Healthcare Getting It Right : 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:

What funding shortfalls are anticipated over the next decade?
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.

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)

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.

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.
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:

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?
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?
What is the projected cost to respond to the disruption and “catch up”?
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?
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?

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.
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]?
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

Healthcare Getting It Right

Friday, December 2, 2022

Tuberculosis

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