Credit: Nichole Sobecki / The Global Fund

By David Bryden
WASHINGTON DC, Sep 24 2018 (IPS)

“I’m alive because of support from my family and the community health worker who brought medicine directly to my house, accompanied me during treatment and gave me hope. Without care and human support, there’s no way I could be here today,” says Melquiades Huauya, a survivor of multi-drug resistant tuberculosis (MDR-TB) from Peru.

From his harrowing experience with tuberculosis (TB), Huauya now knows a lot about how to stop it, the world’s biggest infectious disease killer. The disease, which claims about 4300 lives a day, is the subject of a United Nations’ High-Level Meeting on September 26 in New York, alongside the 73rd General Assembly.

Tuberculosis is an airborne bacterial infection that is preventable and curable, with the right medication. But, as Melquiades Huauya experienced, in addition to appropriate medication, it is “human support” that makes the difference between life and death.

Miriam Were, a noted Kenyan medical doctor and public health expert, states in a recent online presentation that community health workers are essential to providing culturally sensitive care and overcoming the distrust and “social distance” that keeps people from accessing the formal health care system and getting cured of diseases like TB.

Health facilities can also be many hours away from people’s homes, a common barrier to accessing care. As a result, of the 10 million people developing TB every year, 3.6 million are “missed” by the formal system and are unreported, and likely going untreated. In ten of the countries with high TB burdens, more than 45 percent of the people with TB are “missed.”

This includes children, who are highly vulnerable to TB. By fully tapping the potential of community health workers, we can identify and locate these people, connect them to care, and, ultimately, reduce and prevent further TB infections and other health conditions.

Consider the investment case by the South African Medical Research Council, issued in May 2018, entitled “Saving lives, saving costs.” The researchers found that an expanded and well-supported network of community health workers would have enormous benefits for South Africa, translating into 33,064 MDR-TB averted cases and saving 60,642 livesover a 10-year period.

According to the researchers, while such a strategy requires significant financial investment initially, the cost-saving will, ultimately, be more than offset by preventing the disease and costly hospitalization.

By recruiting previously unemployed people from the same disadvantaged communities to visit the homes of TB patients and seek out others in need of TB screening, the economy will also benefit. And, according to the analysis, other health issues can also be addressed through this approach, including HIV/AIDS, maternal and child health, and hypertension.

Several countries are already using an expanded network of community health workers to stop TB, similar to the program in Peru, which was so crucial to Huauya’s recovery. In 2003, Ethiopia began training and employing female village-based health workers, called health extension workers, to regularly visit households in their villages to implement basic packages of healthcare.

These visits have identified people with TB and given essential support to patients already taking the long course of treatment. This has helped deliver very impressive results, with the country seeing a significant reduction in TB. Pakistan and Bangladesh have also successfully used community health workers to reduce TB.

Still, there are also major challenges facing community health workers. Were says most abandon their jobs when they realize it is a dead-end, without prospects of advancement; attrition is as high as 70 percent in some places.

She emphasizes that community health workers need adequate training, supervision, and remuneration to keep serving their communities. They also need back-up from qualified nurses and doctors to whom they can refer patients.

Care-givers also need care themselves. Frontline health workers are frequently exposed to TB and other health risks due to inadequate protection, such as masks and respirators, or environmental measures to lessen the danger.

The result is that healthcare personnel have significantly higher rates of developing TB, including often-deadly MDR-TB , as documented by the South African organization, TB Proof.

Facing a three to six times increased risk, related inadequate working conditions and a lack of supplies or equipment, can lead to poor morale and high rates of attrition, further adversely affecting the quality of care.

Tuberculosis cannot be defeated unless these challenges are addressed head-on. For the UN High Level Meeting, all member states have agreed on a Political Declaration on the Fight Against Tuberculosis, and it contains a key promise: that they “Commit to find the missing people with tuberculosis.”

To keep this promise, governments must lay out specific and costed plans for training, protecting and compensating the frontline health care workers who do the hard work of going out into the community, even going door-to-door, to find people in need and give them hope. As Were puts it, “If it doesn’t happen in the community, it doesn’t happen.”

Inmates at the National Penitentiary in Port-au-Prince, Haiti. Credit: David Bryden

By David Bryden
WASHINGTON DC, Jul 19 2018 (IPS)

Dozens of grown men peered from behind the barred doorway of a crammed window-less prison cell, eyes pleading desperately from sweaty faces.

Their physical discomfort was so palpable, I could almost feel it. Because of my work, I also knew of at least one serious unseen risk facing them – that of contracting tuberculosis in the cramped, poorly ventilated space.

