In this issue of our newsletter, we invite you to read original commentaries by SSHIFTB experts, highlight mental health awareness month and pride month, recent publications by SSHIFTB contributors, our next journal club, and upcoming events and opportunities.
The month of June celebrates Pride Month worldwide. The LGBTQ+ community are a key population affected by TB and whose needs have not been adequately met. Despite this, the community continues to be pioneers in advocacy for health and human rights, education, and stigma reduction efforts. Join us in celebrating pride month to honour the strength and inspirations drawn from the LGBTQ+ community.
SSHIFTB contributors' publications related to TB in the LGBTQ+ community.
The World Health Organization (WHO) is organizing a special Talk Show to commemorate World TB Day on 24 March 2025 at 13:30 CET.
The spotlight this year, under the theme ‘Yes! We Can End TB: Commit, Invest, Deliver’ - is a strong call for hope, urgency, and accountability. Heads of State at the 2023 UN High-Level Meeting on TB made bold, ambitious commitments to accelerate the global fight against tuberculosis, setting concrete, measurable targets for 2027. While these pledges represent a significant milestone, sustained and intensified action is critical. Scaling up interventions requires strong policies, comprehensive national strategies, and substantial financial investment to drive impact at global, regional, and national levels.
The event will take place in a talk-show format with speakers joining in person or connected by video on WHO’s interactive web-platform – End TB Forum. The main speakers will include WHO leadership, Ministers, leaders and other high-level government representatives, Heads of Agencies, TB survivors, civil society, and partners. The Show will be broadcast live, with interactive Q&A from the audience online.
The WHO has released a first-of-its-kind guidance on how to generate evidence on novel TB treatments, explicitly calling for social science evidence on equity, cost, feasibility, acceptability, and user values. SSHIFTB co-lead Nora Engel was involved in the writing team, particularly the generation of qualitative evidence, in consultation with a broader group of experts and representatives.
The Guidance on evidence generation on new regimens for tuberculosis treatment advises researchers, developers, funders, and other actors engaged in the global TB response about how evidence should be generated to optimally inform WHO guideline development groups that decide on novel treatment regimens. It includes key messages for areas such as trial design, selection criteria, outcome choice, sample size, economic considerations, and how to investigate and address GRADE evidence-to-action criteria for equity, feasibility, acceptability, and user values, including through qualitative research.
This guidance promises to build a broader and stronger knowledge base for policy development which can ultimately lead to stronger recommendations. Social sciences are key to this endeavour and this report offers a useful tool for advocating to strengthen that role. At SSHIFTB we look forward to innovative models of integrating social science approaches into or alongside future TB treatment trials and other studies.
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The World Health Organization (WHO) has published a Guidance on evidence generation (GEG) on new regimens for tuberculosis treatment. This first-of-its-kind document informs researchers, developers, funders, and other stakeholders about how evidence should be generated to optimally inform WHO guideline development on novel regimens for TB treatment. It outlines 21 key messages, explains why they are important, and what approaches can increase the chances of research leading to strong WHO recommendations. The key messages cover areas such as trial design, selection criteria, outcome choice, sample size, analytic and economic considerations, and how to investigate the impact of an intervention on health equity, acceptability, and feasibility.
21 Key messages on providing GEG on new regimens for TB treatments
The definitive social history of tuberculosis, from its origins as a haunting mystery to its modern reemergence that now threatens populations around the world.
It killed novelist George Orwell, Eleanor Roosevelt, and millions of others – rich and poor. Desmond Tutu, Amitabh Bachchan, and Nelson Mandela survived it, just. For centuries, tuberculosis has ravaged cities and plagued the human body.
In Phantom Plague , Vidya Krishnan, traces the history of tuberculosis from the slums of 19th-century New York to modern Mumbai. In a narrative spanning century, Krishnan shows how superstition and folk-remedies, made way for scientific understanding of TB, such that it was controlled and cured in the West.
