Global Cases, Best Practices, and Lesson Learn of Tuberculosis Prevention and Care

Tuberculosis in Asia

Tuberculosis (TB) is a leading cause of death from infectious disease in Asia-Pacific and affects Asian people more than others. In 2018, the South-East Asian region of the World Health Organization (WHO) accounted for 44% of the world’s new TB cases. The region also has a high burden of MDR-/RR-TB, accounting for more than 38% of the estimated global incidence of patients with these strains. Six countries in the region have a high burden of TB: Bangladesh, Democratic People’s Republic of Korea, India, Indonesia, Myanmar, and Thailand.

The WHO has developed a Regional Strategic Plan (2016-2020) to control TB in the region with the goal of ending the TB epidemic by 2035. Australia also has programs to help countries in the region deal with TB, including funding efforts to eliminate TB and a regional collaboration initiative focused on TB and malaria control.

TB cases and deaths occur disproportionately amongst men, but the burden of disease amongst women is also high. Most cases of TB are curable if diagnosed early and the appropriate treatment is provided. However, social determinants like poverty and undernutrition can increase the risk of developing active disease and exposure to risk factors like HIV, smoking, and alcohol abuse.

Tuberculosis in Australia

Australia has a relatively low rate of tuberculosis (TB) compared to other countries, with about 1,300 cases reported each year, or 5.5 cases per 100,000 people. The rate has remained relatively stable since the mid-1980s, but has increased slightly since 2003. In 2023, the rate was 5.3 cases per 100,000 people, with 1,430 TB notifications.

In total, 67 Australians were reported to have died due to TB from 2021 to 2023. “Without treatment, the death rate from TB is high,” Dr Viney says. But TB is treatable and “usually curable”.

Tuberculosis in America

In 2023, the United States saw a 15% increase in tuberculosis (TB) rates, from 2.5 cases per 100,000 people in 2022 to 2.9 in 2023. This was the third year in a row that TB cases increased, and the highest number of cases reported since 2013. The increase was seen across all age groups, with the largest increase in children ages 5–14. California had the highest number of cases in 2023 with 2,113, and Alaska had the highest rate at 10.6 cases per 100,000 people.

TB is an airborne infection that can be treated, but it can also be fatal if left untreated. The CDC estimates that 13 million people in the U.S. have latent TB infections, which means the bacteria is inactive and the person isn’t contagious. However, without treatment, 10% of people with latent TB will develop active TB disease, which is highly contagious. There are treatments for both latent and active TB disease.

Tuberculosis in Africa

Tuberculosis (TB) is a significant public health problem in Africa, accounting for 23% of new cases and 31% of TB-related deaths globally, even though the region only makes up 15% of the world’s population. In 2022, an estimated 2.5 million people fell ill with TB in Africa, and 424,000 people died from the disease. TB is the leading cause of death from a single infectious agent in Africa, and is also the leading killer of people living with HIV.

TB is an airborne disease that can be transmitted through close contact with an infected person over the course of a year. Symptoms can be mild for months, such as a cough, fever, night sweats, or weight loss, which can lead to delays in seeking care. People with compromised immune systems, such as those living with HIV, malnutrition, or diabetes, or people who use tobacco, have a much higher risk of falling ill. Without proper treatment, 45% of HIV-negative people with TB and nearly all HIV-positive people with TB will die.

The African region is also struggling to introduce new drugs and scale up TB efforts. Other challenges include limited access to health services, inadequate health infrastructure, insufficient quality of care, and inadequate human resources for health.

Tuberculosis in Europe

In 2021, the European Union/European Economic Area (EU/EEA) reported 33,520 tuberculosis (TB) cases, which was a slight increase from 2020, but still 23% fewer than in 2019. However, the overall notification rate in most countries has decreased over the last five years, especially in the last two years. The COVID-19 pandemic and geopolitical issues may have negatively affected TB epidemiology by reducing diagnosis and reporting, access to health facilities, and increasing the risk of multidrug-resistant TB (MDR-TB).

In 2021, Romania had the highest number of cases, with nearly a quarter of the total, and the highest rate of cases among children. However, the authors of a report on the 2021 figures and trends caution that they should be interpreted with caution due to the impact of pandemic measures on TB detection and reporting.

Other challenges facing TB in Europe include treatment gaps and deteriorating treatment availability.

