Ending TB in Southeast Asia

In 2021, the WHO South-East Asia Region reported a TB incidence rate of 234 per 100,000 population, totaling about 4.8 million new cases, with 38% undiagnosed or unreported. The region also faced a significant TB mortality rate of 37 per 100,000 for HIV-negative individuals, resulting in 763,000 deaths, and an additional 25,000 deaths among those HIV-positive. TB notably ranked third for disability-adjusted life years lost in the productive age group of 15-49 years, highlighting its socio-economic impact. The region was responsible for 38% of the global MDR/RR-TB burden, yet only 42% of these cases were notified.[1] See also: Association of obesity, diabetes, and risk of tuberculosis

The economic burden was substantial, with 30%–80% of families in Indonesia, Myanmar, Thailand, and Timor-Leste facing catastrophic costs due to TB. National responses have varied: India launched the "Pradhan Mantri TB Mukt Bharat Abhiyan" aiming to end TB by 2025; Indonesia issued a Presidential Decree to meet a 2030 target; Maldives seeks to eradicate TB by 2025 with global support; Myanmar has reached the 2020 End TB targets; Nepal introduced the "TB-Free Nepal Declaration" in 2021; and Timor-Leste is leveraging digital technology in its strategy.[1] See also: https://tbreadingnotes.blogspot.com/2024/10/loss-to-follow-up-among-adults-with.html

Regional efforts to combat TB include adopting innovative technologies like digital X-rays and computer-aided diagnostics, direct financial transfers to patients, and using social media for patient engagement. TB treatment coverage improved to 78% by 2019, with a steady decline in TB incidence and mortality observed across several countries.[1] See also: TB and DM

To effectively end TB, the region has adopted a multisectoral approach as outlined in the South-East Asia Regional Strategic Plan, aligning with global 2030 targets. This plan emphasizes enhancing TB program services, integrating TB prevention into broader health and social services, and expanding collaboration beyond the health sector with various governmental bodies to address social determinants of health, ensure social protection, and provide nutritional support. This comprehensive approach underscores the necessity of continued, intensified efforts to address TB as a regional priority.[1] See also: TB and hypertension

In 2018, the TB incidence in the WHO Southeast Asia Region (WHO SEAR) decreased but remained alarmingly high. The region, which includes 11 countries such as India, Indonesia, and Thailand, contributes nearly half of the global new TB cases and over 50% of TB-related deaths, excluding those with HIV co-infection. Thailand stands out as the only high-burden country in the region significantly investing domestic funds into TB control. The region faces a critical need to boost health sector funding, particularly in Bangladesh, India, and Indonesia, where public health spending is currently low.[2] See also: TB burden in Taiwan

There is an urgent requirement for enhanced capacity to absorb and efficiently utilize increased funding across the region. Domestic financing, significantly through taxation, will play a crucial role in sustaining TB control efforts. Additionally, donor funding remains essential, especially for low-income countries, to support global TB initiatives. Collaborative efforts between international development agencies and national governments are necessary to generate more resources and provide technical support. Engaging the private sector and leveraging Corporate Social Responsibility mandates could also augment funding and improve the effectiveness of TB response. Lastly, adopting results-based financing can enhance the efficiency of spending and potentially reduce the need for further resources in settings with limited funds.[2] See also: https://tbreadingnotes.blogspot.com/2024/10/national-tb-elimination-programme-in.html

In Indonesia, tuberculosis incidence remains high despite global declines and improvements in local health services, funding, and diagnostics. The national tuberculosis information system, Sistem Informasi Tuberkulosis (SITB), captures comprehensive patient data that enhances policy and treatment efficacy evaluation. From 2017 to 2019, Indonesia saw an increase in notified cases of drug-susceptible tuberculosis and treatment success rates, alongside a significant uptake in rapid molecular diagnostics. However, less than half of the recommended tests for ongoing treatment monitoring were conducted. While treatment costs remained stable at about $40 for a six-month course, the real costs might be underestimated, especially in private settings. Despite these improvements, mortality rates have not significantly changed, and issues with retreatment cases suggest the need for better monitoring of treatment-resistant patients. These findings, focused solely on drug-susceptible tuberculosis, should be interpreted with caution given the high number of under-reported cases.[3] See also: https://tbreadingnotes.blogspot.com/2024/08/tuberculosis-incidence-and-its.html

