Applied health research for making systems work for all is vital to #endTB

Shobha Shukla *

Dr Bertel Squire is the Director of Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine

"Excellence in health means devoting your life to ending poverty" said physician and comedian Patch Adams many years ago, but these words have gained even more relevance in the current context and development paradigm. One of the early torchbearers to advocate for world's attention upon linkages between poverty and TB, Professor (Dr) Bertel Squire, shared key insights on how we could do better to progress towards ending TB and keeping the promise of UN Sustainable Development Goals (SDGs).

Dr Bertel Squire is the Director of Centre for Applied Health Research and Delivery, Liverpool School of Tropical Medicine and honorary consultant for Infectious Diseases and Tropical Medicine, Royal Liverpool University Hospital. He is also the former President of International Union Against Tuberculosis and Lung Disease (The Union) and among key researchers conducting the STREAM study comparing effectiveness of shortened treatment regimen for multidrug-resistant TB (MDR-TB). Dr Squire gave this exclusive interview to CNS (Citizen News Service) at the 48th Union World Conference on Lung Health in Guadalajara, Mexico.

If poverty persists then no ending TB

"The biggest game-changer is the attention on perspective of poverty in TB, both in terms of how patients access services and in terms of our response. The WHO End TB Strategy has a goal on reducing catastrophic costs for TB patients, and that sits alongside the epidemiological targets. There is an increasing recognition that, unless we address this suffering and catastrophic cost, we would not hit the epidemiological targets of the WHO End TB Strategy" rightly said Dr Squire, while sharing some of the game-changers that happened in the fight against TB in the past two decades.

"TB in many ways is a male epidemic"

Although gender based inequities jeopardize access to TB services and aggravate TB related stigma and discrimination, yet, in terms of prevalence, TB epidemic leans more towards the male population. There has been "the recognition in recent years that TB, in many ways, is a male epidemic. Evidence from prevalence surveys has shown for the first time that the ratio of male to female TB patients is around 2:1.

This is not the same in every country, and there are countries like Afghanistan where there are more women than men affected by TB, but if you take the average, it is a male epidemic; and that links to a whole series of actions which I do not see us taking yet. It is a complex piece to unpick, especially as there is also evidence that lost or missed cases are more amongst the men than amongst women. This again, relates to the whole issue of catastrophic cost – it is a complex intersection between masculinity and the sense that men need to provide for households, which is one of the contributors to late presentations" shared Dr Squire.

Research to ensure health systems work for all is vital

Undoubtedly, research for finding better TB diagnostics, drugs and vaccines, needs to be accelerated. If we are to end TB, we need to have more effective tools to help with TB prevention, accurate diagnosis, effective treatment and cure. But are we using the existing tools optimally to their fullest potential in a rational and evidence-based manner? Perhaps not. Else, the challenges TB poses could have been mitigated more. For instance, we could have averted the anti-TB drug resistance that has emerged as a major threat to global health security. We definitely need to find better ways to use existing tools to help fight TB.

Dr Squire has been a force to reckon with, on advocacy around the importance of applied health research and delivery. "We do have a lot of momentum around research needs for new tools and globally, the politicians and the public recognize that research will give us new drugs, diagnostics and vaccines. But I do not see much recognition that we need applied health research in order to make systems work for patients. I see lots of investment in new things but I see less investment in that. We need this applied health research to make sure that the new tools, as they come off the line, get into the health system in a way that really works and goes to scale. We have to get the message across that applied health research is crucial. "

Do not ignore big drivers of diseases

Another important insight Dr Squire shares, is not to forget major drivers of infectious and non-infectious diseases. "We should be looking at upstream influencers of these diseases. For example, we need to be reaching out to the community that looks at air pollution and tobacco control, as these are big drivers of infectious diseases as well as of incoming non-communicable epidemics. Similarly, we need to reach out with neglected tropical diseases (NTDs) to communities around water and sanitation - as these are also big drivers."

STREAM Study: game-changer?

