If we fail to find all cases of an infectious disease (and put them on care), then it will keep spreading. "We are not able to find all TB cases as of now. We had an estimated 1.1 million new TB cases in 2023 in Indonesia as per the latest WHO Global TB Report 2024. But the highest we could reach with TB services was around 804,800. So, we still missed a few hundred thousands. If we do not find these missing cases, and put them on treatment, they will remain there as a source of infection to the rest of the community," rightly said Dr Erlina Burhan, a widely acclaimed TB and lung disease medical expert.

Breaking the chain of infection transmission is central to disease prevention and control

"So, while we cure people who we find, it is also critically important to note that those who we miss are still transmitting the disease to others - and going through avoidable suffering because treatment, care and support is free in public sector. So, I am very supportive of the global call to #FindAllTB, #TreatAllTB and #PreventAllTB - so that we can #endTB. If we miss even one of these pillars, we will not be able to achieve TB elimination," added Dr Burhan. And we have to find, treat and prevent TB in a people-centred, rights-based and gender transformative manner.

Dr Erlina Burhan, is a leading lung infection specialist at the Persahabatan Hospital, Jakarta, Indonesia, and Professor of Pulmonology at the University of Indonesia. She is on the Board of Directors of the International Union Against Tuberculosis and Lung Disease (The Union) and is also a member of the WHO TB Guideline Development Board. Dr Burhan was in conversation with CNS at the Union World Lung Health Conference (largest world conference on TB and lung diseases) held recently in Bali.

As per the WHO Global TB Report 2024, 30 high TB burden countries accounted for 87% of the global TB burden in 2023. Eight countries accounted for more than two thirds of the worldwide total: India (26%), Indonesia (10%), China (6.8%), the Philippines (6.8%) and Pakistan (6.3%), Nigeria (4.6%), Bangladesh (3.5%) and the Democratic Republic of Congo (3.1%).

Failure to prevent TB

It is ironical that on one hand governments have promised to end TB by 2030 but on the other hand they are not addressing the risk factors that put people at heightened TB risk.

"We have not fully addressed the poor socio-economic problems of the people that lead to malnutrition. TB is a transmissible disease and unless all infection prevention and control measures are in place it will spread to others," said Dr Erlina Burhan.

As per the WHO Global TB Report 2024, malnutrition, tobacco use, alcohol use, diabetes and HIV continue to be the top five TB risk factors worldwide. Malnutrition is usually the biggest risk TB factor in most high TB burden nations but in Indonesia, tobacco use is the biggest TB risk factor as it caused TB in 147,000 people in 2023. Undernutrition was the close second TB risk factor in Indonesia in 2023 with 84,000 people developing TB disease because of it, followed by diabetes (32,000 people got TB because of it), HIV (23,000 people got TB because of HIV), and alcohol use (16,000 people got TB because of it).

What is preventing us from finding the missing cases?

"TB can never be eliminated by merely a medical response. We surely need a robust medical and health component but we also need to pay attention to all other necessary non-medical partners who can help end TB. This is where the problem lies. We have all the latest technology for diagnosis and treatment. Sputum microscopy is already being replaced by molecular testing [globally over half of TB cases are found using an upfront molecular testing]. And we have got all the different treatment regimens- even the new shorter regimens are being rolled out," said Dr Burhan.

"The tools are there but there is very weak implementation on the ground. Indonesia has more than 2500 WHO recommended rapid molecular diagnostic devices. It also has the point-of-care and decentralised molecular testing machines - Truenat. There is also an incredibly strong political will and commitment, led by the new President. But Indonesia consists of 17,000 islands and many of them are in remote and hard to reach geographical locations. We have to make extra efforts to deploy the tools more efficiently in remote areas of the archipelago- especially the point-of-care tools/devices that are user-friendly and can be deployed in low infrastructure situations," she added.

"Ideally we should screen everyone through artificial intelligence (AI) supported ultraportable handheld x-ray devices, and diagnose presumptive TB cases with upfront molecular testing," rightly says Dr Burhan.

What should change if we have to end TB?