Touring the largest prison in Port-au-Prince was part of a research visit I made there in 2106. Two years later, the image of those men still haunts my memories—more so now that the first ever United Nations High-Level Meeting (UNHLM) on Tuberculosis (TB) approaches in September and the global spotlight gets set to turn on this neglected disease and conditions that continue to influence its spread.

At the upcoming 22nd International AIDS Conference, in Amsterdam July 23 – 27, civil society organizations will seek to put the spotlight on vulnerable populations and deepen collaboration to ensure a united position on key issues such as the link between HIV/AIDS and TB and the need for an integrated approach to diagnosis and treatment.

A special session, Friday, July 27, titled “Seizing the moment for TB: Current challenges in TB care and in TB and HIV integration,” will feature Eric Goosby, the United Nation’s Secretary General’s Special Envoy on TB; Paul Farmer, co-founder of Partners in Health; and Carol Nawina Kachenga, of the Zambian-based group CITAMplus. Former US President Bill Clinton will give the special sessions opening keynote.

The scale of the prison problem is particularly staggering. In 2016, The Lancet published a study by Kate Dolan and her colleagues at the University of New South Wales explaining that of the total global incarcerated population of 10.2 million, 2.8 percent or 286,000 have active TB.

A further 3.8 percent or 389, 000 also have HIV. The Stop TB Partnership estimates that, the risk of TB in prison on average, is 23 times higher than in the general population.

The high rate of HIV in prisons is exacerbated by a lack of prevention options as well as sexual violence. However, even prisoners living with HIV who can overcome barriers to treatment, face a much greater risk of TB.

Data from sub-Saharan Africa show a prevalence of HIV infection among prisoners from 2.3 percent to 34.9 percent and of TB, from 0.4 to 16.3 percent.

Overcrowding seems to be the single biggest root cause of the prison TB epidemic. Dolan et al lay the blame on the practice of mass incarceration of people who inject drugs. They urge decriminalization, alternatives to incarceration, and access to opioid agonist therapy.

Another driver of overcrowding is the use of pre-trial detention and the slow process of adjudication. Slow judicial processes have been blamed for the massive overcrowding in jails in the Philippines, a country with a high level of TB, including drug resistant TB.

In Port-au-Prince, the National Penitentiary was built for 800 prisoners, but now houses 4600; the rate of tuberculosis is 17 times that of the general population of the country. There is no prison hospital in which patient can be appropriately isolated and treated.

The prisoners are poorly fed, with only one or two meals a day and little or no protein, making tuberculosis – caused by an airborne bacterium- even more likely. The state of the world’s prisons ensures they are “factories” for TB transmission, including drug resistant TB—now the single biggest infectious disease killer in the world. Tackling prison conditions, therefore, is essential to ending the disease.

Some countries are directly addressing the issue. Mongolia, for instance, reported a two-thirds reduction from 2001 to 2010 of TB among prisoners through active TB case finding and upgrading health services and living conditions. Reducing prison populations and improved nutrition was important to this success.

In a project in Zambia, supported by TB REACH, peer educators have been trained from among the prison population to support TB screening as well as HIV counseling. This approach was found to be highly effective and sustainable, since the peer educators knew the prison culture and were enthusiastic and committed.

Experts on TB also point to the need for screening and treatment, not only for active TB, but also for latent TB infection, which is very widely prevalent among prisoners, to support better TB prevention. TB preventive therapy, a course of antibiotics, has been proven highly effective but is still not widely used in high burden countries.

At the penitentiary in Port-au-Prince, I saw the dedicated work of an NGO, Health Through Walls, to provide TB and HIV services, despite adverse conditions. With USAID and Global Fund support, they are providing HIV and TB diagnoses, including using the latest methods, as well as treatment and nutritional supplementation, in eleven prisons in Haiti. With a tiny budget, they are saving many lives.

During a civil society hearing on TB held earlier this year at the United Nations, Assembly in preparation for the UNHLM, Donald Tobaiwa, from Jointed Hands Welfare Organization, Zimbabwe, called for urgent action to address TB in prisons, as well as in the mining industry.

“What are countries doing about this?” he asked. “The question, he said, was not what it costs to find people with TB, but what it will cost us if we fail to find them.”

Advocates gathering at the UNHLM plan to make this their rallying cry to heads of state. With a strong commitment to finding TB cases, including those hiding in plain sight in prison populations, and support from member states for an independent and regular progress assessment, the meeting cane be a turning point in the drive to end this disease.

