TimeBomb

TB is a ticking TimeBomb, as legendary Lee Reichman made clear 15 years ago and reminded us again today. Here are a few thoughts (not cleared by TB Proof, but I suspect most members would agree).

  • We need to pay much more attention to ongoing TB transmission in health care facilities, prisons, and the community.
    • Any time there is a TB outbreak anywhere around the globe, we need a “TB swat team” to jump into action.
    • The media division will have a spokesperson who will immediately speak with the press about the threat that DR-TB poses.
    • The social media division will raise awareness via Twitter, Whatsapp, Facebook, etc.
  • We need stories so we can raise urgency / make people empathize with those suffering.
    • TB Proof is focusing on health care worker stories.
    • Individuals should also take the effort to WRITE their own stories. It is an invaluable exercise as we become activists. I wrote mine here, as an example.
    • Videos should be shot, tweeted, WhatsApped, etc.
    • As we get to know each other better, we should think “outside the box” and get outside our comfort zones.
    • Learn a new language. Make a new friend from someone outside your normal circle.
    • These connections– cross cultural– will help us in the years ahead.
  • We need numbers so we can raise money and get the attention of global bodies.
    • What percentage of notified TB cases were health workers?
    • What cadre were they? Nurse, doctor, community health worker, etc.
    • Ministries of Health and WHO could start counting this data immediately by adding a column to the facility TB register (see below).
    • This is not going to be simple, but it can absolutely be accomplished with a little bit of effort.
    • Once those numbers start coming in, we will have data to pressure countries to make their health facilities safer.
    • Ministers of finance, global bodies, etc will listen to numbers.
    • Confidentiality is extremely important when health care workers with TB have their data reported to the MoH.
  • Nurses, nurses, nurses.
    • We must make reaching out to nurses one of our top priorities.
    • This movement cannot remain focused on doctors in Cape Town.
    • We should establish chapters of organizations like APIC in Sub-Saharan Africa.
  • Safety will depend on the setting but could include natural ventilation, cough triage, FAST, UVGI, etc.
    • We should focus on the concept of “transmission.”
    • But, we shouldn’t reinvent the wheel.
    • WHO and CDC have already developed a number of TB IC good tools, checklists, and videos that can be used/adapted in the local context.
    • Natural ventilation is key at the small health facility level.
    • Cough triage is critically important in health facilities everywhere.
    • FAST is important in settings where rapid molecular diagnostics (i.e. Xpert) and DR-TB drugs are available.
    • FAST may be less feasible if Xpert turnaround time is slow.
    • New UVGI fixtures with LED must be developed that can be powered by solar/ battery.
    • UVGI is thought by many people not to be cost effective but that hasn’t been demonstrated to be the case.
    • I’m personally not that impressed with N95 respirators– I think they provide a false sense of security.
    • If I had to take care of a coughing patient with XDR-TB, I would hope for an “outside hospital” – as TB is rapidly killed by the sunlight.
    • As we design new health facilities, we desperately need architects who are trained in infection control.
    • Researchers can define the optimum package of interventions that will reduce TB transmission and take that data to the funders
    • Traditional funders like the NIH may not be the best source for this implementation science research. It might be best done by private foundations, for example
  • We must never forget stigma.
    • There is profound fear of TB, of losing one’s job, of dying, etc.
    • Fear/stigma is especially important in settings of poverty and a lack of education.
    • Fatalism is a common emotion in people who are working in high-TB burden settings.
    • There is the assumption that everyone will have LTBI (and many people may get LTBI in settings like South Africa).
  • We will never stop TB unless we eliminate poverty.
    • The TB movement must immediately ally itself with the anti-poverty movements globally.
    • In settings of poverty, the upstream social determinants of health must be considered.
  • The TB movement must ally itself with the HIV movement.
    • That means TAG, HealthGap, Section 27, Black Lives Matter, etc.
    • The International AIDS Conference and the Union meeting should be held in the same location at the same time, to help allies interact.
    • This will rejuvenate both movements.
  • Find TB and treat TB (including MDR-TB and XDR-TB).
    • Active case finding (ICF) in poor, rural/urban communities is extremely important.
    • What is the case detection rate? If it is low, we aren’t going to stop the force of TB transmission.
    • Treating MDR-TB and XDR-Tb is difficult so it would be much better to prevent ongoing transmission.
    • We are talking about potentially difficult-to-take drugs like terizidone, clofzimine, bedquiline, linezolid, and PAS.
    • An apple a day keeps the doctor away.
  • Activists have a vital role to play.
    • Doctors, nurses, professional organizations, international labor organizations, etc must organize.
    • Technology such as WhatsApp and Twitter will play a vital role but activists must continue the face-to-face discussions.
    • Being an activist is not a dirty word. You can be a serious academic and an activist.
  • Despite all of the above, I am unsure we will stop the drug-resistant TB crisis unless we have a vaccine.
    • We must convince donors to invest much more money in basic vaccine research.
    • This is an absolutely urgent priority, even if it takes years to achieve.
  • We need to preserve our energy for a long fight.
    • Despite the urgency that the international TB conference engenders, this will not be over any time soon.
    • There’s constant bickering among some people about tactics, personalities, resources, etc. This negativity is draining, stressful, and unnecessary.
    • We must spend as much time as possible with our families/loved ones. They will help us get through the challenges ahead—the upcoming Satyagraha.
  • A few people I am hoping to get in touch with in the next few days if they are still here in Cape Town.
    • Yogen Pilay, from the South Africa MoH
    • Max O’Donnell from Columbia

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