Brazil installs Interministerial Committee for the Elimination of Tuberculosis

In addition to tuberculosis, the elimination plan by 2030 includes HIV, viral hepatitis, trachoma, onchocerciasis, schistosomiasis, filariasis, geohelminthiasis and Chagas disease

In an unprecedented way, the federal government installed, on June 6, the Interministerial Committee for the Elimination of Tuberculosis and Other Socially Determined Diseases (Cieds). Among the objectives of this Committee is the development of articulated actions to achieve social inclusion and comprehensive care for people with tuberculosis and other socially determined diseases. It will be up to the Ministry of Health to coordinate the actions of the body that will operate until January 2030. The other eight ministries that are part of it are: Science, Technology and Innovation; Development and Social Assistance, Family and Combating Hunger; Human and Citizenship Rights; Education; Racial equality; Integration and Regional Development; Justice and Public Security; and Indigenous Peoples.

According to data from the Ministry of Health, between 2017 and 2021, socially determined diseases were responsible for the deaths of more than 59,000 people in Brazil. The populations considered most vulnerable are the homeless, who have a risk of falling ill from tuberculosis 56 times higher than the general population; the population deprived of liberty (PPL), which represents approximately 0.3% of the Brazilian population, and contributed with 9.9% of the new cases of tuberculosis notified in the country in 2021 (8,637 new occurrences), and people living with HIV . It is estimated that, currently, one million people live with HIV in Brazil, and of these, 900,000 know their diagnosis. In this scenario, the goal is to have 95% of people living with HIV diagnosed; 95% of these people in treatment and, of those in treatment, have 95% with an undetectable viral load. Tuberculosis is one of the conditions with the greatest impact on the mortality of this public.

To learn more about the subject, the press office of the Brazilian Society of Tropical Medicine (SBMT) interviewed Dr. Draurio Barreira, director of the Department of HIV/AIDS, Tuberculosis, Viral Hepatitis and Sexually Transmitted Infections at the Secretariat for Health Surveillance and Environment of the Ministry of Health (Dathi/SVSA). Check the interview in full.

SBMT: What are the reasons or justifications for the creation of the Interministerial Committee for the Elimination of Tuberculosis and what are the main objectives and goals established?

doctor Draurio Barreira: Tuberculosis is one of the oldest diseases in the world , with cases recorded in ancient Egypt, in sarcophagi, dating back to 3,000 years before Christ . it is still the infectious disease that kills the most in the world. This is not due to a lack of tools for control, as we have good conditions for diagnosis, treatment, methods ofprevention and even a vaccine, BCG, which is not 100% effective because it works more to prevent cases among young children, since it does not confer immunity over time. In other words, it has been demonstrated, historically, that through purely biomedical actions, we will never eliminate tuberculosis. We haven’t eliminated it in the last 3 thousand years, and it won’t be now, doing the same things, that we’re going to have different results. Tuberculosis drugs have been around for 70 years; Diagnosis has been possible since the discovery of Koch’s bacillus over a hundred years ago. What needs to be done to effectively eliminate tuberculosis is to face the social determinants of the disease and not a purely biological approach, that is, these are issues related to poverty, social exclusion, inequality, lack of access to all the goods that would protect against the disease, such as housing, food, work, etc. Without tackling all the factors that determine the disease, we will not achieve a different result than what we have achieved so far and that is the reason why the Committee was created with the participation of nine ministries, with the possibility that, later on, still others enter, like the Ministry of the Environment, with whom we believe it is important to work as well. Eventually we will have to work with some organizations, some secretariats that were not foreseen in the first Presidential Decree, but that have contributions to face these determinants. we are not going to achieve a result that is different from what we have achieved so far and that is the reason why the Committee was created with the participation of nine ministries, with the possibility that, later on, others may join, such as the Ministry of the Environment, with the which we understand to be important to work on as well. Eventually we will have to work with some organizations, some secretariats that were not foreseen in the first Presidential Decree, but that have contributions to face these determinants. we are not going to achieve a result that is different from what we have achieved so far and that is the reason why the Committee was created with the participation of nine ministries, with the possibility that, later on, others may join, such as the Ministry of the Environment, with the which we understand to be important to work on as well. Eventually we will have to work with some organizations, some secretariats that were not foreseen in the first Presidential Decree, but that have contributions to face these determinants.