Recurrent tuberculosis (TB) occurs due to either a relapse or reinfection with Mycobacterium tuberculosis, often influenced by factors like treatment adherence, severity of initial infection, and patient immune status. Retreatment in TB is common among patients experiencing relapse, treatment failure, or those lost to follow-up, and these patients often see lower cure rates and more side effects from drugs. Significant risk factors for TB retreatment include irregular medication use, presence of diabetes mellitus, and uncontrolled HbA1C levels. Diabetic patients, especially those failing to meet HbA1C targets, are at a higher risk, alongside those with multiple prior TB episodes, indicating a greater susceptibility in immunocompromised individuals.[4] See also: https://lintblab.weebly.com/ 

It is generally assumed that a country’s TB burden status is positively associated with its TB-related mortality rate. However, previous reports do not fully support this assumption. Over a 5-year study period, we observed an overall TB mortality rate of 8.9% (95% CI: 7.4%-10.8%) in Brunei Darussalam. Significant risk factors for TB mortality included advancing age, female gender, renal disease, and cancer. Our finding that female gender was positively associated with TB mortality contrasts with other studies, where male gender was reported as a risk factor. Furthermore, most TB deaths were not directly related to TB itself, underscoring the importance of clinicians considering non-TB aspects of a patient's history, such as the presence of comorbidities.[5]

In a study of 34,249 participants, significant predictors of TB diagnosis included occupational stress, rural residency, age, and health insurance. Stress and TB diagnosis were assessed via survey responses, with job-related stress and medical diagnosis of TB as key indicators. The analysis showed that older individuals (44+ years), those with high job stress, and rural residents were more likely to be diagnosed with TB. Factors such as cigarette consumption, education, and proximity to medical facilities were not significant predictors.[6]

References:

1. Bhatia, V., Rijal, S., Sharma, M., Islam, A., Vassall, A., Bhargava, A., Thida, A., Basri, C., Onozaki, I., Pai, M. and Rezwan, M.K., 2023. Ending TB in South-East Asia: flagship priority and response transformation. The Lancet Regional Health-Southeast Asia, 18.

2. Bhatia V, Srivastava R, Reddy KS, et al. Ending TB in Southeast Asia: current resources are not enough. BMJ Global Health 2020;5:e002073.

3. Iskandar, D., Suwantika, A.A., Pradipta, I.S., Postma, M.J. and van Boven, J.F., 2023. Clinical and economic burden of drug-susceptible tuberculosis in Indonesia: national trends 2017–19. The Lancet Global Health, 11(1), pp.e117-e125. 

4. Habib, M.A., Afrin, K., Efa, S.S., Hossain, M.D., Islam, M.R., Rahman, M.M., Islam, N., Afroz, F., Rahim, M.A. and Hossain, M.D., 2024. Effects of diabetes mellitus on retreatment of Tuberculosis: A multi-centered case-control study from Bangladesh. Journal of Clinical Tuberculosis and Other Mycobacterial Diseases, 36, p.100450.

5. Chaw L, Jeludin NH, Thu K. Prevalence and risk factors associated with tuberculosis mortality in Brunei Darussalam. Asian Pac J Trop Med 2023; 16(1): 9-15.

6. Adam, N., Pallikadavath, S., Cerasuolo, M. and Amos, M., 2021. Investigating the risk factors for contraction and diagnosis of human tuberculosis in Indonesia using data from the fifth wave of RAND’s Indonesian Family Life Survey (IFLS-5). Journal of Biosocial Science, 53(4), pp.577-589.