The cure was never available to black and brown nations. And the tuberculosis bacillus showed a remarkable ability to adapt – so that at the very moment it could have been extinguished as a threat to humanity, it found a way back, aided by authoritarian government, toxic kindness of philanthropists, science denialism and medical apartheid.
Krishnan’s original reporting paints a granular portrait of the post-antibiotic era as a new, aggressive, drug resistant strain of TB takes over. Phantom Plague is an urgent, riveting and fascinating narrative that deftly exposes the weakest links in our battle against this ancient foe.
With an estimated two billion people being carriers of latent tuberculosis infection (LTBI), the gains achieved by increasing access to diagnostics and treatment, although substantial, have had a modest impact on the global burden of tuberculosis (TB). At the same time, increased access to treatment has had the unintended consequence that drug-resistant TB (DR-TB) has increased dramatically. Earlier TB control strategies strongly emphasizing medical treatment have failed to address these issues effectively. The current strategy to eliminate TB by 2050 is accompanied by a call for a paradigm shift, emphasizing patient rights and equity more. Based on ethnographic fieldwork in Odisha, India, and global-level TB conferences, this paper contrasts the dynamics of global health policy and strategy-making with the lived realities of patients with DR-TB. A more thorough rethinking of the biosocial dynamics that impact the pathogenic disease is required to develop a comprehensive paradigm shift for TB control in the twenty-first century.
Keywords: antimicrobial resistance; biosocial; global health; tuberculosis.
Globally, tuberculosis (TB) is the leading infectious cause of morbidity and mortality, with the risk of infection affected by both individual and ecological-level factors. While systematic reviews on individual-level factors exist, there are currently limited studies examining ecological-level factors associated with TB incidence and mortality. This study was conducted to identify ecological factors associated with TB incidence and mortality. A systematic search for analytical studies reporting ecological factors associated with TB incidence or mortality was conducted across electronic databases such as PubMed, Embase, Scopus, and Web of Science, from each database's inception to October 30, 2023. A narrative synthesis of evidence on factors associated with TB incidence and mortality from all included studies, alongside random-effects meta-analysis where applicable, estimated the effects of each factor on TB incidence. A total of 52 articles were included in the analysis, and one study analysed two outcomes, giving 53 studies. Narrative synthesis revealed predominantly positive associations between TB incidence and factors such as temperature (10/18 studies), precipitation (4/6), nitrogen dioxide (6/9), poverty (4/4), immigrant population (3/4), urban population (3/8), and male population (2/4). Conversely, air pressure (3/5), sunshine duration (3/8), altitude (2/4), gross domestic product (4/9), wealth index (2/8), and TB treatment success rate (2/2) mostly showed negative associations. Particulate matter (1/1), social deprivation (1/1), and population density (1/1) were positively associated with TB mortality, while household income (2/2) exhibited a negative association. In the meta-analysis, higher relative humidity (%) (relative risk (RR) = 1.45, 95%CI:1.12, 1.77), greater rainfall (mm) (RR = 1.56, 95%CI: 1.11, 2.02), elevated sulphur dioxide (μg m-3) (RR = 1.04, 95% CI:1.01, 1.08), increased fine particulate matter concentration (PM2.5) (μg/ m3) (RR = 1.33, 95% CI: 1.18, 1.49), and higher population density (people/km2) (RR = 1.01,95%CI:1.01-1.02) were associated with increased TB incidence. Conversely, higher average wind speed (m/s) (RR = 0.89, 95%CI: 0.82,0.96) was associated with decreased TB incidence. TB incidence and mortality rates were significantly associated with various climatic, socioeconomic, and air quality-related factors. Intersectoral collaboration across health, environment, housing, social welfare and economic sectors is imperative for developing integrated approaches that address the risk factors associated with TB incidence and mortality.
