
• There is a lot to injury and a lot to violence. Perhaps these should be separated in health topics, with new definitions to tie the common and overlapping issues.

References

1.       https://www.who.int/publications/i/item/9789240047136

2.       https://pubmed.ncbi.nlm.nih.gov/28513531/

3.        https://journals.sagepub.com/doi/full/10.1177/0963721416655883

4.       https://pubmed.ncbi.nlm.nih.gov/25356696/  

5.       https://pubmed.ncbi.nlm.nih.gov/20795459/

6.        https://pubmed.ncbi.nlm.nih.gov/28039683/ 

7.       https://pubmed.ncbi.nlm.nih.gov/28042961/  

8.       https://pubmed.ncbi.nlm.nih.gov/16376728/

9.       https://pubmed.ncbi.nlm.nih.gov/19474562/

10.  https://pubmed.ncbi.nlm.nih.gov/31129675/

11.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4958590/

12.   https://www.cdc.gov/injury/index.html

13.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4710475/

14.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4006087/    

15.   https://pubmed.ncbi.nlm.nih.gov/36062896/

16.   https://link.springer.com/article/10.1007/s11121-020-01156-w

17.   https://link.springer.com/article/10.1007/s10566-020-09544-7   

18.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3684171/

19.   https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1532-7795.2012.00786.x

20.   https://www.sciencedirect.com/science/article/abs/pii/S004723521630006X

21.   https://www.sciencedirect.com/science/article/abs/pii/S0047235216300150

 

Antimicrobial Resistance

Global health excels at attention to antimicrobial resistance. This attention is mirrored nationally and locally in the US. 

The WHO Global Action Plan from 2015 [1] could be updated. 

• Global burden estimates, broader surveillance strategies, and laboratory solutions that solve for barriers to optimal research [2] could be a component to an updated plan.
• SORT-IT and TDR work [3] could take a leadership position in the Global Action Plan. 
• Specific interventions could be determined using strength of evidence, available recommendations or feasibility, yet there should be consensus. For example, anti-malarial resistance research lists 24 separate intervention actions [4]. Funding and philanthropy could set expectations. 
• The culture around patient safety and antimicrobial resistance should include access to pharmaceuticals and labs through measures of wrong diagnosis or wrong treatment. In essence, global health should know an average estimate of delayed labs, no access to labs and the wrong antibiotic given.  
• The pharmaceutical industry should be specific about their pursuit of antibiotics. We often here how R&D funding goes to new antibiotic research, and how necessary various industry practices with questionable revenue are to R&D. Is the pursuit a match to the evidence [2]?

Excellent attention to antimicrobial resistance is mirrored nationally and locally in the US.

• Local and state public health should be consistent and up to date on actions taken to support antimicrobial resistance in the community. 
• Specific steps to measure and collaborate with long-term care facilities should be clear. Local and state health should be able to report this work with standardization, especially as healthcare-acquired infections and other patient safety data is reported federally. State alignment is not out of reach.
• Specific steps to better address urgent care and primary care partnerships should be outlined by state health departments. 
• Local and state public health reports from 2013 and 2015 [5] should be updated. 
• US National Action Plan [6] on Antimicrobial Resistance is really clear. 
• Objectives with deadlines during the height of the pandemic should be evaluated for extension of date. There’s no reason to wait for 2025 to assess whether or not these have been met.
• All objectives needing deadline extensions should be assigned those extensions now. Or, funding should spark immediate movement forward to get the job done.
• Objectives involving local and state health departments need clarity and realization. It is not enough to ask local health departments to refer to NHSN. What are the hospitals, long term care and ambulatory care doing alongside local health? What are the short, medium and long term goals outlined in local and state plans? 
• CDC could be tasked with real-time updates [8] to acknowledge ongoing barriers or challenges with plan implementation. 
• Research on antimicrobial resistance should fall under a strategic gameplan across federal agencies. The funding and implementation of the research [7] could match the National Action Plan [6]  and WHO Global Action Plan [1]. Research could also set expectations for local and state health department involvement. 

Military involvement in antimicrobial resistance is strong. 