Best Practice

Tuberculosis (TB) remains a significant global health challenge, despite advancements in diagnosis and treatment. Effective prevention and care strategies are crucial to combatting this disease. Here are some of the best practices:

Prevention

Vaccination: The Bacillus Calmette-Guérin (BCG) vaccine is widely used to prevent TB, especially in infants and children. However, its effectiveness varies depending on the region and population.
Contact Tracing: Identifying and treating individuals who have been in close contact with TB patients helps prevent further transmission.
Preventive Treatment: Individuals at high risk of developing TB, such as those with HIV infection or weakened immune systems, can receive preventive treatment to reduce their chances of developing active TB.
Infection Control: Implementing proper infection control measures in healthcare settings and other high-risk environments is essential to prevent the spread of TB.
Social Determinants of Health: Addressing social determinants of health, such as poverty, malnutrition, and overcrowding, can help reduce the risk of TB.

Care

Early Diagnosis: Prompt diagnosis of TB is crucial for effective treatment and prevention of transmission. This can be achieved through diagnostic tests like chest X-rays, sputum culture, and rapid molecular tests.
Standardized Treatment: Adhering to standardized treatment regimens, including the Directly Observed Therapy (DOT) approach, is essential to ensure patient compliance and prevent drug resistance.
Drug-Resistant TB Management: Effective management of drug-resistant TB, including multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB, requires specialized treatment regimens and careful monitoring.
Patient Support: Providing comprehensive patient support, including counseling, nutrition, and social services, can help improve treatment outcomes and reduce the impact of TB on individuals and their families.
Health Systems Strengthening: Investing in strong health systems, including adequate infrastructure, human resources, and diagnostic capabilities, is essential for effective TB control.

International Organizations and Initiatives

Several international organizations and initiatives are working to address the global TB epidemic. These include:

World Health Organization (WHO): The WHO provides technical guidance, supports countries in implementing TB control programs, and promotes research and development for new TB diagnostics, drugs, and vaccines.
Stop TB Partnership: This global partnership brings together governments, NGOs, civil society organizations, and the private sector to accelerate progress towards ending TB.
Global Fund to Fight AIDS, Tuberculosis, and Malaria: The Global Fund provides financial support to countries to implement TB programs and strengthen health systems.

By implementing these best practices and leveraging the support of international organizations, we can make significant progress towards ending the TB epidemic.

TB Diagnosis: A Closer Look

Tuberculosis (TB) diagnosis involves a combination of clinical evaluation, laboratory tests, and imaging studies. Early and accurate diagnosis is crucial for effective treatment and prevention of transmission.

Traditional Diagnostic Methods

Chest X-ray: A chest X-ray can often reveal abnormalities in the lungs associated with TB, such as cavitations or infiltrates. However, it is not always conclusive, especially in early-stage TB or in individuals with other lung conditions.
Sputum Culture: Sputum culture remains the gold standard for diagnosing TB. It involves collecting a sample of sputum (mucus coughed up from the lungs) and culturing it in a laboratory to grow and identify Mycobacterium tuberculosis, the bacteria that causes TB. This process can take several weeks to complete.

Modern Diagnostic Techniques

Recent advancements in technology have led to the development of more rapid and sensitive TB diagnostic tests:

Nucleic Acid Amplification Tests (NAATs): NAATs, such as polymerase chain reaction (PCR), can detect TB DNA directly from sputum samples. These tests are faster than sputum culture and can provide results within a few hours.
GeneXpert MTB/RIF: This is a rapid molecular test that can simultaneously detect TB and rifampicin resistance, a common form of drug resistance in TB. It has revolutionized TB diagnosis and treatment, particularly in settings with high rates of drug resistance.
Liquid Culture: Liquid culture systems are becoming increasingly popular due to their faster turnaround time compared to traditional solid culture. They can also detect TB in samples with low bacterial load.

Challenges in Diagnosis

Latent TB Infection: Differentiating between active TB and latent TB infection can be challenging. Individuals with latent TB infection do not have symptoms and may not have detectable bacteria in their sputum.
Drug-Resistant TB: Diagnosing drug-resistant TB requires specialized testing and can be time-consuming.
Extra-Pulmonary TB: TB can affect organs other than the lungs, making diagnosis more difficult.

In conclusion, TB diagnosis has evolved significantly in recent years with the introduction of rapid and sensitive molecular tests. However, challenges remain, and a combination of traditional and modern diagnostic methods is often necessary for accurate diagnosis and effective management of TB.

TB Treatment Regimens

The standard treatment for TB involves a combination of antibiotics taken over several months. This approach is designed to kill the Mycobacterium tuberculosis bacteria and prevent the development of drug resistance.