Implementation of TB infection prevention and control (IPC) measures in health facilities is frequently inadequate, despite nosocomial TB transmission to patients and health workers causing harm. We aimed to review qualitative evidence of the complexity associated with implementing TB IPC, to help guide the development of TB IPC implementation plans. We undertook a qualitative evidence synthesis of studies that used qualitative methods to explore the experiences of health workers implementing TB IPC in health facilities. We searched eight databases in November 2021, complemented by citation tracking. Two reviewers screened titles and abstracts and reviewed full texts of potentially eligible papers. We used the Critical Appraisals Skills Programme checklist for quality appraisal, thematic synthesis to identify key findings and the GRADE-CERQual method to appraise the certainty of review findings. The review protocol was pre-registered on PROSPERO, ID CRD42020165314. We screened 1062 titles and abstracts and reviewed 102 full texts, with 37 studies included in the synthesis. We developed 10 key findings, five of which we had high confidence in. We describe several components of TB IPC as a complex intervention. Health workers were influenced by their personal occupational TB risk perceptions when deciding whether to implement TB IPC and neglected the contribution of TB IPC to patient safety. Health workers and researchers expressed multiple uncertainties (for example the duration of infectiousness of people with TB), assumptions and misconceptions about what constitutes effective TB IPC, including focussing TB IPC on patients known with TB on treatment who pose a small risk of transmission. Instead, TB IPC resources should target high risk areas for transmission (crowded, poorly ventilated spaces). Furthermore, TB IPC implementation plans should support health workers to translate TB IPC guidelines to local contexts, including how to navigate unintended stigma caused by IPC, and using limited IPC resources effectively.
Tuberculosis and Mental Illness (TB-MI) often co-occur with a varying range of interactions of both. The rising incidence of both in Low- and Middle-income countries (LMICs) is an emergent public health problem with accompanying higher morbidity and complications in management. The objective of this review is to gather insights into how healthcare providers can enhance their support for patients with TB-MI, to improve treatment adherence and overall health outcomes. Addressing the complexities of TB-MI treatment requires a multi-component approach that includes psychological interventions, monitoring the course of mental health comorbidities, patient education, looking into barriers to adherence, and involving healthcare providers. These coupled with increased patient awareness, integrated care model, patient education and empowerment, simplified treatment approaches, social support programs, and sensitizing healthcare providers can decrease the burden on the healthcare system while improving patient outcomes.
Keywords: Mental illness; Patient centered care; Treatment compliance; Tuberculosis.
This study evaluated the barriers that interfere with access to diagnosis and treatment of tuberculosis (TB) from the perspective of the patient and health professionals globally. Using the PICo acronym, the question we asked was "What are the barriers that interfere with access to tuberculosis diagnosis and treatment (I) from the perspective of patients and/or health professionals (P) across countries globally (Co)?". We searched the following databases: EMBASE, Scopus, MEDLINE, Latin American and Caribbean Literature in Health Sciences (LILACS), and Web of Science. On Rayyan, duplicates were removed and extraction was done afterward by two authors independently, followed by a tiebreaker. Using a Critical Appraisal Tool proposed by the Joanna Briggs Institute, the methodological quality of the article was assessed. From 36 published articles, the barriers to tuberculosis diagnosis as obtained from our study include information scarcity/low TB knowledge, exorbitant cost of transport, sample collection challenges, long distance to health facility, gender limitations, lack of decentralized diagnostic services, payment for diagnosis and testing, medication side effects, multiple visits during therapy, delayed diagnosis, poor human resources, low knowledge of medical practitioners, concerns regarding the efficacy of treatment, poor facility coordination, poor socioeconomic factors, fear and stigmatization of TB, and wrong initial diagnosis. The review of studies on TB diagnosis and treatment barriers evidences the diverse barriers to the eradication of tuberculosis. Eliminating these barriers is an onus that lies on policy makers, citizens, and health workers alike, with the joint aim of reducing the global TB burden.
Keywords: Barriers; Diagnosis; Health professionals; Human Resources; Knowledge; Patients; Social Treatment; Tuberculosis; World Health Organization.
