Comprehensive care for all individuals with tuberculosis is needed now
Authors: Riitta A Dlodlo, Einar Heldal
Journal: The Lancet Global Health (2019)

The UN High-Level Meeting on Universal Health Coverage will be held in September, 2019. Of relevance to this meeting is the question of whether people with presumed and diagnosed tuberculosis enjoy equity in access to services that are of good quality without risk of financial harm. The answer is a resounding no.1Kweza PF Van Schalkwyk C Abraham N et al.Estimating the magnitude of pulmonary tuberculosis patients missed by primary health care clinics in South Africa.Int J Tuberc Lung Dis. 2018; 22: 264-272Crossref PubMed Scopus (34) Google Scholar, 2Cazabon D Alsdurf H Satyanarayana S et al.Quality of tuberculosis care in high burden countries: the urgent need to address gaps in the care cascade.Int J Infect Dis. 2017; 56: 111-116Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 3Republic of KenyaMinistry of HealthThe first tuberculosis patient cost survey 2017. National Tuberculosis, Leprosy and Lung Disease Program. 2018. Nairobi, Kenya.https://www.chskenya.org/wp-content/uploads/2018/07/TB-Patient-Cost-Survey-2018.pdfDate accessed: March 3, 2019Google Scholar The modelling study by Juan Vesga and colleagues4Vesga JF Hallett TB Reid MJA et al.Assessing tuberculosis control priorities in high-burden settings: a modelling approach.Lancet Glob Health. 2019; (published online March 20.)http://dx.doi.org/10.1016/S2214-109X(19)30037-3Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar published in The Lancet Global Health applied a delay-care cascade approach to identify the losses that, if addressed, could maximise reduction in tuberculosis incidence and mortality in selected countries. The study illustrated major challenges in the proportion of patients visiting the private sector (India), missed diagnosis in health facilities (Kenya), and drug sensitivity testing (Moldova). Despite a substantial decrease of all losses and an extensive timeline, the effect was insufficient to reach the WHO End TB strategy targets.5WHOEnd TB Strategy.https://www.who.int/tb/strategy/end-tb/en/Date: 2015Date accessed: March 3, 2019Google Scholar The proportion of individuals with tuberculosis on high-quality treatment was proposed as a new monitoring tool. The model had to simplify complex cascades and it could be fine-tuned to capture gaps and delays that are programmatically relevant and measurable. The recording and reporting system of national tuberculosis programmes contains, if satisfactory quality is ensured, solid data for all cascade transitions. These range from identifying people with presumptive tuberculosis to completing treatment using presumptive registers (in place in many countries although not recommended by WHO since 2013 or The International Union Against Tuberculosis and Lung Disease [The Union]), laboratory and tuberculosis registers that should include all diagnosed patients, and individuals who died or were lost to follow-up before treatment initiation. The model kept health service gaps at 5% or less, a level that should be feasible and measurable, whereas earlier gaps (and delays) from start of disease, start of symptoms, and first contact with services are uncertain and improvements are hard to assess. People with symptoms suggestive of tuberculosis should be included in facility outpatient registers and compared with entries in presumptive tuberculosis registers to ensure no individual is lost. Data quality poses challenges but it should be improved because programmes are battling with the fact that people with classic symptoms often need to attend services several times before tuberculosis investigations are started. The model does not include important issues, such as laboratory support and availability of tuberculosis medicines and other supplies.6Rusen ID Harries AD Heldal E et al.Drug supply shortages in 2010: the inexcusable failure of global tuberculosis control.Int J Tuberc Lung Dis. 2010; 14: 253-254PubMed Google Scholar The proposed indicator—proportion of individuals with tuberculosis on high-quality treatment—is difficult to measure because the real number of cases of tuberculosis remains uncertain. The way forward should rather be improving data for notifications and other indicators provided by the tuberculosis recording and reporting system. We need to move urgently from modelling to action, and strengthen quality and use of the data generated by national tuberculosis programmes. The cascade approach is helpful in showing all the steps of patient care and revealing those with challenges that should be corrected. We recommend strengthening programmatic recording and reporting, which provide data from district to province, and then to national levels. Unfortunately, these data are hardly used locally and therefore, of low quality. The Union and the National Tuberculosis Programme in Zimbabwe have developed an inexpensive and practical bottom-up approach whereby health staff, including individuals at the facility level, are trained and supported through data-driven supervision, not only to collect and submit but also analyse and use their data. Every 3 months they review tuberculosis indicators, find those that need improvement, and, if possible, remedy them. Areas with missing cases can be located by comparing the rate of presumptive and confirmed tuberculosis cases per 100 000 population between facilities and districts to identify those with rates that differ from the average. Such findings raise questions about functioning of services, drawing attention to areas with low rates (ie, cold spots) and high rates (ie, hot spots). Local staff become motivated to improve tuberculosis patient and programme management, which reduces cascade gaps and ultimately, strengthens data quality.7Heldal E, Dlodlo RA, Mlilo N, et al. Local staff making sense of their tuberculosis data: key to quality care and ending tuberculosis. Int J Tuberc Lung Dis (in press).Google Scholar We agree with the authors' key needs for tuberculosis control. First, we need primary prevention globally to end tuberculosis. While we await better vaccines, we should fix what we already have and provide tuberculosis care within health services, be they public or private, built on the principles of Universal Health Coverage. We should ensure high-quality patient-centred care to people with tuberculosis and attend to comorbidities that they might have. We should intensify management of household contacts to improve detection of individuals with tuberculosis, and also people who should be offered preventive treatment. Second, courteous staff and comprehensive services with good reputations can overcome barriers to early care seeking.8Mavhu W Dauya E Bandason T et al.Chronic cough and its association with TB-HIV co-infection: factors affecting help-seeking behaviour in Harare, Zimbabwe.Trop Med Int Health. 2010; 15: 574-579PubMed Google Scholar Third, resources permitting, campaigns and community and civic organisational activities can be developed to identify tuberculosis among at-risk groups. We should remember that active screening cannot replace permanent health services. When tuberculosis rates in industrialised countries declined from 1950–70 with the high speed that we now hope to repeat, only 12–25% of patients with tuberculosis were detected by regular mass radiography because most patients were diagnosed when they attended health services that were easily accessible.9Rieder H What is the role of case detection by periodic mass radiographic examination in tuberculosis control?.in: Frieden T Toman's Tuberculosis. Case detection, treatment, and monitoring. Questions and answers. 2nd edn. World Health Organization, Geneva, Switzerland2004: 72-79Google Scholar It is time to ensure that the health services we already have fully care for people with tuberculosis. We should ensure universally available and accessible high-quality services and address gaps and delays by actively using tuberculosis programme data complemented by operational research and surveys. We declare no competing interests. Assessing tuberculosis control priorities in high-burden settings: a modelling approachLinked to transmission, the care cascade can be valuable, not only for improving patient outcomes but also in identifying and monitoring programmatic priorities to reduce tuberculosis incidence and mortality. Full-Text PDF Open Access