Standard Treatment Regimen

The recommended treatment regimen for drug-susceptible TB typically includes:

Rifampicin
Isoniazid
Pyrazinamide
Ethambutol

These drugs are usually taken together for 2 months, followed by a continuation phase with rifampicin and isoniazid for an additional 4 months.

Drug-Resistant TB Treatment

Treating drug-resistant TB is more complex and requires longer treatment regimens. The specific drugs used and the duration of treatment depend on the type of drug resistance (e.g., multi-drug resistant or extensively drug-resistant TB).

Multi-drug resistant (MDR) TB: MDR TB is resistant to rifampicin and isoniazid. Treatment often involves a combination of second-line drugs, such as fluoroquinolones and aminoglycosides, for at least 18 months.
Extensively drug-resistant (XDR) TB: XDR TB is resistant to rifampicin, isoniazid, fluoroquinolones, and at least one of the injectable aminoglycosides. Treatment options are limited, and outcomes can be challenging.

Challenges in TB Treatment

Adherence: Ensuring patient adherence to the treatment regimen is crucial for successful outcomes. Directly Observed Therapy (DOT) programs can help monitor medication intake and provide support.
Drug Resistance: The development of drug resistance is a major challenge in TB control. Adhering to treatment regimens and preventing transmission can help reduce the risk of drug resistance.
Side Effects: Some TB drugs can cause side effects, such as liver damage, neuropathy, or skin rashes. Monitoring for side effects and adjusting the treatment regimen as needed is important.

Recent Advances in TB Treatment

New Drugs: The development of new TB drugs, such as bedaquiline and delamanid, has improved treatment options for drug-resistant TB.
Combination Therapies: Combining multiple drugs can help shorten treatment duration and improve outcomes.
Personalized Treatment: Tailoring treatment regimens based on individual patient factors, such as drug resistance and genetic susceptibility, can improve treatment effectiveness.

While TB treatment can be challenging, advancements in medical science and improved treatment strategies offer hope for individuals with TB.

TB Prevention Strategies

Preventing the transmission of tuberculosis (TB) involves a multifaceted approach that addresses both individual and community-level factors. Here are some of the most effective strategies:

Individual-Level Interventions

Vaccination: The Bacillus Calmette-Guérin (BCG) vaccine is the primary tool for preventing TB, especially in infants and young children. While its effectiveness varies depending on the region and population, it can provide some protection against developing active TB.
Preventive Treatment: Individuals at high risk of developing TB, such as those with HIV infection or weakened immune systems, can receive preventive treatment with isoniazid to reduce their chances of developing active TB.
Contact Tracing: Identifying and treating individuals who have been in close contact with TB patients helps prevent further transmission.
Proper Hygiene: Practicing good hygiene, such as covering your mouth and nose when coughing or sneezing, washing your hands regularly, and avoiding close contact with people who are sick, can help reduce the spread of TB.

Community-Level Interventions

Infection Control: Implementing proper infection control measures in healthcare settings and other high-risk environments, such as prisons and shelters, is essential to prevent the spread of TB.
Social Determinants of Health: Addressing social determinants of health, such as poverty, malnutrition, and overcrowding, can help reduce the risk of TB.
Health Systems Strengthening: Investing in strong health systems, including adequate infrastructure, human resources, and diagnostic capabilities, is essential for effective TB control.
Public Health Campaigns: Raising awareness about TB and promoting preventive measures through public health campaigns can help reduce the stigma associated with TB and encourage early diagnosis and treatment.

Role of Vaccination

While the BCG vaccine is not 100% effective, it can significantly reduce the risk of developing TB in children. It is especially effective in preventing severe forms of TB, such as TB meningitis. However, the effectiveness of the BCG vaccine can vary depending on factors such as the region, the strain of the vaccine, and the age at which it is administered.

In conclusion, preventing TB transmission requires a comprehensive approach that addresses both individual and community-level factors. Vaccination, preventive treatment, contact tracing, and infection control are essential components of effective TB prevention strategies.

Social Determinants of Health and TB

Social determinants of health (SDOH) play a significant role in the transmission and development of tuberculosis (TB). These factors can create conditions that increase the risk of TB infection and make it more difficult to prevent, diagnose, and treat.

Here’s how some key SDOH contribute to TB:

Poverty

Limited Access to Healthcare: Poverty can limit access to quality healthcare, including TB screening, diagnosis, and treatment.
Unsanitary Living Conditions: Poverty may lead to unsanitary living conditions, such as overcrowding, poor ventilation, and lack of access to clean water, which can increase the risk of TB transmission.
Malnutrition: Poverty can lead to malnutrition, which weakens the immune system and makes individuals more susceptible to TB infection.

