New tuberculosis targets present challenges and opportunities
Humanity has been battling tuberculosis (TB) for at least 3,300 years, and the disease still accounts for more than 10 million new cases annually and kills some 1.6 million people per year. Deaths caused by TB had been declining in years before 2020, but the COVID-19 pandemic saw the progress end as global resources were diverted from TB to emergency response, and both TB fatalities and the incidence of drug-resistant cases began a resurgence.
It was against this backdrop that the United Nations met in September 2023 to set new global targets for combating TB.
Improving access to testing and care
Despite also responding to COVID-19, USAID’s Infectious Disease and Surveillance (IDDS) project continued its work to improve TB diagnostics and patients’ access to testing in 16 countries in Africa and Asia. ICF-led IDDS has supported health systems with new diagnostic technology, piloted a new testing method for pediatric TB, and brought the private sector into testing and treatment in India.
Among the new commitments adopted by member states at the UN High-Level Meeting on Tuberculosis was “reaching 90% of people with TB prevention and care services, using a WHO-recommended rapid test as the first method of diagnosing TB.”
This refers to the World Health Organization’s recommended rapid molecular tests, such as Truenat® and GeneXpert®, which offer results in about an hour or less and can also test for drug-resistant TB.
IDDS joined with the Stop TB Partnership to introduce Truenat technology in 11 countries across Africa and Asia as part of the Introducing New Tools Project. Truenat can greatly increase patient access to TB testing: It is portable, does not need a controlled climate, and can operate on battery power, making it suitable for peripheral health clinics—the type of local clinic that provides the first line of health care for much of the world.
Health care staff also need the right training to operate Truenat. IDDS learned that to be most effective, users needed post-training mentoring and troubleshooting help, as many had no experience with molecular testing tools. To address this need, IDDS piloted training of “super-users”: National- and regional-level laboratory specialists who become subject matter experts and can pass on their troubleshooting skills and provide mentorship. Building on lessons learned with the pilot, IDDS trained super-users during Truenat’s introduction in the Democratic Republic of the Congo (DRC) and seven other countries: Malawi, Nigeria, Kenya, Uganda, Zimbabwe, Tanzania, and Cambodia.
Equipping and upgrading
Also in DRC, IDDS supported the upgrade and efficient functioning of the national TB reference laboratory in Kinshasa and provincial TB reference laboratories in Lubumbashi and Kisangani to ensure regular specimen testing activities and minimize the risk to staff of infection and specimen contamination. These upgrade activities included revamping the power supply and providing backup power, biosafety improvements, and equipment for antimicrobial resistance sensitivity testing of anti-tuberculosis drugs.
Reaching “90 percent of people with TB prevention and care services," as the United Nations aims, means making sure fewer people go undiagnosed—especially young children who are particularly vulnerable to TB. But a major challenge with pediatric TB diagnostics is that children struggle to produce sputum, and testing sputum for TB bacterium is the standard method of confirming an initial diagnosis of TB. Producing sputum can also be very difficult for people living with HIV.
To overcome this challenge, IDDS has implemented an alternative method using stool samples to diagnose TB in children. When children with pulmonary TB cough and swallow their sputum, the genetic material of TB bacterium survives the digestive process and can be detected in stool samples. The collection of stool is not invasive and can be implemented in outpatient settings or even in the home. This alternative method has been endorsed by the World Health Organization, and IDDS has run successful pilots in DRC, Malawi, and Vietnam, with additional pilots in process in Cambodia, Mozambique, and Zimbabwe.
Reaching the ambitious new TB targets will require innovation, including engaging the private sector to expand access to TB diagnostics, prevention, and care services. In the Hisar district of the state of Haryana in northern India, IDDS worked with the national TB program to engage a private laboratory to support timely TB testing and treatment for patients served by community-level health facilities. IDDS identified and integrated 44 private facilities into the newly developed “one-stop” TB testing model. Patients can now access testing and treatment at one local clinic, rather than moving between facilities as they did previously.
Results show that the new model increased access to rapid TB tests (specifically, rapid molecular testing) from 26% to 63% and drastically reduced the waiting period for patients to receive their test results. “The work in Hisar has the potential to change Hisar, India, and even the world,” said the chief medical officer for Hisar.