The psychological burden is greatly felt by people living with tuberculosis because the characteristics of the disease are very visible and very contagious, and the obligation to take the right dose of medication with long treatment. This is what makes tuberculosis a very stigmatic disease. The aim of this research is to explore the psychological burden felt by people living with tuberculosis due to social stigma by society and how coping efforts are made. This research uses a qualitative phenomenological design through in-depth face-to-face interviews which take place in a semi-structured manner with the hope of obtaining complete data. The purposive sampling method was used in this research with Participatory Interpretative Phenomenology analysis involving 25 participants consisting of 16 men and 9 women. This research produced several themes, including 1) "The Perception of stigma limiting space and time", 2) "The Opportunities for interpersonal interaction become narrow", 3) "The mental stress as a challenging emotion", and 4) " Expanding coping efforts". The psychological burden is felt by people living with tuberculosis because society's treatment is felt to be very discriminatory due to the social stigma that has developed in society so they lose the opportunity to interact with society. For that reason, they tried to explore some of the personal and environmental resources used to modify adaptive coping in resolving perceived psychological burdens. Given the possibility of ongoing stigma and discrimination during tuberculosis treatment programs, it is important to consider the psychological burden in this context, both on the general population and on groups affected by stigma.
Reducing systemic inequities in testing, access to care, social protection – and in the scientific process – is essential to end TB. Incorporating social science methods and expertise on inequity into the mainstream TB response would help ensure that political commitments to equity move beyond symbolic gestures. We convened a meeting between TB social scientists, people with lived experience, civil society and community members to discuss equity within the global TB response. Here, we propose five means by which a social science lens can strengthen equitable, person-centred responses and reconcile the public health significance of TB with the principles of social justice.
TB disproportionately affects poorer, vulnerable people and communities, and has severe social and economic impacts on those affected. However, many countries do not yet include social protection in their programmatic response to TB. Here, we provide a critical perspective on the guidance developed by the WHO and the International Labour Organization (ILO) to help countries implement social protection programmes. The guidance emphasises the need for a multisectoral response to TB, and includes practical information on how to design appropriate social protection programmes that respond to the needs of people affected by TB.
Background: The disability-adjusted life year (DALY), a key metric for health resource allocation, encompasses morbidity through disability weights. Widely used in tuberculosis cost-effectiveness analysis (CEAs), DALYs play a significant role in informing intervention adopt/reject decisions. This study reviews the values and consistency of disability weights applied in tuberculosis-related CEAs.
Methods: We conducted a systematic review using the Tufts CEA database, updated to July 2023 with searches in Embase, Scopus and PubMed. Eligible studies needed to have included a cost-per-DALY ratio, and additionally either evaluated a tuberculosis (TB) intervention or included tuberculosis-related weights. We considered all tuberculosis health states: with/without human immunodeficiency virus (HIV) coinfection, TB treatments and treatment side effects. Data were screened and extracted independently by combinations of two authors.
Findings: A total of 105 studies spanning 2002-2023 across 50 countries (mainly low- and middle-income countries) were extracted. Disability weights were sourced primarily from the Global Burden of Disease (GBD; 100/165; 61%), with 17 non-GBD studies additionally referenced, along with primary derivation. Inconsistencies in the utilisation of weights were evident: of the 100 usages of GBD-sourced weights, only in 47 instances (47%) had the weight value been explicitly specified with an appropriate up-to-date reference cited (constituting 28% of all weight usages, 47/165). Sensitivity analyses on weight values had been conducted in 30% of studies (31/105). Twelve studies did not clearly specify weights or their sources; nine further calculated DALYs without morbidity. The review suggests methodological gaps in current approaches for representing important aspects of TB, including TB-HIV coinfection, treatment, drug-resistance, extrapulmonary TB and psychological impacts. We propose a set of best practice recommendations.
Interpretation: There is a need for increased rigour in the application, sensitivity testing and reporting of TB disability weights. Furthermore, there appears a desire among researchers to reflect elements of the tuberculosis experience beyond those allowed for by GBD disability weights.
