TB-related stigma in workplaces and population-wide active case finding

The adapted tool to measure tuberculosis-related stigma in workplaces in Indonesia is valid, internally consistent, reliable, and ready for broader external validation among workers in both formal and informal business sectors in Indonesia. However, the tool may not be generalizable to other areas, including rural regions. Indonesia also has a wide variety of cultures that may affect the interpretation of the questions and findings. Therefore, the items will need to be reviewed and refined before any wider implementation.

Questions List:

1. I do not want to eat or drink with coworkers with TB.
2. I feel uncomfortable about being near coworkers with TB.
3. I do not want to talk to coworkers with TB.
4. I try not to touch coworkers with TB.
5. I am worried about being infected by a coworker with TB.
6. I would behave differently towards coworkers with TB.
7. I do not want someone with TB working in my department/division/working room.
8. I think that a coworker with TB should be ashamed.
9. I think that a coworker with TB should be fired from his/her position.
10. I think that a coworker with TB has a more limited capacity to work than a coworker without TB.
11. I think that coworkers with TB can negatively impact the enterprise/workplace.

Soemarko, D.S., Halim, F.A., Kekalih, A., Yunus, F., Werdhani, R.A., Sugiharto, A., Mansyur, M., Wingfield, T. and Fuady, A., 2023. Developing a tool to measure tuberculosis-related stigma in workplaces in Indonesia: An internal validation study. SSM-Population Health, 21, p.101337.

== Related paper:

Nguyen, T.A., Teo, A.K.J., Zhao, Y., Quelapio, M., Hill, J., Morishita, F., Marais, B.J. and Marks, G.B., 2024. Population-wide active case finding as a strategy to end TB. The Lancet regional health. Western Pacific, 46, p.101047. [TB0043]

Robert Koch discovered Mycobacterium tuberculosis in 1882. M. tuberculosis spreads through the air via coughs, sneezes, talking, or breathing of infected individuals, releasing infectious droplets. For 125 years, diagnostic methods like microscopy, culture, and chest radiology have been available. The BCG vaccine has reduced TB-related mortality in young children for over a century. Effective TB drugs have been available for seven decades, starting with streptomycin and isoniazid in the 1950s, and multi-drug 'short-course' regimens in the 1960s. In 1995, WHO launched the DOTS strategy to diagnose and treat TB effectively. In 2022, 10.6 million people contracted TB, with 1.3 million deaths.

TB transmission in high-incidence settings and implications for screening strategies

Nearly 90% of all TB cases are in 30 high-burden countries. TB incidence is higher in high-risk groups, such as those in close contact with TB patients, individuals with compromised immune systems (e.g., HIV), severe undernutrition, poorly controlled diabetes, silica or cigarette smoke exposure, and those in crowded, stressful conditions like prisoners and refugees. In high-incidence areas where TB is endemic, the risk of infection is widespread, and most TB cases are not confined to high-risk groups. Although TB prevalence is higher in these subpopulations, the absolute number of cases is limited by their smaller population size.

Passive case finding is insufficient to identify all infectious TB cases and reduce transmission. Active case finding is essential but must consider feasibility. In high-incidence settings, most TB cases result from recent infections within the past 1-2 years. In low-incidence settings, TB typically arises from reactivation of old infections. Treating TB infection in high-incidence areas offers only temporary benefits due to the risk of reinfection and progression to active disease. Without universal active TB case finding, many will unknowingly spread the infection, even those who have completed preventive treatment.

Ongoing TB transmission persists due to untreated infectious TB cases, often undiagnosed or underreported. WHO estimates over a third of TB cases fall into this category. Diagnosis is hindered because half of TB patients do not show symptoms that prompt care-seeking. When symptoms like cough, fatigue, and mild fever appear, they are often mistaken for less severe illnesses. Limited access to TB services, especially in resource-limited settings, delays medical attention. Even recognized symptoms can go untreated due to lack of healthcare access, resulting in delayed presentation, self-medication, or reliance on traditional healers. Healthcare providers may miss TB diagnoses if symptoms are nonspecific or if appropriate tests are unavailable or misinterpreted. Rapid molecular tests, while advanced, are often centralized, limiting access. Inadequate healthcare infrastructure hampers timely diagnosis and treatment. Poorly trained providers may use suboptimal regimens, risking resistance. Economic, logistical, and societal barriers, including stigma and high costs, further impede access to care, sustaining TB transmission.

Breaking the chain of TB transmission in high-incidence settings

To end TB, disrupting the transmission chain is crucial. This involves preventing primary infection and reinfection by protecting uninfected individuals, including those previously treated or who have avoided disease progression. Key measures include cough triage, respiratory isolation, improved ventilation in enclosed spaces (especially in healthcare facilities), personal respiratory protection, and timely, effective TB treatment. Using surgical masks by infectious TB patients reduced hospital TB infection by 14.8%. Improved ventilation can also help. The Bacillus Calmette-Guérin (BCG) vaccine offers some protection, mainly against primary progressive TB in children, but is insufficient at the population level. A new vaccine candidate, VPM1002, is in clinical trials to evaluate its effectiveness in preventing TB infection.

Preventing TB disease in those with TB infection involves providing TB preventive treatment (TPT) to individuals testing positive for TB infection without active disease. Shorter rifamycin-based regimens (3HP, 3RH, 4R, and 1HP for HIV patients) have improved treatment completion over the traditional 6-9 months isoniazid regimen. Challenges include a lack of cost-effective TPT implementation models, regulatory and funding frameworks, differing risk-benefit perceptions, and the absence of biomarkers to identify those at highest risk. Post-exposure vaccines may help, but this is unproven. Addressing comorbidities and reducing vulnerability through prompt antiretroviral therapy for HIV, better diabetes control, smoking cessation, social protection, poverty elimination, food assistance, and access to quality healthcare is essential. A person-centred approach with active case finding should ensure prompt treatment initiation and support throughout the treatment journey for a sustained, relapse-free cure.

Population-wide active case finding to end TB

Effective active case finding starts with social mobilization and identifying local champions. Engaging community leaders, healthcare workers, and local networks in planning and implementing interventions fosters ownership and collective responsibility. Sensitive screening and diagnostic tests are essential. Chest radiographs, with ≥85% sensitivity and specificity, and AI-assisted interpretation show promise for large-scale, low-cost TB screening. When combined with molecular rapid diagnostic tests, this approach is efficient and accurate. Early diagnosis through active case finding front-loads diagnosis and treatment, increasing population impact. Active case finding will identify more subclinical disease compared to passive programs. Close communication with local TB programs and alignment with existing TB case management capacity are crucial.

WHO guidelines suggest considering universal population-wide screening in areas with a TB prevalence of >500/100,000. Effective active case-finding requires high coverage and intensity, strong political support, and community acceptance. This necessitates funding beyond current TB program levels. Cost-effectiveness should include broader population impacts, like transmission control. Success relies on multisectoral engagement, training, community health workers, NGOs, and community members. Epidemiological data is crucial for guiding interventions. Persistent high case detection or endemic attributes warrant population-wide screening, regardless of symptoms or risk factors. Piloting such screening and evaluating outcomes can inform scale-up.

Conclusion

Ending TB requires a comprehensive strategy integrating socio-economic development, reduced inequality, health system strengthening, multisectoral collaboration, sufficient funding, and political commitment. Until an effective vaccine is developed, the only way to reduce transmission in high-incidence settings is by finding and treating as many infectious TB cases as possible. Population-wide active case finding faces context-specific challenges, but the necessary tools are available.