It's Time: Match words with actions to #endTB

Bobby Ramakant *

Dr Nguyen Viet Nhung, head of national TB programme in Vietnam and Director of National Lung Hospital, Hanoi

Alongside boosting research and development of new tools to prevent, diagnose and treat TB, there is an acute need to optimally deploy and maximally utilize existing tools for preventing, diagnosing and treating TB, says Dr Nguyen Viet Nhung, head of national TB programme in Vietnam and Director of National Lung Hospital, Hanoi.

Dr Nhung was conferred upon the 'Honorary Associate Professor' title by University of Sydney Central Clinical School, Faculty of Medicine and Health, on 13th December 2018 (a day after the Universal Health Coverage Day - UHC Day).

Mind the gap: It's Time, to be honest

Are we doing all what we can, to end TB? Dr Nhung acknowledges the funding gap in the global fight against TB, especially the resource crunch which is slowing down research and development (R&D) of new tools for preventing, diagnosing and treating TB. "Funding gap for TB R&D is very big, US$ 1.2 billion per year. If we don't have this funding gap then new effective tools for preventing, diagnosing and treating TB may come out sooner" says Dr Nhung.

More importantly Dr Nhung points out that gap is not only in funding, but also between what-we-can-do to end TB and reality on the ground. Business as usual is not an option and we have to maximally utilize all evidence-based ways to prevent, diagnose and treat TB, while we accelerate science for finding better tools.

Doing TB control more effectively

Innovation is not only about finding new tools, but also about finding better ways of doing what-we-know-works more effectively in TB control. "In Vietnam we not only pay attention to R&D but also to innovation. We apply new tools in optimal ways" said Dr Nhung. For example, new molecular test (cartridge based bucleic acid amplification test) GeneXpert, has been deployed in more efficient manner in Vietnam.

Dr Nhung further explained: "X-ray is very sensitive for TB screening but not for confirming the disease. If we screen people using x-ray first, and those who are found with abnormalities consistent with TB, are tested with GeneXpert, then it is not only optimal but also a cost-effective strategy. We have increased active case finding which has now reached above 90% now."

Scientific evidence must shape policies and programmes

Dr Nhung said that well-documented studies provide the data for decision making on policy innovation and scale-up of new interventions in Vietnam. "There are gaps in implementation of TB control too, which can be bridged by better management, resource maximization, and using budget to support key activities, integration of services and making services friendly and accessible to our clients (patients)" reflected Dr Nguyen Viet Nhung.

We cannot ignore sustainability, said Dr Nhung, as it is vital to ensure full support to fight against TB till the 'finish line'. At the United Nations High Level Meeting (UNHLM) in September 2018, Dr Nhung was among those who advocated with heads of nations to end TB. Since then, TB is rising up on the agenda of Vietnam's national commission which is tasked with multistakeholder accountability framework. This may soon reflect in the law, approved by the national assembly, and eventually result in national action plan to end TB by 2030. A very concrete development, said Dr Nhung.

Communities: cog in the wheel to #endTB

Dr Nguyen Viet Nhung rightly says that gap in involvement of community at every level of the fight against TB cannot be ignored, if we are to end TB. "What use will be state-of-the-art diagnostics, treatment and care if people who are in need, are unable to use it?" Scientific innovations such as vaccines will have to reach all those who need them, otherwise we are failing to convert scientific breakthroughs into public health gains.

"We need to bring healthcare services and people who need these services, together! We have to narrow the gap between provider and client, where client is community and not just the patient" emphasized Dr Nhung. Reducing and eventually ending TB related stigma is of prime significance, said Dr Nhung.

Catastrophic expenditure is blocking progress

Dr Nguyen Viet Nhung emphasized on yet another major obstacle which impedes efforts to fight TB: catastrophic expenditure. Even when TB diagnostics and drugs are free, there are a range of medical and non-medical costs that become a barrier for people with TB. All countries including Vietnam had unanimously supported the adoption of the World Health Organization (WHO) End TB Strategy in May 2014 World Health Assembly, of which, promise to end catastrophic expenditure is among the major pillars.

Dr Nhung stresses on the need to have local data to estimate TB costs so that locally feasible solutions can be found to reduce or eliminate such barriers. "We can seek support from foundations or charity or health insurance systems to ensure there is no medical cost that is preventing people from accessing TB care. We have a patient support foundation to end TB in Vietnam to help those who get diagnosed with TB (especially those who do not have health insurance card).