• Research involving military funds or operational support should be a component to the national research gameplan, not a luxury or nice-to-have partner.
• DoD and VA involvement in the National Action Plan [6] should be assessed now, not after 2025, and tweaks should be made accordingly.
• DoD and VA data should be a component to local health department work. The federal tables of DoD and VA should not be separate from the state and local tables. Antimicrobial resistance work is a great way for public health to facilitate the shared table. 

References

1. https://www.who.int/publications/i/item/9789241509763  

2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)02724-0/fulltext 

3. https://tdr.who.int/activities/tackling-antimicrobial-resistance 

4. https://www.tandfonline.com/doi/full/10.1080/14787210.2021.1962291

5. https://www.astho.org/topic/infectious-disease/antimicrobial-resistance/ 

6. https://aspe.hhs.gov/reports/national-action-plan-combating-antibiotic-resistant-bacteria-2020-2025

7. https://www.ahrq.gov/hai/hai-carb-funding.html

8. https://www.cdc.gov/drugresistance/index.html

Tuberculosis

TB is one of our greatest undefeated challenges, yet it needn’t remain the primary antagonist to our global team. Global health does an excellent job prioritizing TB, including with knowledge sharing [1]. 

Funding for TB support and TB research continues, and funding shortfalls continue. Questions that could be asked, with responses weaved into strategic planning, include:

1. What funding shortfalls are anticipated over the next decade?
2. What are the alternative plans for continued shortfalls in funding? Are there workarounds to fill the identified needs? Is there a way to disseminate suggested workarounds?
• Have recent high-level discussions included finance and front-line logistics to examine alternatives to the monetary needs?  In example, prevalence studies may take the place for surveillance systems in countries that cannot afford surveillance systems [2]. How long will this be acceptable?
• How are alternatives analyzed as part of a continued need?  For example, system work-arounds like prevalence surveys [2] may mask the issue of improved surveillance needs. 
3. Are resources and funding tied to updated framework development? Are countries required to adhere to recommendations or build medical infrastructure that complies with framework guidance [3]? 
• How does funding oversee and support updates to clinical guidance [4]
• How does funding support environmental health factors for healthcare infrastructure (ventilation, tuberculocidal disinfectants, etc)
4. What is the plan to create tangibility to public-provider TB engagement? The work is important yet broad. Narrow and specific metrics could be clearer [5].

Concerns over increases in tuberculosis disease and deaths during COVID [6] have initiated work to get back on track.

1. What track are we getting back to? Pathways that labeled TB progress as ‘slow’ or stagnant 7,8] should be reconstructed. Getting back to progress should not include a track that no longer fits.  
2. Recent meetings have refreshed the attention and consideration of TB management [9].  Any plan to adopt a strategic plan should include all global analytical partners. The targets and goals set by WHO and recent meetings should be consistent across philanthropic, non-profit and global organizations.         

Comorbidity work is excellent [10,11]. There are opportunities to improve the organization of the issue.

     1. Mixed messaging on TB risks, and interventions to address these risks, should be improved. 

•     Recommendations to prevent and manage TB are often targeted to physical healthcare operations, including provision of TB prevention, diagnostic and treatment services within the context of progress towards universal health coverage (UHC), multisectoral actions to address broader social and economic determinants of TB, and technological breakthroughs (such as a new vaccine by 2025) [12]. Access to services remains a primary issue in TB management [6].  Yet despite reports that detail operational interventions to improve TB response and prevention, wording continues to point to behavioral and lifestyle risks.  The statement “Many new cases of TB are attributable to five risk factors: undernutrition, HIV infection, alcohol use disorders, smoking and diabetes” [6] negates public infrastructure risks (crowding, etc) and blurs poor healthcare infratrsutcure. Better definitions and descriptions could be cohesive across these reports.
• Messaging to the public also includes facts on disproportionate TB incidence and burden based on country income and geography [13], not based on incidence and prevalence of behavioral and lifestyle factors. A result of all this mixed messaging is chaotic blame that radiates without discretion. The public is left without a clear, detailed plan for progress. This should be improved.