Preliminary results of STREAM study were released at the 48th Union World Conference on Lung Health. The STREAM study (Standardised Treatment Regimen of Anti-TB Drugs for Patients with MDR-TB) showed that the nine-month shortened treatment regimen achieved favourable outcomes in almost 80 percent of those treated. The preliminary results suggest the nine-month regimen is very close to the effectiveness of the 20-24 month regimen recommended in the 2011 WHO guidelines, when both regimens are given under study conditions.

This STREAM study is the world's first multi-country randomised clinical study to test the efficacy, safety and economic impact of shortened MDR-TB treatment regimen. This study was initiated by the International Union Against Tuberculosis and Lung Disease (The Union) in 2012 with its main partner, the Medical Research Council Clinical Trials Unit at UCL, and was funded by the US Agency for International Development (USAID) and UK Department for International Development (DfID) among others.

Dr Bertel Squire who is among the key researchers of this study shared that "The results of this trial are really a milestone. This is the first ever randomized controlled study of a regimen for MDR-TB and that in itself is an achievement. Another very crucial aspect of this study is that, for the first time in TB [research], we have seen integrated within the trial, studies on health systems and patient costs - that is going to be very important in thinking about how to implement and how to scale up. A big surprise is that the 20 month WHO regimen in the control arm of the study, really performed well - it had an 82% success rate." Treatment success rate of this MDR-TB regimen in most high burden countries has been much lower than this. But it gave a success rate of 82% in clinical study conditions - underlining the importance of applied health research and delivery which can provide key insights on how to make health systems work for everyone, especially the key affected populations.

Added Dr Squire: "The shortened regimen throws up complex clinical management issues - questions around ECG monitoring, for example - which will require similar attention to detail to get the same results. Having said that, the next big headline I would give is, the cost of the shortened regimen to the health system is about one third of what it cost in the control arm [with 20-24 months WHO recommended regimen for MDR-TB]. The patients on the shortened regimen themselves saved, not just in health seeking costs, but they also returned to work sooner, even while on treatment. So it was not just the accumulation of that time after completion of treatment but they were returning to work during the time of the shortened regimen. I think these are really crucial findings."

What should policy makers infer from this preliminary study result? Both regimens [20-24 months regimen vs 9 months shortened treatment regimen for MDR-TB] have performed relatively similar. Dr Squire recommends that "I think our decision should be based upon benefits to patients, and benefits to health systems. The fact that this could translate into patients' savings is really crucial. Also the fact that we will be able to generate greater momentum about the provision for MDR-TB is going to be very important for WHO End TB Strategy. We currently have only 1 in 5 MDR-TB cases accessing treatment and that is largely because the control regimen requires such a lot of effort to get going. I hope we see countries really move forward and accelerate implementing the shortened MDR-TB regimen."

MDR-TB prevention is a compelling priority

Dr Bertel Squire hoped that the savings the health systems make from the shortened regimen, are reinvested in the health system for prevention purposes. "In our efforts to deal with MDR-TB, we forget that the biggest action on MDR-TB is prevention. We must strengthen infection control in hospitals, congregated settings and other places, and ensure we are not generating new cases of TB."

'Health solutions for the poor' and The Union

"I honestly do n0t feel that I have any particular moments of individual pride. I feel an enormous pride for having been a part of, what now has become a movement around, addressing the poverty perspective in TB. It was a huge honour to serve The Union as President when it formulated its forward vision of health solutions for the poor" shared Dr Bertel Squire.

Will TB get world's attention?

The first WHO Global Ministerial Conference on ending TB in sustainable development era, will soon open in Moscow in mid-November 2017. Also the first-ever and potentially path-breaking opportunity to turn world's attention on TB is in 2018 at the UN General Assembly when a High Level Meeting on TB is held. "Do not be faint hearted. TB has beaten the human population for a long time. We have a huge opportunity right now for the first time with the 2018 UN General Assembly looking at TB, as well as the Moscow meeting coming up in November 2017. TB has suffered from not being high up on the political agenda. I think if we do not seize these opportunities, we are going to miss that chance to make that difference" rightly cautioned Dr Squire.

This interview is part of CNS Inspire series – featuring people who have had decades of experience in health and development, and learning from them what went well and not-so-well, and how these learnings can shape the responses for sustainable development over the next decade.