The committee’s objective, which its name already defines, is to eliminate tuberculosis as a public health problem. Not only tuberculosis, but all socially determined infectious diseases, such as leprosy, schistosomiasis, onchocerciasis, trachoma, leishmaniasis, vertical transmission of HIV, hepatitis B, syphilis, Chagas disease, and also HIV as a public health problem. We need to make it clear that we are talking about elimination as a public health problem and not eradication, which means definitively putting an end to a disease, and this is only possible through a highly effective vaccine, with efficacy close to 100% added to the vaccination coverage of 100% of people. Without these two factors, no disease can be eradicated and the examples are very clear. In human history, we have only managed to eradicate smallpox and we are close to eradicating polio. But we haven’t managed it yet, we are in the elimination phase with a public health problem. That’s what we want for tuberculosis and for all the other diseases that the Interministerial Committee proposes to eliminate.

Goals are operational. In the case of tuberculosis, we need to reach an incidence indicator of less than 10 cases per 100,000 population by the year 2030. Today we have practically 38 cases per 100,000. The same applies to HIV and leprosy. As for other diseases, the targets are bolder because they are much closer to elimination. For example, lymphatic filariasis currently only exists in Brazil in four municipalities in the metropolitan area of ​​Recife. So we must eliminate this disease so that we have virtually no cases in the country. But for tuberculosis, we have an operational target of 10 cases of tuberculosis per year for every 100,000 inhabitants.

SBMT: What are the political, economic and social challenges that can be addressed by the Committee to achieve the elimination of tuberculosis?

doctor Draurium Barrier:I believe that the main thing was convincing the government, President Lula, to make the elimination of tuberculosis not a program of the Ministry of Health, exclusively a health program, but a government program, a goal of the Lula government. Therefore, the edition of a Presidential Decree constituting the Interministerial Committee. This was the most difficult step, I would say, from a political point of view, because we had been trying to do this for over 10 years. I worked as coordinator of the National Tuberculosis Control Program (PNCT), at the time it had that name, and the goal was actually control, not elimination, which is why the name of the program referred to control and not elimination. So, since that time, 2008 when I joined, until 2015 when I left, we tried to convince the government to create an Interministerial Committee, and only now, in this new administration of President Lula, the challenge was overcome. The other issues are very much related to funding and we hope to have funding that will provide the means for these interministerial actions to be carried out. That is, we need to draw up work plans with each of the ministries involved, with their areas of contribution in eliminating the disease and, therefore, have financial support to carry out the agreed actions.

SBMT: What specific strategies and actions will the Committee implement to improve prevention, early diagnosis, treatment and support for patients with tuberculosis?

doctor Draurio Barreira: This really is the heart of the matter. As I explained in the answer to the previous question , we are going to discuss with each of the ministries how they can contribute to resolve each of these issues. I’ll give you some examples: at the Ministry of Science and Technology we need to discuss the best diagnostic tools, that is, rapid molecular tests, similar to what we have for Covid, for example. These tests must be cheap, accessible, so that we can substantially expand the detection of tuberculosis cases in an agile, effective and cheap way. Regarding prevention, we have the BCG vaccine, which,as previously mentioned , its effectiveness is restricted to a period of life, childhood . In other words, we need better vaccines. But the creation, the development of avaccine is not a simple task, something that a country alone can do, but we can and must contribute to the global coordination for the development of a new vaccine. Another example of prevention is the shortened treatments, currently available to prevent tuberculosis, called 3HP or 1HP, which consists of a 3-month treatment with a weekly dose of the drugs rifapentine and isoniazid, in a single weekly dose, for 3 months, i.e. , 12 doses of these drugs, for the prevention of tuberculosis, against the existing treatment today, of 6 months with isoniazid, every day. This means that it goes from 180 doses to 12 doses, or 1HP, which is taking the same drugs, rifapentine and isoniazid, for 30 consecutive days, 1 refers to a month, while 3HP refers to 3 months, although they are only 12 doses, one per week.

With regard to treatment, it has been demonstrated that we cannot have a treatment that is 100% effective, because there is a lot of abandonment. Those affected by tuberculosis are generally extremely vulnerable, such as the homeless population, the indigenous population and the population deprived of liberty (PPL), so we need to promote forms of social support so that these people have continuity in treatment. That is, it is not just a matter of giving the medicine, but ensuring adherence throughout the 6 months of treatment. In this sense, we need the action of other ministries. I have already mentioned the Ministry of Technology; but, thinking in terms of treatment, perhaps the most important ministry in this process is that of Social Development, through incentives for adherence to treatment or, for example, the Ministry of Justice for treatment within prisons, the Ministry of Indigenous Peoples for reaching and maintaining treatment among the indigenous population, and so on. There are many examples that show us the possibility of working with different ministries to improve diagnosis, prevention and treatment of tuberculosis.

