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Tuberculosis: We must join forces to face this global threat

The 2017 world report on tuberculosis showed that nearly 1,7 million people in the world lost their lives in 2016 as an outcome of the disease


To address the problem, the Health Ministry launched in 2017 the National Plan to End Tuberculosis

The recent 2017 world report on tuberculosis, presented by the World Health Organization (WHO) showed that worldwide, nearly 1,7 million people died in 2016 as an outcome of the disease. From these, 374 thousand also had AIDS. From the Portuguese-speaking countries, Angola, Brazil and Mozambique are among the 20 nations with most cases. In the same list are China, North Korea, Nigeria, Pakistan and Russia, among others. According to numbers from the Health Ministry, currently 32.4 people per hundred thousand inhabitants are affected. In 2016, 69.5 thousand new cases were reported along with 12.8 thousand re-treatment cases. The most affected states were Amazonas and Rio de Janeiro, with 68.2 and 63.8 cases per 100 thousand inhabitants.

To address the problem, the Health Ministry launched in June 2017, the National Plan to End Tuberculosis. Since then, it has been disclosed and discussed with the states TB programs coordinators in order to support the implementation of the strategies recommended in the Plan. Among the recommendations, the National Plan for Tuberculosis Control (NPTC) has approached the intra and inter-sector articulation with partners as the Basic Attention Department, STDs, HIV and Viral Hepatitis Department and Special Secretary for Indigenous Health. Other actions have contributed to the Plans implementation, as the expansion of the Rapid Molecular Test network (TRM-TB), that enhances the diagnostic of the disease; the elaboration of clinical pediatric and adult TB management, performing two treatments with 100 multipliers for all states; release of the death surveillance protocol; publication of the 1st epidemiological bulleting for TB-HIV, in partnership with the Department of STDs, HIV and VH.

The infectious diseases specialist, Dr. Julio Croda, believes most of these deaths could have been prevented. To him, early and free diagnostic, as well as free medication supply are fundamental. This is done in Brazil, but several countries in the world still lacks universal health coverage. Brazil has been a role model in this sense, ensuring free diagnostic, medical care and treatment for patients. Besides this, the wealth distribution programs have been used as examples for other countries, especially because the disease strikes the most vulnerable and poorest population groups, he completes.

Regarding the deaths in Brazil, the Health Ministry informed that the deaths are not related solely to treatment failures, as noncompliance or poor treatment compliance, but also to late diagnosis, which takes place in an advanced stage of the disease. We miss the opportunity for early diagnosis for not having an active case surveillance, contact identification, besides other strategies to enhance the link between the patient and the health services.

Investments and technology are necessary to meet the goals

The goal of the National Plan to End Tuberculosis presented by the Health Ministry is to reach at least 10 cases per 100 thousand inhabitants until 2035, as agreed with the WHO. However, to Dr. Croda, neither Brazil nor the World will meet this goal. He explains there is a clear lack of investments to control the disease in the Country and in the world. In 2017, there was a USD 2,7 billion budget cut, and in Brazil, a difference estimated in USD 12,1 million. The investment to control TB dropped from USD 75,6 million in 2013 to USD 54,3 million in 2017. Our incidence remained with a reduction rate of 1,2% a year. But without increasing investments and without new technologies, we will not meet the WHOs goals, he alerts.

The board informed that in order to incorporate the new technologies and research support recommended in the Plan, they are developing a work in partnership with the National Network of Tuberculosis Researchers (Rede TB) and with the Department of Sciences and Technology, besides national and international partnerships for epidemiological studies involving Brasilia University (UnB), São Paulo University (USP), Harvard University, Yale University and the WHO.

The Health Ministry agreed that in order to meet the goals, additional efforts to what has been done are necessary. The definition of TB scenarios to classify Brazilian municipalities by socioeconomic, epidemiological and operational indicators was one of the strategies defined in the Plan to support the work of the three management spheres reaching the goals. Within each of the three pillars that compose the Plan, objectives and specific strategies were defined to qualify the existing actions and inclusion of new diagnostic and treatment routines and technologies.

Increase of preventive treatment to vulnerable populations

Asked whether medications and preventive treatments are reaching the people who need them, the Board answered they perform centralized purchase of all 1st and 2nd class medications for active and latent TB treatments. However, the NPET acknowledges the access to care and treatment depend on multiple factors. We must reduce barriers to ensure the medications, available by the Unified Health System, reach these people. Croda stated that access to medications is not a problem for most cases identified in Brazil, but he stresses the need to increase access for the treatment of multi-drug resistant strains.

Despite having the preventive treatment with isoniazid, the numbers are decreasing due to the lack of tuberculin test (PPD). We must increase preventive treatment for the most vulnerable population groups, as people living with HIV/AIDS, indigenous populations and persons deprived of freedom, he says while adding that Brazil has implemented the fast molecular test in several states, however, the diagnostic among these populations is still long lasting. The infectious diseases specialist defends the need to provide diagnostic in a more systemic way by active screening of people living in the streets, persons deprived of freedom and indigenous populations.

To him, the disease will always be a social, political and economic problem and the most effective control measure is poverty reduction. Cases are focused in the poorest communities, where transmission conditions are ideal. Lack of health care access delays the diagnostic. These communities need a differentiated look from public policies, with greater investments and guarantees of better access to diagnostic and treatment. We must change the strategy against TB, rethink the role of slums and include the population deprived of freedom, where access to social services are even worse, he defends.

The creation of the Parliamentary Front Against Tuberculosis in 2012, result of a joint action between government and the civil society, gave the disease a greater visibility, reflecting in initiatives related to social protection for people with TB, among which, bill N. 6991/2013, that creates a monthly financial benefit, worth half minimum wage, to families registered in the Single Registry of the Federal Government Social Programs, and that, have members under treatment for tuberculosis or leprosy. This bill is progress in the Deputys Chamber.…