"We cannot do business as usual anymore. We need to take aggressive transformative actions. National TB programmes will have to do "business unusual" in order to find all the TB cases, including drug-resistant TB cases, to end TB. Also we have to do something more than just to diagnose and to cure. We have to go back to the basics - do infection control and prevention. And not only talk about TB preventive therapy but also the TB vaccine (which is currently under research). There are now 6 new TB vaccine candidates in Phase 3 clinical studies. Indonesia is one of the countries that is taking part in the study of M72. I am very hopeful that this new vaccine will have a good efficacy and safety profile. If this is achieved hopefully in two years, then we will have to move fast to get approvals from various authorities for its registration, licensing, marketing and use it rapidly for the community. No business as usual procedure," asserts Dr Burhan.

[CNS Editor’s note: If shown to be well-tolerated and effective, M72 could potentially become the first vaccine to help prevent pulmonary TB in adolescents and adults, and the first new TB vaccine in over a century].

But having new health technologies is not enough. We have to ensure these are rolled out equitably where they are needed the most. "We also have to learn from our experiences of the inequitable distribution of the COVID-19 vaccine- and put in place beforehand all measures for the accessibility, affordability, and availability in all countries- especially high TB burden countries," says Dr Burhan.

Also engaging with other stakeholders is lacking. If we can engage with and collaborate with different sectors (as had happened during COVID-19 pandemic where almost whole of society and whole of government approach became a reality)- public and private sector, the community, opinion leaders, influencers, religious leaders- I am sure we can end TB, she said.

Science has given us evidence-based tools, which can help prevent TB infection, diagnose TB early on and put those diagnosed with TB on treatment without delay. So early and accurate diagnosis followed by treatment without any delay and its completion is crucial to end TB.

But one also has to take a nutritious diet, quit smoking and alcohol, do physical exercise, protect oneself from HIV or diabetes and those with HIV and diabetes need to ensure standard management, and all of us should lead a healthy lifestyle. The Global TB Report 2024 lists undernutrition as the top risk factor for developing TB. A study conducted in India has also proven beyond doubt that giving good nutrition to the community can reduce TB incidence substantially.

[CNS Editor’s Note: The RATIONS (Reducing Activation of Tuberculosis by Improvement of Nutritional Status) study done in India found that providing nutritional support to TB patients and their household members reduced TB incidence and mortality substantially. It was conducted in a population with high rates of malnutrition in contacts and very severe undernutrition in patients. It was the first study globally to aim for a reduction of TB incidence by improving the nutritional status of those at risk, and it was the largest cohort study of patients with TB who were given nutritional support to improve TB treatment outcomes. TB incidence was reduced by nearly 40-50% in household contacts of TB patients, while in the case of patients with TB, there was 35-50% lower mortality, better weight gain, low rates of loss to follow up and high rates of return to normal work].

Dr Burhan’s message for all is that we should not wholly rely on the government- it has its own budgetary constraints. It is time for the community also to help each other. Be kind to your neighbour. In all religions we spare some money to help people in need. We should use this religious activity to help others in need- especially in the form of providing them with good nutrition. As a human being, please be kind to other human beings.

Ani Herna Sari, a TB survivor and Chairperson, Rekat Peduli Foundation Indonesia, reiterated Dr Burhan’s appeal for diagnosing and treating TB early on. Sharing her personal experience of surviving drug-resistant TB (and again surviving drug-sensitive TB along with her son), in a webinar organised by WHO during the World AMR Awareness Week this year, she said that, “There is a very clear link between test and treatment. Genetic sequencing enables rapid and comprehensive testing of drug-resistant TB directly from clinical samples. The comprehensive drug resistance profiling provided by sequencing will ensure that affected people get the right treatment. Reaching out to the missing millions is crucial- they are the ones who remain undiagnosed due to diagnostic barriers, and/or get delayed treatment. To find the missing millions we need to innovate. But innovations are useful only when all those in need of them can access them. We need to ensure that the existing rapid molecular diagnostics and drug sensitivity testing are available for all.”