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By David Bryden
WASHINGTON DC, Mar 22 2018 (IPS)

A good education for every child is an urgent global imperative, but what if entering schools puts children at serious health risks? Tuberculosis (TB), the single biggest infectious disease killer, poses a major risk for young people in countries with high prevalence of TB, and schools are among the places where they are most likely to catch it.

A young boy suspected with TB. Credit: The Global Fund to Fight AIDS, TB and Malaria

Tuberculosis is spread when a person with the active disease is coughing or speaking and expelling tiny droplets containing the live bacteria. In a school setting, a student, teacher or other person in the school with TB can unwittingly spread the disease. The microscopic droplets can remain suspended in the air for extended periods, 30 minutes or more.

Globally, 67 million children are estimated to have TB infection. For children under five years of age, the greatest risk is in the home where they usually catch the infection from family members. Infants under one year of age are at especially high risk to develop TB disease, including severe, life-threatening forms, if they have been infected with the bacteria that causes it.

But, for older children, the picture changes dramatically with the greatest risk of infection being outside the home, particularly in overcrowded, poorly ventilated places—like schools.

In South Africa, where TB kills even more people than HIV/AIDS, a 2014 study found that adolescents faced a 14 percent chance over one year of acquiring TB infection, which investigators termed “extremely high.” . By adolescence, more than half of the children in South Africa are already infected with TB, and given the rate of drug resistance, some would have a resistant infection.

According to another recent study, up to half of TB transmission in young adults in South Africa age 15–19 is occurring in schools, in part due to the high proportion of “re-breathed air” in such settings. The study concluded that schools were a “particularly high-risk environment for transmission among young adults.”

A comparable investigation in Tanzania found an annual risk of TB infection in schools of 4 percent, lower than in South Africa, though still high. The study attributed the difference to the warm climate of Tanzania where schools rely on open windows and are better ventilated compared to South Africa.

Each day about 28,000 people across the globe develop TB disease, when the infection becomes active. Though curable, it has devastating consequences for them and their families, including frequent debt, job loss and impoverishment.

On average, 5–10 percent of those who are infected will develop active TB disease over their lifetime. Typical risk factors include undernutrition, diabetes, alcohol abuse, and smoking, and when a woman becomes pregnant her chance of developing TB disease doubles.

However, when children enter late adolescence their risk rises far above average. For the age group 15-19 the rate of developing active TB, as well as the mortality rate, is approximately double that of 10-15-year olds, according to the Global Burden of Disease Study 2015, published in Lancet Infectious Diseases, March 2018.

The first-ever estimate of active TB among young people, across all regions, was published in 2018 According to the estimate, 1.78 million adolescents and young adults aged 10–24 years developed tuberculosis in 2012, with the largest numbers in South East Asia and Africa. The authors noted the marked increase in TB between early adolescence and young adulthood, and urged attention to the special needs of this vulnerable population.

Adolescents living with HIV are up to 27 times more vulnerable to TB. However, TB risk extends to all young people. A study in western Kenya found a very high rate of active TB among adolescents, aged 12-18, most attending school and most HIV negative.

Urgent action is needed to address this health crisis impacting young people.

First, active steps must be taken to find and provide person-centered treatment to everyone with active TB disease, including in school settings, along with psychosocial support. Once on the correct treatment a person with TB rapidly becomes un-infectious.

Second, though seldom done in high burden countries, we must rapidly identify anyone who has been in contact with people with active TB and provide a course of preventive antibiotic treatment. These preventive antibiotics are highly effective and a relatively short course of medication, taken weekly, has been developed. Since people living with HIV are especially at risk, they should take the preventive antibiotics along with HIV medication.)

Third, improving ventilation and reducing overcrowding in school settings—and in any indoor environment in high TB burden countries where people, of any age, spend large amounts of time together—is s critically important. This applies not only to schools but also places such as clinic waiting rooms, places of worship, prisons, and public transport.

Fourth, we must raise TB awareness, since knowledge of the disease is low, even in high burden countries. In this and in many other areas, South Africa has been leading the way forward. With support from the US Agency for International Development (USAID), the Department of Education is providing training of teachers and learners to be TB ambassadors, carrying out community activations and media campaigns focused on TB in children, and conducting TB screening.

Finally, governments must do more to establish adolescent-accessible health services, to meet the special needs of this group, including their vulnerability to TB infection and disease, as well as to other risks such as HIV. Addressing TB among this group will require breaking the silence and confronting the stigma, shame and myths that have slowed the response.

We must not delay. In Africa, 41 percent of the population is under 15, with a further 19 percent between the ages of 15 and 24. In India, 300 million people are under the age of 15. We will fail these and many other young people if we ignore tuberculosis.

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