 

TB management in the US is excellent, and it is a strength of the US public health system. As such, the US has a responsibility to set the example for reduction and eventual elimination of TB [14] here. Here are a few questions to pose when shaping a unified strategic gameplan:

1. If ending TB will require a dual approach of maintaining and strengthening current TB control priorities, while increasing efforts to identify and treat latent TB infections [15], what are the specific steps and measures the US will take?
2. TB increases are attributed in part to the COVID pandemic, including with delayed health care–seeking behavior, interruptions in health care access, or disrupted TB services [16]. What are the specific measures and action items to respond to the interruptions? What are the steps the US will take so that infrastructure is not so easily disrupted?
3. What is the projected cost to respond to the disruption and “catch up”?
4. How has healthcare emergency preparedness incorporated the learnings into better public health design? Improved communication between health agencies, better home health, better diagnostics, access to technology and improved pharmaceutical shipping are some ideas for preparedness coordination. How has federal emergency preparedness oversight assisted in action from the COVID experience?
5. A report states that “a small increase in the prevalence of smear positivity at diagnosis, predominantly among non–U.S.-born persons, suggests more advanced pulmonary disease, which might result from delayed diagnosis [16].” Is there ongoing national data to review time from point of entry to healthcare system to TB diagnosis?
•  Is there a recommended timeframe for imaging, labs, health department notification, health department response and contact to the individual? 
• Could continuous evaluation be transparent and public?
6. Who is evaluating the inter-agency TB coordination, who is setting the bar for improvement and what metrics are being used? What can be designed from recent case study work involving NACCHO and others [17]? This would include how hospitals, primary care providers, health departments, outpatient laboratories, outpatient radiology and pharmacies are working together for TB management. This also includes reimbursement and quality accreditation components to physician outpatient offices. 
7. How can medical organizations evaluate TB guidance dissemination and adherence? Can TB controller work be linked to infectious disease organizations, including IDSA/SHEA [18-20]?
8. What agencies are evaluating latent TB and non-U.S. born cases for feedback and improved international TB coordination? How is USAID encouraged to sit at the table or invite a national conversation at their table?

The United States and global health excel in tuberculosis work. Pandemic disruption of this work is an opportunity to address and improve on reported stagnation and slowed progress.

 

References

1.  https://tbksp.org/en/home
2.  https://www.who.int/news/item/13-10-2022-who-convenes-global-experts-to-update-guidance-on-national-tb-prevalence-surveys
3. https://www.who.int/publications/i/item/9789240055056
4.  https://www.who.int/news/item/30-09-2022-who-announces-updates-to-its-guidelines-on-tests-for-the-diagnosis-of-tb-infection
5.  https://www.who.int/news/item/09-11-2022-global-meeting-on-strengthening-public-private-provider-engagement-calls-for-greater-collaboration-with-all-care-providers-to-get-the-tb-response-back-on-track-and-to-enhance-accountability
6.   https://www.who.int/news/item/27-10-2022-tuberculosis-deaths-and-disease-increase-during-the-covid-19-pandemic
7. https://www.sciencedirect.com/science/article/pii/S1201971222001497  
8. https://www.who.int/news/item/14-10-2020-who-global-tb-progress-at-risk
9. https://www.who.int/news/item/21-09-2022-key-highlights-from-the-un-general-assembly-side-event--progress-and-multisectoral-action-towards-achieving-global-targets-to-end-tb 
10. https://www.who.int/news/item/01-12-2022-equalize---addressing-inequalities-to-end-tb-and-aids
11. https://www.who.int/news/item/14-11-2022-joining-forces-to-enable-access-to-essential-prevention-and-care-services-for-people-with-diabetes-and-tb  
12. https://www.who.int/publications/digital/global-tuberculosis-report-2021/tb-disease-burden/incidence
13. https://www.who.int/publications/digital/global-tuberculosis-report-2021/tb-disease-burden/
14. https://www.cdc.gov/tb/publications/factsheets/statistics/tbtrends.htm
15. https://www.cdc.gov/tb/statistics/default.htm
16.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8956339/
17. https://www.naccho.org/blog/articles/new-naccho-case-study-series-highlights-lhd-and-health-center-partnerships-to-address-tb-and-covid-19
18.  https://www.naccho.org/blog/articles/new-resource-testing-and-treatment-of-latent-tuberculosis-infection-in-the-united-states-clinical-recommendations
19. https://www.tbcontrollers.org/docs/resources/tb-infection/LTBI_Clinical_Recommendations_Version_002052021.pdf
20. https://www.tbcontrollers.org/resources/tb-infection/clinical-recommendations/#.YCKheuhKhPZ