The path out of the tuberculosis crisis

Dr Peter Small, chief medical officer, Hyfe, explains why the G20 needs to bring the urgency and digital technology of the response to COVID-19 to fight against tuberculosis. 

Recently I had the privilege of addressing attendees of the G20 Summit in Indonesia at their health meeting about tuberculosis. It was an important event given the G20 nations comprise approximately half the global burden of tuberculosis. These countries also have an even greater percentage of the opportunity and the responsibility to fight tuberculosis globally. The G20 is uniquely suited to shape and scale transformational data-driven digital solutions in their countries and ensure these solutions are made available to the rest of the world.

Looking at the current sad situation as it relates to tuberculosis, it is easy to forget 2019 was a golden year in which new tools and increased financial commitments showed tuberculosis was solvable. A comprehensive assessment by a Lancet Commission once again showed the diagnosis and treatment of tuberculosis was the most cost-effective interventions of all diseases studied. For every $1 invested in the treatment of tuberculosis, there was an estimated return of $24 in benefit. Achieving these returns on investment had become even more likely because the tuberculosis community was beginning to embrace the use of better data and pilot a variety of digital tools to improve the quality and cost effectiveness of tuberculosis care.

For example, the use of AI to read chest X-rays and identify tuberculosis was shown to greatly improve screening and triage. Evaluations by the Stop TB Partnership and others clearly illustrated that AI outperformed radiologists. Based on this evidence, the World Health Organisation recommended automated radiography for tuberculosis screening and triage.

It was also revealed that the ability to digitally connect molecular diagnostic instruments with software like Aspect and DataToCare could better link diagnosis to care and in the process speed up testing, decrease stockouts and increase trust between laboratories and programs. Mobile apps were developed to help frontline healthcare workers and empower communities. DiMagi’s CommCare allowed local developers to quickly build custom mobile software that improved the quality and efficiency of front-line workers. OneImpact, developed by the Stop TB Partnership, Dure Technologies and tuberculosis communities collects, analyses and acts in real time to identify and remove barriers to accessing tuberculosis care.

Digital adherence technology was introduced to help patients take their medication. Technology such as that of Wisepill and the providers of Video Observed Therapy also helped foster a global shift in the mindset of tuberculosis control programs toward a more patient-centric model of care. TB REACH showed digital adherence technology to be feasible, acceptable, and impactful.

Tuberculosis control programs began to use digital approaches to integrate and improve service delivery. Everwell Health Solutions supported India's tuberculosis program to develop, deploy and scale a national data system. By enabling real-time dashboards, integrating government payments with patients’ banks, and making this part of both public and private health care provision, Nikshay improved the timeliness of national data from months to minutes.

Despite all of this, global tuberculosis care and control is currently in a crisis. COVID has had devastating effects on every aspect of global health, however tuberculosis services have been disproportionately affected. During the past two years the number of undiagnosed and untreated cases of tuberculosis has skyrocketed. And for the first time in a decade, tuberculosis mortality has increased.

It is said that with the right perspective, crises are opportunities in disguise. The silver lining of COVID is that the G-20 made it abundantly apparent how fast a health system can muster a response to a health threat if the power of digital data and health is embraced.

Central to the COVID response was the use of digital tools such as HealthConnect from Praekelt and WhatsApp. When combined, these platforms enabled the early detection, mapping and management of patient care while increasing patient empowerment with tools for self-triage and diagnosis. Together these digital systems enabled better resource allocation, patient care, contact tracing and infection control. This simply could not have happened without embracing mobile phones, the power of digital data and state of art technology.

COVID has shown us the impact of patient empowerment and how people can and will self-test. Tuberculosis programs must double down on trends and technologies for patient empowerment, remote patient monitoring and delivering care to patients' homes.

Tuberculosis programs must be better integrated into mobile phone apps used by community health workers to get all providers to consider tuberculosis when treating chronic cough and perform the right evaluations. Perhaps we can even achieve the holy grail of integrating tuberculosis screening and case finding into primary health care. Public health dashboards that have been developed for COVID should be expanded to include event-generated tuberculosis data, such as that coming from AI enabled CXR machines and connected diagnostic instruments.

By embracing digital technology, tuberculosis care and control can hitch its wagon to the exponential engine of global innovation. One of these innovations, the potential of which has gone completely untapped, is ambient sound which can help us understand, diagnose, treat, and monitor health conditions. The ubiquity of smartphones is spawning the new field of acoustic epidemiology, which is the use of sound to understand the distribution and control of diseases.

After a career as an academic and as a philanthropic funder I recently left the public sector to join Hyfe, a small start-up whose ambition is nothing short of changing the way the world manages cough. The current approach to cough is rather pathetic. Cough is critical in identifying, diagnosing, and treating tuberculosis patients and yet we don't measure it. Together with the Gates Foundation and Global Health Labs, Hyfe has created an app that anyone in the world with a smartphone can download and use for free.

This app allows patients to monitor their cough while preserving their privacy passively and unobtrusively. This technology will help individuals quantify their cough, know if their tuberculosis is resolving with treatment and promptly recognise if their treatment is failing.

Several multinational research teams are also working on technology that can help diagnose tuberculosis based on just the sound of the cough. If this comes to fruition, imagine a world in which anyone with a phone can diagnose their own tuberculosis. Hyfe is not alone in the vision that mobile phones will become the workhorse for global health and its cough app is just one example of thousands of digital technologies being developed that have the potential to help solve the tuberculosis problem.

This path is not without barriers, but the G-20 is uniquely suited to address them. A recent study done by Stop TB and The Global Fund showed that countries have an ambition to go digital, but many will require significant technical and financial support.

We need to call on the G-20 to bring the same sense of urgency and focus on data and digital technology demonstrated during the pandemic to other global health threats, starting with tuberculosis. Failing to do so will perpetuate the chaotic and inefficient propagations of unimpactful technology and ultimately cost billions of dollars and millions of avertable deaths. With leadership and strategic funding from the G-20, we can pivot tuberculosis from crisis to exponential progress.