Malnutrition

Weakened Immune System: Malnutrition can impair the immune system’s ability to fight off TB bacteria.
Increased Risk of Infection: Malnourished individuals may be more likely to develop active TB if they are exposed to the bacteria.

Overcrowding

Increased Transmission: Overcrowding can increase the likelihood of TB transmission, as it facilitates the spread of the bacteria through the air.
Poor Ventilation: Overcrowded spaces often have poor ventilation, which can trap TB bacteria and increase exposure.

Other Social Determinants

Discrimination and Stigma: Discrimination and stigma associated with TB can discourage individuals from seeking diagnosis and treatment, leading to delayed care and increased transmission.
Lack of Education: Limited education can contribute to poor health outcomes, including TB, as it may lead to inadequate knowledge about TB prevention and treatment.

In conclusion, social determinants of health play a crucial role in the development and spread of TB. Addressing these factors is essential for effective TB control and prevention. By improving access to healthcare, addressing poverty, and promoting social justice, we can create healthier communities and reduce the burden of TB.

Global Efforts to Combat TB

Several international organizations and initiatives are working to address the global TB epidemic. These organizations provide technical guidance, support countries in implementing TB control programs, and promote research and development for new TB diagnostics, drugs, and vaccines.

Here are some of the major players in the fight against TB:

World Health Organization (WHO): The WHO is the leading global health agency and plays a central role in coordinating international efforts to combat TB. It provides technical guidance, supports countries in developing and implementing TB control programs, and promotes research and development for new TB tools.
Stop TB Partnership: This global partnership brings together governments, NGOs, civil society organizations, and the private sector to accelerate progress towards ending TB. It works to mobilize resources, promote advocacy, and support countries in implementing effective TB control programs.
Global Fund to Fight AIDS, Tuberculosis, and Malaria: The Global Fund is a global financing mechanism that provides grants to countries to support their TB control programs. It focuses on investing in health systems, providing access to essential medicines, and promoting prevention and treatment.
UNITAID: UNITAID is a global health partnership that works to increase access to affordable diagnostics, treatments, and vaccines for neglected diseases, including TB. It supports research and development for new TB tools and provides financial support to countries to implement TB control programs.
Partners in Prevention (PiP): PiP is a global initiative that aims to prevent TB in people with HIV. It works to improve access to preventive treatment for TB in people living with HIV and to strengthen health systems to deliver effective TB care.

These organizations and initiatives are working together to address the challenges of TB control, including drug resistance, limited access to diagnostics and treatment, and the impact of social determinants of health. Through their efforts, they are helping to improve the lives of millions of people affected by TB and working towards a TB-free world.

Lesson Learn

The global fight against tuberculosis (TB) has yielded significant progress, but challenges remain. Here are some key lessons learned from decades of experience:

Importance of Integrated Approach

Multisectoral Collaboration: Effective TB control requires collaboration between health, social, and economic sectors to address the underlying social determinants of health.
Community Engagement: Engaging communities in TB prevention and care is crucial for improving access to services and reducing stigma.

Strengthening Health Systems

Investment in Infrastructure: Investing in health infrastructure, including laboratories, clinics, and hospitals, is essential for providing quality TB services.
Human Resource Development: Ensuring adequate training and support for healthcare workers is crucial for effective TB diagnosis, treatment, and prevention.

Addressing Social Determinants of Health

Poverty Reduction: Addressing poverty and inequality is essential for reducing the burden of TB, as these factors can increase vulnerability to the disease.
Housing and Nutrition: Improving access to affordable housing and nutritious food can help reduce the risk of TB transmission and improve treatment outcomes.

Innovation and Research

New Diagnostics: Continuous development of rapid and accurate diagnostic tests is essential for early detection and treatment of TB.
Drug Development: Research and development of new TB drugs, especially for drug-resistant TB, are crucial for improving treatment outcomes.
Vaccines: Developing effective vaccines against TB remains a priority for global health.

Addressing Drug Resistance

Prevention: Implementing measures to prevent the development and spread of drug-resistant TB, such as adherence to treatment regimens and infection control measures, is essential.
Treatment: Developing new treatment regimens for drug-resistant TB is a critical challenge.

Global Collaboration and Partnerships

International Cooperation: Strengthening international collaboration and partnerships is essential for sharing knowledge, resources, and best practices in TB control.
Financing: Ensuring adequate funding for TB control programs is crucial for achieving global targets.

By learning from past experiences and applying these lessons to future efforts, we can accelerate progress towards ending the TB epidemic.