Why tobacco control should be a priority agenda item of Joint External Monitoring Missions for TB control?

INTRODUCTION: Tobacco smoking is a significant risk factor for developing tuberculosis (TB), contributing to diagnostic delays, poor treatment outcomes and an increased risk of death and relapse. The World Health Organization (WHO) has reported that TB rates could decline by as much as 20% if smoking were eliminated. Tobacco smoking was a risk factor in at least 860,000 TB cases in 2018, and has been documented as one of the leading contributors to TB in India, Indonesia, Myanmar, Nepal and Philippines. METHODS: Joint External Monitoring Missions (JEMM) are arranged by WHO to review the progress, challenges and plans for national TB control programs and provide guidance for improvement of policies, planning and implementation. During May and June 2021, JEMM reports from five South-East Asian countries that had a JEMM in 2019 and early 2020 were reviewed. Reports reviewed from India, Indonesia, Myanmar, Nepal and the Philippines. Any mention of the association of TB and smoking, TB and tobacco use, impact of tobacco use/smoking on TB outcomes, current practices and challenges of TB and tobacco in the TB control program and proposed actions were documented. RESULTS: Of the five country JEMM, Myanmar's did not recognise the impact of smoking tobacco on TB at all, and only one of the five countries, India, identified a very limited number of current TB-Tobacco practises including that a collaborative framework for TB/tobacco was in place. Nepal's 2019 JEMM acknowledged that there was no smoking cessation within the TB Control program and health providers were not aware about the brief advice and smoking cessation program. The Philippines and Myanmar reported neither current practices nor challenges in implementing tobacco intervention in TB control programs. CONCLUSION: Given the importance of tobacco smoking as a key risk factor for TB, assessing its burden on the national TB epidemic should be included as one of the key indicators in the JEMM framework. Key interventions include brief cessation support through regular TB services and the use of Nicotine Replacement Therapy (NRT) and other medications as part of a comprehensive package of care for people with TB to improve the quality of the services they receive. Multisectoral efforts to stop smoking also contribute the non-communicable disease agenda as well as protecting against poor outcomes for COVID-19. The support of TB programs to integrate tobacco control is critical and will contribute to national TB control program targets that support WHO's End TB Strategy.

Turning threats into opportunities: how to implement and advance quality TB services for people with HIV during the COVID-19 pandemic and beyond.

INTRODUCTION: Until COVID-19, tuberculosis (TB) was the leading infectious disease killer globally, disproportionally affecting people with HIV. The COVID-19 pandemic is threatening the gains made in the fight against both diseases. DISCUSSION: Although crucial guidance has been released on how to maintain TB and HIV services during the pandemic, it is acknowledged that what was considered normal service pre-pandemic needs to improve to ensure that we rebuild person-centred, inclusive and quality healthcare services. The threat that the pandemic may reverse gains in the response to TB and HIV may be turned into an opportunity by pivoting to using proven differentiated service delivery approaches and innovative technologies that can be used to maintain care during the pandemic and accelerate improved service delivery in the long term. Models of care should be convenient, supportive and sufficiently differentiated to avoid burdensome clinic visits for medication pick-ups or directly observed treatments. Additionally, the pandemic has highlighted the chronic and short-sighted lack of investment in health systems and the need to prioritize research and development to close the gaps in TB diagnosis, treatment and prevention, especially for children and people with HIV. Most importantly, TB-affected communities and civil society must be supported to lead the planning, implementation and monitoring of TB and HIV services, especially in the time of COVID-19 where services have been disrupted, and to report on legal, policy and gender-related barriers to access experienced by affected people. This will help to ensure that TB services are held accountable by affected communities for delivering equitable access to quality, affordable and non-discriminatory services during and beyond the pandemic. CONCLUSIONS: Successfully reaching the related targets of ending TB and AIDS as public health threats by 2030 requires rebuilding of stronger, more inclusive health systems by advancing equitable access to quality TB services, including for people with HIV, both during and after the COVID-19 pandemic. Moreover, services must be rights-based, community-led and community-based, to ensure that no one is left behind.