This foundation also helps patients when they need to be hospitalized. Non-medical expenditure is the bigger chunk of catastrophic expenditure for TB patients. Universal Health Coverage (UHC) will help reduce some of these costs, as well as, making healthcare services friendly and easier to access at the grassroots will help. We have to help establish and strengthen community based management to avoid hospitalization when possible, said Dr Nhung.

Dr Nhung recommended to engage other non-health sectors such as labour sector to minimize or eliminate labour or income loss for those who seek TB care. By working together with labour sector and other stakeholders we should agree on a labour policy to support TB patients.

"Without the involvement of the community we cannot end TB", if we are to end TB, we need to find solutions with community and break down all barriers to TB care, emphasized Dr Nguyen Viet Nhung.

Rehabilitation is integral part of healing and care

"Previously we only thought of bacilli but now we have to think beyond treating the disease, and focus on the patient's wellbeing. Patient may be cured of TB but despite being cured, lives with consequences of getting TB, such as, large scar in the lungs. Another example is sometimes chronic TB can cause severe COPD (Chronic Obstructive Pulmonary Disease). Rehabilitation is a very important part of TB care. In Vietnam we have developed Rehabilitation Treatment Programme which not only includes treatment with medicine but also has more comprehensive elements, such as exercises etc, to support rehabilitation of the patient."

Empty the pool of latent TB to #endTB

"Addressing latent TB is a very important component of the strategy to end the epidemic. When we treat latent TB, the new infection (not disease) is very different from primary infection because the other infection has already been killed, which results in patient developing immunity against TB. Globally we have set a target of providing TB prevention treatment (for latent TB) to 30 million people between 2018 and 2022, based on new WHO guidance. This target is not ambitious, and we think, it has to be much more!" said Dr Nhung.

Dr Nhung suggests that target to provide preventive therapy to people with latent TB should at least be 60 million by 2022.

One of the challenges slowing progress on addressing latent TB is lack of diagnostics that can be scaled up to the required level of potential public health impact. Unfortunately, there is no gold standard diagnostic test for latent TB infection, and existing tests have poor ability to predict which individuals will go on to develop active TB disease. Tuberculin skin test is not specific enough and Interferon Gamma Release Assay (IGRA) tests (like Quantiferon) are "complicated (need specialist laboratory processing) and expensive" says Dr Nhung. "We cannot do it for everyone in a programmatic setting."

But there is some hope: "C-Tb is a novel specific skin test developed in Denmark, Europe, based on 2 specific antigens (ESAT-6 and CFP10), and results are unaffected by BCG vaccination status." Such tests which can be used in programmatic settings of high-burden TB nations, with good specificity and sensitivity, can potentially jump the numbers of people receiving preventive therapy for latent TB, says Dr Nhung.

Cost is another barrier: preventive therapy for latent TB (based on rifapentine and isoniazid regimen) is very effective but expensive: "we need to find a way to do global negotiations for quality assured standardized drug procurement so that we can reduce the cost of this regimen and make it more affordable for people" said Dr Nhung.

Dr Nhung committed that with the support of the Global Fund to fight AIDS, TB and Malaria (The Global Fund), Vietnam is likely to aim for much bigger targets for addressing latent TB in the country, compared to global goals. Dr Nhung also underlined the importance of research to evaluate the impact of this latent-TB-intervention in reducing the epidemic and hoped it will be studied in near future in Vietnam.

Rollout of Bedaquiline in Vietnam

Bedaquiline is among the only two new TB drugs that have been approved over the last 40 years. Although phase-III clinical study is still going on, Bedaquiline, was provided marketing authorisation by the US-FDA under a procedure of "accelerated approval" for the treatment of MDR-TB, in December 2012. By end of September 2018, over 70,000 cumulative treatments of Bedaquiline-based-regimens were given in 108 countries.

"Bedaquiline is very important for TB control especially when we think of ending TB. Bedaquiline rollout began in Vietnam two years ago. Its first pilot with 100 eligible patients (with pre-extensively drug-resistant TB or extensively drug-resistant TB) have successfully been completed last year. We extended the pilot to another 100 eligible patients and have almost met the target. Treatment outcome is very good with over 80% success rate, and side-effects remain under control" said Dr Nguyen Viet Nhung. For all patients of multidrug-resistant TB (MDR-TB) we offer the WHO approved short regimen. We need to reserve the new drug for patients who have exhausted current treatment options."

Dr Nhung cautioned on cross-resistance between new drug Bedaquiline and Clofazamine. To avoid cross-resistance in Vietnam, patients who have a history of taking clofazamine, are not eligible for Bedaquiline.