SBMT: How does the Committee intend to coordinate the activities of different sectors to achieve and fulfill the commitment to eliminate tuberculosis by 2030?

doctor Draurium Barrier:Let’s go into a little more detail about what I said above. We need to prepare eight work plans, that is, the Ministry of Health working with eight other ministries, defining the specific actions of each one of them to contribute to the elimination of tuberculosis. Among the examples cited, we can add: working with the Ministry of Justice so that we have access to the prison population and are able to detect, treat and prevent cases of tuberculosis in the prison system. Work with the homeless population, together with the Ministry of Social Development, promoting forms of social support, incentives, Bolsa Família, shelter, housing, both for patients and families affected by tuberculosis. Work with the Ministry of Indigenous Peoples to work among the indigenous population. Anyway,

SBMT: What monitoring and evaluation mechanisms should be adopted by the Committee to track progress and results in TB elimination?

doctor Draurio Barreira: In the process of preparing the work plans, there will be a monitoring and evaluation team that will be working together, pari passu , to prepare the work plan with the mechanisms for monitoring and evaluating these actions. Then the monitoring and evaluation plan will be developed at the same time as each of the eight workplans.

SBMT: What resource mobilization strategies did the Committee implement to ensure adequate and sustainable funding for disease elimination actions?

doctor Draurio Barreira: In this first year, 2023, which is the year for drawing up plans, mobilizing other ministries and articulating the work to be carried out by 2030, we already have a largely sufficient budget, due to the fact that the Ministry of Health had an unexpected surplus of resourcesdue to the fact that the purchase of the vaccine for Covid 19 will not be carried out in the quantities foreseen when preparing last year’s budget. That is, there was a budget to buy the vaccine for Covid, but as the pandemic cooled down worldwide and in Brazil, there was no need for us to make the purchase planned last year. As a result, there was a surplus of resources that guarantee the Committee’s execution throughout 2023. For the following years, from 2024 to 2030, we are looking for additional sources and we have several alternatives that will be discussed throughout that year. One of them, for example, is a loan from the World Bank that is in line with this agenda of eliminating neglected diseases, there are 14 diseases in total, and we have already spoken with World Bank technicians in Brasilia and they are in line with the idea of ​​providing funding for the Committee. This obviously requires the participation of ministries, including Finance, authorizing a Consultation Letter to obtain the loan and several other steps, but conversations have already started and there are some alternatives. There is also the possibility of working with the BRICS Bank and also with resources from Caixa Econômica Federal (CEF), especially with the use of resources from taxes on prizes from all federal lotteries that are drained to health and education. This means that we can define this program as a funding priority, which is a priority for the government and not just for the Ministry of Health, it would be an alternative source of funds, the unclaimed prizes of people who win the lottery and do not seek it in the first three months after the award, this resource can also be channeled to health and, with that, it is possible to finance the Committee. Anyway, there are several ideas that will be discussed collectively. The proposals we have today were developed during the preparation of the Committee by the Ministry of Health, but now it needs and should be discussed with the other actors of the Committee.

SBMT: How does the Committee intend to involve civil society, non-governmental organizations and other relevant actors in the planning and implementation of tuberculosis elimination actions?

doctor Draurium Barrier:This is very clear to all of us, because before proposing the creation of this Committee to the Minister, we had already been discussing with civil society and organizations of people affected by tuberculosis, in addition to the academic sector and other sectors of the community so that we would have the support, the support and contribution of those involved in the fight against tuberculosis. That is, the Plan, in its genesis, already includes the contribution of all these sectors. In launching the Committee, we had the participation of nine ministries, six networks of people affected by different diseases and several societies of professional categories (Pulmonology, Infectious Diseases, Tropical Medicine, Nursing, etc.). From the outset we have been concerned with the broad participation of civil society; even for the learning we had with the national response to HIV,

SBMT: What plans were designed to promote public awareness and the active participation of society in the fight against tuberculosis?

doctor Draurium Barrier:This was also discussed even before the drafting of the Presidential Decree, as this new management of the Ministry of Health has already been debating the need for information and advertising campaigns not to be punctual and referring only to a certain time of the year. For example, running a campaign against tuberculosis not just on World Tuberculosis Day, March 24, but throughout the year and focusing on those populations most affected. So much so that the campaign we ran recently did not have as much visibility in general, but it had much more visibility for the affected populations. In other words, we had a great performance in the communities of the great urban centers, in the slums, in the poorest communities, in the prisons, in homeless shelters and among health professionals who work with certain populations, such as the indigenous population. We are doing awareness work focused on the most vulnerable populations and with professionals who need to know about the relevance of the problem. At this moment, we are still working from a health perspective, but after the creation of the Committee, the idea is to go beyond and start working not only with health professionals in raising awareness of the need to eliminate the disease, but with all the partners engaged in the Committee.