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From guidelines to implementation: Strategies to improve tuberculosis case detection

  • Author(s): Miller, Cecily
  • Advisor(s): Hopewell, Philip
  • et al.
Abstract

In order to win the battle to end the global tuberculosis (TB) epidemic, we need new and better tools. Approximately one-third of the world's population is infected with the TB bacterium, and in 2015 over 10 million people become sick with the disease and almost 2 million people died, meaning TB is now one of the top ten causes of disease worldwide, outranking HIV and malaria. In addition, over 40% of TB cases each year do not get diagnosed or notified. These missed or delayed diagnoses lead to increased morbidity and mortality for those suffering from the disease, and help drive the TB epidemic through continued transmission. The World Health Organization’s (WHO’s) new “End TB Strategy” envisions a 90% reduction in TB incidence by 2035, but in order to achieve this target there is an urgent need to develop, evaluate, and deploy strategies to improve TB case detection in high burden settings.

There are numerous barriers to TB case detection, operating at several interacting levels. Those at highest risk of falling ill with TB are disproportionately from poor, disadvantaged, and marginalized populations that are much more likely to face barriers to accessing health care when sick. Those who do fall ill with TB can face numerous economic, geographic, and social/cultural barriers before reaching health care. And once they do reach care, patients can still be hampered by significant provider and health system barriers.

To address some of these barriers to TB case detection, my dissertation research focuses on three perspectives on improving case detection for TB: policy, implementation, and social implications. My first paper describes a tool I helped develop for the WHO called ScreenTB that assists National TB Control Programmes (NTPs) to develop TB screening programs well suited to their local epidemic by modeling the potential yields and costs of a variety of approaches to TB screening. My second paper presents the findings from a year-long pilot implementation of a TB screening intervention, “STAMP out TB”, in primary care clinics in Jakarta, Indonesia. My third paper explores the potential social implications of TB case-finding in Dar es Salaam, Tanzania.

Together these papers contribute to the field of TB case detection by providing tools for, and information about, the development and implementation of TB case-finding strategies in high burden settings. These three papers also characterize the diversity of my work in this field, as they each represent a distinct skillset that I have acquired during my time at UCSF. Put together, these papers will demonstrate that I have mastered an array of different tools and approaches used in the field of global infectious disease epidemiology.

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