Journal of Public Health Policy
Volume 35, Issue 4 (November 2014)
http://www.palgrave-journals.com/jphp/journal/v35/n4/index.html

Editorial
A proposal to rethink how we track tuberculosis spread around the world
Phyllis Freemana and Anthony Robbinsa
aCo-Editors
Journal of Public Health Policy (2014) 35, 423–424. doi:10.1057/jphp.2014.36; published online 11 September 2014

We are pleased to publish in this issue an article that lays out a novel and promising global strategy for tuberculosis (TB).1 Becerra and Swaminathan start with children, who within the global epidemic remain largely invisible. They explain why it is useful to think of children with TB as ‘sentinels’ – as well as a neglected population that urgently needs quality attention.

Every year about 1 million children get sick with TB. Children are exposed to TB, mostly in homes shared with others who cough the mycobacterium into the air. Each child is a sentinel, helping detect the infecting cases, and creating an opportunity for preventive treatment for some, treatment of active disease for many others. But it will not be easy.

Becerra and Swaminathan identify key difficulties:
– the very nature of pediatric TB;
– the inadequacy of diagnostic tools;
– lack of data for good disease burden estimates; and
– failure, in most of world, to field contact investigations.

The plight of children signals a continuing failure of two decades of global TB policy – focused on Directly Observed Therapy with a set regime of ‘first line drugs’ (effective in the absence of drug resistance) – for all but the most affluent countries. If the world were to adopt additional tools used commonly in wealthier nations, contact investigation followed by use of existing diagnostic tools, and drug sensitivity testing to learn about the infecting organisms, it should be possible to set quantitative treatment and prevention targets among children exposed at home to multidrug-resistant TB, country by country. The article describes the strategy in detail.
These authors are not satisfied with their ambitious proposal for case finding and preventive treatment. They have organized a science-advocacy network to take action – the Sentinel Project on Pediatric Drug-Resistant Tuberculosis. Their activities warrant following (sentinel-project.org).

Those in developing countries seem more aware of today’s dilemma for improving response to TB than those in more affluent settings. An Indian colleague writes: ‘It is disheartening to see that whenever the problem of TB is discussed among experts, it gets largely confined to multidrug resistant TB and HIV induced TB, as if the regular form is already under control’.2 His comment may reflect the difference between richer countries, where TB spread has nearly been halted compared with countries with fewer resources, where prevalence is high in the general population and epidemic spread persists. For richer countries two exceptions require special attention: continuing vulnerability for people infected with drug-resistant strains and for those with compromised immune systems.

To mount more urgent and informed global support, this article provides a crucial link between ‘business as usual’ in TB action, and a future where attention to children can protect many in danger and lead to a more comprehensive and effective set of programs worldwide.

.

Commentary: A targets framework: Dismantling the invisibility trap for children with drug-resistant tuberculosis
Open
Mercedes C Becerraa and Soumya Swaminathanb
aDepartment of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Avenue, Boston, MA 02115, USA
bNational Institute for Research in Tuberculosis, Chennai, India
The online version of this article is available Open Access
Abstract
Tuberculosis (TB) is an airborne infectious disease that is both preventable and curable, yet it kills more than a million people every year. Children are highly vulnerable, but often invisible casualties. Drug-resistant forms of TB are on the rise globally, and children are as vulnerable as adults but less likely to be counted as cases of drug-resistant disease if they become sick. Four factors make children with drug-resistant TB ‘invisible’: first, the nature of the disease in children; second, deficiencies in existing diagnostic tools; third, overreliance on these tools; and fourth, our collective failure to deploy one effective tool for finding and treating children – contact investigation. We describe a nascent science-advocacy network – the Sentinel Project on Pediatric Drug-Resistant Tuberculosis – whose goal is to end child deaths from this disease. Provisional annual targets, focused on children exposed at home to multidrug-resistant TB, to be updated every year, constitute a framework to focus attention and collective actions at the community, national, and global levels. The targets in two age groups, under 5 and 5–14 years old, tell us the number of: (i) children who require complete evaluation for TB disease and infection; (ii) children who require treatment for TB disease; and (iii) children who would benefit from preventive therapy.

.

Building capacities of elected national representatives to interpret and to use evidence for health-related policy decisions: A case study from Botswana
Open
Anne Cockcrofta, Mokgweetsi Masisib, Lehana Thabanec, and Neil Anderssond,e
aCIET Trust Botswana, PO Box 1240, Gaborone, Botswana
bMinister for Presidential Affairs and Public Administration, Office of the President, Private Bag 001, Gaborone, Botswana
cDepartment of Epidemiology and Biostatistics, McMaster University, Canada
dCentro de Investigación de Enfermedades Tropicales, Universidad Autónoma de Guerrero, Acapulco, Mexico
eCIET/PRAM, Department of Family Medicine, McGill University, Montreal, Canada
Correspondence: Anne Cockcroft, E-mail: acockcroft@ciet.org
The online version of this article is available Open Access
Abstract
Elected national representatives make decisions to fund health programmes, but may lack skills to interpret evidence on health-related topics. In 2011, we surveyed the 61 members of Botswana’s Parliament about their use of epidemiological evidence, then provided two half-days of training about using evidence. We included the importance of counter-factual evidence, the number needed to treat, and unit costs of interventions. A further session in 2012 covered evidence about the HIV epidemic in Botswana and planning the best mix of interventions to reduce new HIV infections. The 27 respondents reported they lacked good quality, timely evidence, and had difficulty interpreting and using evidence. Thirty-six, including seven ministers, attended one or both trainings. They participated actively and their evaluation was positive. Our experience in Botswana could potentially be extended to other countries in the region to support evidence-based efforts to tackle the HIV epidemic.