Tuberculosis (TB) has risen once again, as of 2023, to return to being the world’s deadliest infectious disease. TB causes around one million deaths annually, leaving devastating impacts on patients and their communities.1 Historically, TB has been treated in separate TB clinics worldwide that are independent under public health systems, generally isolated from standard primary-care clinics. In the USA, typical TB out-patient clinics evaluate subjects for active or latent TB and provide medical and nursing follow-up solely focused on TB management. Global efforts to combat TB have saved an estimated 79 million lives since 2000.1 The charge and funding of such TB clinics are often restricted to the care of TB alone. The general model of TB clinics provides TB evaluation, diagnosis, giving medications accordingly to treat individual TB, treatment follow–up, treatment completion and finally, discharge from the clinic. However, more effective short- and long-term care of patients with TB needs a comprehensive approach that extends beyond merely targeting the TB infection or disease.
TB disease has a high cure rate if patients can complete effective, uninterrupted treatment. However, TB is often accompanied by additional challenges such as medical comorbidities, imprisonment and homelessness. The key risk factors and comorbidities that drive the global TB epidemic and lead to poorer TB treatment outcomes include HIV, diabetes, malnutrition, chronic lung disease, chronic obstructive pulmonary disease (COPD), hypertension, cardiovascular disease and tobacco- and substance-use disorders.2,3 There is a profound interplay between the cure of TB and the treatment of co-existing health conditions. Without attending to the treatment of comorbidities, TB treatment is less effective and has a higher risk of treatment failure, drug resistance and drug toxicity.4
People with HIV are at an elevated risk of progression to active TB, 19 times higher than that of people without HIV.5 The odds of poor TB treatment outcomes in people coinfected with TB–HIV are 2.6 times greater than in patients without HIV.2 Diabetes impedes the immune response against TB, which can lower the effect of anti-TB medications, leading to TB treatment failure and relapse. Diabetes elevates the risk of TB development by twofold to threefold, deaths during treatment by twofold, TB relapse after treatment by fourfold and drug-resistant TB by twofold.3 Vulnerable patients, for example, people on immunosuppressive therapy for cancer or with autoimmune disease, and those who are malnourished, are at elevated risk of TB progression and reactivation.6,7 Moreover, comorbidities can sometimes mask or mimic the symptoms of TB, leading to diagnostic delays that elevate transmission risks.
The Coronavirus disease 2019 (COVID-19) pandemic has highlighted the need for a comprehensive care model that looks beyond isolated TB treatment. There is growing interest in the idea that community-based primary care (PC) coordination can improve TB care and reduce disparities.8 However, managing comorbidities and care coordination within a TB clinic setting is challenging and often fragmented.
Multi-disciplinary on-site approach
The Wetmore TB Clinic in New Orleans has been providing care to residents with TB for over 50 years, most of whom are either under- or uninsured. Many patients at this clinic also lack designated PC or specialty care (SC), are underprivileged and face healthcare inequities and disparities.8 In addition, they often have multiple comorbidities, leading to poor treatment outcomes that hinder achieving TB cure. TB care and follow-up at the Wetmore TB Clinic were improved by addressing onsite immediate primary-bridge care, identifying PC/SC needs, eliminating barriers to care and focusing on SC pathways for the management of comorbidities. The process improvement programme at the Wetmore TB Clinic demonstrated initial success in integrating on-site PC into a comprehensive TB care model, with positive outcomes.8
From our own published clinical experience at the Wetmore TB Clinic in New Orleans and other studies, a structured approach is crucial to identify common comorbidities in patients with TB during the early stages of treatment to ensure improved TB care.8–11 Thus, we have developed an integrated care strategy, augmented with nutritional support if needed, to address comorbidities and move beyond siloed TB care. This includes the following:
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Proactive screening for comorbidities, early TB detection and co-management.
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A customized approach, with immediate onsite bridge PC if needed, tailored care plans to treat comorbidities and provision of robust support systems to improve treatment adherence, such as transportation and housing help.
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Healthcare collaborations to ensure specialists’ partnership capable of addressing comorbidities.
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Addressing socio-economic health determinants, such as poverty and limited healthcare access, by directly approaching available local social welfare organizations on behalf of patients.
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Organizing regular patient support groups and identifying challenges and opportunities to improve multi-disciplinary care coordination.
Our model has shown that incorporating PC measures and establishing pathways for a multi-disciplinary care plan improve patient care and patient experience.8 This model could improve TB treatment outcomes, reduce recurrence rates and assist in managing long-term post-TB lung disease. On-going data are being collected to evaluate this impact. Undoubtedly, these approaches need additional funding and operational cohesiveness. Our model has been supported by the Wetmore Foundation grant, other local philanthropic organizations and the cooperation of community health centres. However, experiences incorporating robust, proactive onsite PC and a multifaceted approach form part of ongoing global efforts to integrate TB care in a comprehensive, multi-disciplinary manner.12–14
Conclusions
Addressing interconnected health issues while managing both latent and active TB is crucial for effective TB control, ensuring successful treatment outcomes and reducing treatment failure. We propose that coordination with community-based primary healthcare, starting at the TB clinic level, may improve adherence to treatment, improve completion rates and reduce the risks of complications and impact of comorbidities that challenge a successful TB programme. Along with risk stratification and targeted screening for TB to identify latent and active TB and implement appropriate treatment, there is an important need for immediate onsite bridge care for PC issues, as well as follow–up and continuity of care across specialties. These multifaceted health initiatives can significantly enhance the quality of TB treatment, may improve outcomes and be a part of global efforts to control TB. We believe that TB cannot, and thus should not, be treated in isolation.
