The Clock is Ticking for Tuberculosis Care and Prevention
Published: 24 Mar 2021
As we battle COVID-19, we are at risk of losing hard-won gains in ending TB in Singapore. The collaborative efforts of the government as well as private and social organisations are critical to #ENDTB.
By Catherine Ong, Ying-Ru Jacqueline Lo and Tauhidul Islam
Every year, World Tuberculosis Day is commemorated on 24 March, but unlike previous years, the world is now simultaneously contending with the COVID-19 pandemic. Tuberculosis (TB) remains a leading killer among infectious diseases, claiming an estimated 1.4 million lives in 2019, only to be surpassed by COVID-19 in 2020. The Western Pacific Region of the World Health Organization (WHO), which Singapore is in, bears one fifth of the global TB burden. In Singapore, there were 3,094 TB patients notified in 2018 and while the country is categorised as having a low incidence rate for TB, strong and inclusive TB control programming is needed to continue to make further progress towards TB elimination.
In 2015, WHO and its Member States committed to end TB through the adoption of the “End TB Strategy”. This was followed by the first high-level meeting of the UN General Assembly on TB in 2018 to reaffirm commitments as laid forth in the Strategy and the UN’s Sustainable Development Goals. The high-level meeting resulted in a political declaration to strengthen action toward the TB response and set new global targets with a focus on prevention, care and research. The WHO End TB strategy targets include reducing TB deaths by 95%, cutting new cases by 90% between 2015 and 2035, while the UN high level meeting also called for providing TB treatment to 40 million people and preventive treatment to at least 30 million people by 2022.
WHO estimates that the delays in diagnosis, inadequate TB treatment and disruption of essential services could result in hundreds of thousands of additional deaths annually. Multiple international studies show that national lockdowns coincided with a drastic drop in TB clinic attendances and case notifications, pauses to TB surveillance, and a decrease or even cessation of TB services as priorities shifted to COVID-19. This threatens to reverse progress made in achieving global targets for the elimination of TB and Singapore is no exception. It is only with people-centred delivery of TB prevention, diagnosis, treatment and care services, ensured in tandem with the COVID-19 response, that we can continue to make progress against TB.
Preventive treatment is key to keeping TB disease at bay
TB presents as a spectrum of infection, ranging from the latent stage, known as TB infection, where patients do not have symptoms, to TB disease, which can present with severe symptoms and be transmitted to close contacts such as family members in the household. Treatment of the disease requires multiple pills to be taken together for a minimum of six months stretching to more than a year for multi-drug resistant TB. However, it is possible to stop the progression from infection to disease with a treatment regimen that consists of one or two anti-TB drugs taken together as part of TB preventive treatment, also known as TPT.
TPT is an important tool and the only scalable health intervention to prevent progression to active TB disease today. It is critical to use it in conjunction with systematic screening, to ensure we can detect TB cases early and identify people with TB infection who could benefit from TPT to help reduce the risk of progression to disease.
WHO recommends two broad groups of at-risk populations for systematic assessment of eligibility and provision of TPT; people with elevated risk of progression from TB infection to TB disease—such as people living with HIV, patients receiving dialysis, patients preparing for organ or bone marrow transplant—and people with increased likelihood of exposure to TB disease such as contacts of people with TB and people who live or work in institutional or crowded settings.
The 2019 Singapore Ministry of Health Screening Test Review Committee Guidelines recommended latent TB infection testing among people with elevated risk of progression from latent infection to active disease. Despite more patients receiving preventive treatment than ever before, systematic testing and preventive treatment of TB infection among people living with HIV could be further expanded in Singapore.
A local study carried out from 2005 to 2016 showed that only two out of 320 (0.6%) HIV patients were screened for latent TB infection. In addition to those living with HIV, dialysis patients, renal, liver and bone marrow transplant patients and those with other immunodeficiencies are at increased risk of contracting TB and would benefit from screening and preventive treatment. Those who live or work in institutional or crowded settings, such as prisoners, healthcare workers, recent immigrants from countries with a high TB burden, homeless people and people who use drugs should be also included in TB infection testing protocol.
People with TB are among the most marginalized and vulnerable, facing stigma and discrimination when accessing care. Continuity and expansion of TPT and screening services are crucial to curbing the disease, especially during the COVID-19 pandemic when resources have been re-prioritised. Because of the burden COVID-19 has posed to even the most robust of healthcare systems, many essential services have been disrupted and TB diagnostics and treatment are no exception. As people around the globe, come together to commemorate World TB Day, the WHO is calling on governments, affected communities, civil society organisations, healthcare providers, donors, partners and the industries to unite and step up the TB response – including for preventive treatment – to ensure no one is left behind.
COVID-19 has been a lesson in how communicable disease can be devastating if not contained in time. It highlights the importance of a whole-of-government approach and the need for innovative ways to deliver health services. All of these are necessary to put an end to TB.
The clock is ticking. It is time to fulfil our commitments and #ENDTB.
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Catherine Ong is Assistant Professor in the Infectious Diseases Translational Research Programme, Department of Medicine, National University of Singapore and Consultant in the Division of Infectious Diseases, National University Hospital.
Ying-Ru Jacqueline Lo is Head of Mission and World Health Organisation (WHO) Representative to Singapore, Malaysia and Brunei Darussalam.
Tauhidul Islam is Coordinator for the End TB and Leprosy Unit, Division of Communicable Diseases, Regional Office for the Western Pacific of the WHO.
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