Today, Uganda joins the rest of the world to commemorate World TB Day, with the theme 'Yes! We can end TB!'. Vision Reporter had a chat with Dr Yonas Tegegn Woldemariam, the World Health Organization (WHO) Representative in Uganda concerning WHO’s milestones in combating TB and the way forward.

Q: In 2019, Uganda’s Ministry of Health declared the Karamoja region, with an estimated population of 1.2 million, to have one of the highest TB burdens in Uganda. Within the region, the Ministry of Health approximated that five of every 10 TB patients complete treatment successfully, and only three in 10 are cured. The number of TB patients dying in Karamoja is still high. What can be done to reduce this high mortality rate? 

A: The Karamoja region has episodes of drought and food insecurity. Research shows that undernourished people are three times more likely to have TB compared to those who are well-nourished. Addressing the TB challenge in the region requires reinforcing multisectoral engagement by bringing on board other stakeholders like various Ministries, Departments and Agencies (MDA’s), Civil Society Organizations (CSOs), the private sector, UN agencies, cultural leaders and the communities.

Q: Many people in rural communities think that having TB automatically means that you have HIV/AIDS and therefore patients are highly stigmatized. How can this myth be dispelled so as to have the disease properly diagnosed and proper treatment given? 

A: It is important to emphasize that anyone can contract TB regardless of HIV status. One of the challenges of underestimating number of TB cases is that several people with TB do not know that they have the disease. Therefore, awareness creation in the community plays a key role in dispelling stigma. The other intervention is incorporating TB into workplace policies and nondiscrimination regulations.

Q: World TB Day 2023’s theme is 'Yes! We can end TB!' It aims to inspire hope and encourage high-level leadership, increased investments, faster uptake of new WHO recommendations. What are these recommendations, and which high level leadership is being targeted so as to get better results? Ministry of Health? NGOs? Who is WHO working with to see this dream become a reality? 

A: Multisectoral engagement is critical, given the impact of COVID-19 on health systems and economies worldwide, especially on the poorest people. That is why WHO works with both state and non-state stakeholders at the central, district and community level in the fight against TB.

The political declaration of the 2018 United Nations (UN) General Assembly high-level meeting on TB includes a commitment by countries to enable and pursue multisectoral engagement and accountability at global, regional, national and local levels to end TB. The declaration also includes a request to ensure timely implementation of a multisectoral accountability framework for TB (MAF-TB) in collaboration with partners, civil society and affected communities. The Office of the Prime Minister (OPM) and Ministry of Health fast-tracked development and launch of the National MAF-TB guidelines in 2020. OPM tasked permanent secretaries of other ministries to identify TB focal persons from senior management to facilitate TB mainstreaming.

Initially, the fight against TB used to be treated as the business of Ministry of Health and the sector, with a wide knowledge gap in other sectors. This widened the stigma at workplaces and in the communities. Implementation of MAF-TB has widened the knowledge base and participation of other sectors. Drafting of integrating TB in workplace policies is ongoing to address workplace stigma.

Orientation has been done for the TB focal persons in MDAs, followed by TB screening in MDAs and public places. With support from MDAs, approximately 18,000 people were screened from their work places in 2022, with about 340 positively diagnosed and started on treatment.

Q : WHO seeks to upscale the adoption of innovations, accelerated action, and multisectoral collaboration to combat the TB epidemic. Emphasis is being put on opportunities to raise visibility and political commitment at the 2023 UN High-Level Meeting on TB. How does Uganda fit into this global goal to end TB? 

A: Uganda, with support from WHO and other partners is implementing a Multisectoral Accountability Framework for TB, an approach which brings all together all the relevant stakeholders to contribute towards ending TB. At the same time, Uganda has strengthened civil society engagement and reinforcement of meaningful involvement of affected people and communities. WHO is supporting ministries and government departments to integrate TB into workplace policies to minimize stigma and discrimination of people affected by TB. Between 2018 and 2022, the TB treatment success rates improved from 72% to 87% of the targeted cases.  A total of 1,208,375 HIV-positive patients also accessed TB preventive therapy.

Q: The COVID-19 pandemic drew attention to the deep disparities that persist between and within countries. People with TB are among the most marginalised and vulnerable, facing barriers in accessing care. How best can Uganda improve the wellbeing of TB patients in as far as accessing care is concerned?

A: In 2021, the Ministry of Health launched the Community Awareness, Screening, Testing and Treatment to end TB and Leprosy in Uganda Campaign (CAST), an enhanced case-finding approach for the un-diagnosed TB and leprosy cases (including those missed during the COVID-19 pandemic period) towards combating community TB and leprosy transmission and end TB and leprosy in Uganda.

One VHT is engaged per village to conduct house-to-house visits while conducting community mobilization, sensitization, symptom screening, sputum sample collection, referral, and treatment support for those on treatment.  The facility health workers conduct support supervision to the VHTs, TB hotspot mapping and screening, linkage to TB testing and treatment for individuals diagnosed with TB. In addition, contacts of people with Leprosy are identified and screened for Leprosy. In 2021, TB case detection improved from 77% to 82% of estimated TB cases with the treatment success rate improving from 72% to 87%. A total of 581 Leprosy cases were diagnosed in 2022 (with 12% children) while 32% of the Leprosy contacts were traced.  The treatment success rate for Leprosy was at 87.5%

Q: Approximately 15 of every 100 cases of TB in Uganda are children aged less than 14 years. Are there any special interventions to curb TB infections among children? 

A: TB in children can be prevented by BCG Vaccination at birth, Timely diagnosis and treatment of TB in adults and provision of TB preventive treatment to children who have been in direct contact with a confirmed TB patient. The TB preventive medicines can be taken for three or six months depending on the type of medicine used. Between 2018 and 2022, a total of 38,395 children were detected with TB.  A total of 48,666 children aged under five years, who were in contact with TB patients, were initiated on preventive treatment. The notification for children with TB improved from 7.5% to 14% of total notified cases (against the TB national strategic plan target of 15%).  

Q: TB is the number 4 cause of death among communicable, maternal, neonatal & nutritional diseases. This is an epidemic situation. How best can the government address this killer disease so as to ensure a healthy population? 

A: The Government of Uganda aims to end the national TB epidemic and Leprosy by 2030. This calls for nation-wide efforts to find every missing person with TB and leprosy, start them on treatment, support them to complete treatment, and provide preventive treatment to their close contacts.

Ministry of Health in collaboration with partners implements WHO-recommended guidelines and innovative approaches prioritizing interventions at health facilities and communities, to improve identification of people with TB including quality improvement-driven approaches such as the Active Case Finding (ACF) tool kit and DETECT Child TB approach. 

At health facilities, implementing the ACF toolkit is aimed at improving TB screening, case detection, and treatment outcomes using a quality improvement approach, improvement in access to and use of TB diagnostic services, including microscopy, GeneXpert, and X-ray services to facilitate TB diagnosis, especially in people at increased risk for TB.

Q: What is WHO’s key message to Ugandan public?

A: Ending TB is a public health, and development challenge. Despite universal acknowledgement that TB is driven by social and economic determinants, response to the disease is still mainly driven by the health sector. We need to re-focus our attention on a multispectral approach, re-enforce the role of households and communities in addition to health systems support. We should not forget that TB affects all of us irrespective of gender, age, level of education or HIV status.

To ensure full impact, efforts to end TB must build on principles of government stewardship, engagement of civil society, human rights and equity, and adaptation to the unique context of diverse epidemics and settings. The struggle cannot be left for the health sector alone. Working together, we can end TB. Each of us has a role in preventing and managing TB infections. The task may appear challenging, but we can scale up efforts to address this growing threat. We must embrace a multisectoral approach by complimenting each other’s efforts in the fight.