United Nations High Level Meeting Research Articles

Uptake and Completion of Tuberculosis Preventive Treatment Using 12-Dose, Weekly Isoniazid-Rifapentine Regimen in Bangladesh: A Community-Based Implementation Study.

The United Nations high-level meeting (UNHLM) pledged to enroll 30 million in tuberculosis preventive treatment (TPT) by 2022, necessitating TPT expansion to all at tuberculosis (TB) risk. We assessed the uptake and completion of a 12-dose, weekly isoniazid-rifapentine (3HP) TPT regimen. Between February 2018 and March 2019 in Dhaka, community-based TPT using 3HP targeted household contacts of 883 confirmed drug-sensitive pulmonary TB patients. Adhering to World Health Organization guidelines, contacts underwent active TB screening before TPT initiation. Of 3193 contacts who were advised health facility visits for screening, 67% (n = 2149) complied. Among these, 1804 (84%) received chest X-rays. Active TB was diagnosed in 39 (2%) contacts; they commenced TB treatment. Over 97% of 1216 contacts began TPT, with completion rates higher among females, those with more education and income, non-slum residents, and those without 3HP-related adverse events. Adverse events, mainly mild, occurred in 5% of participants. The 3HP regimen, with its short duration, self-administered option, and minimal side effects, achieved satisfactory completion rates. A community-focused TPT approach is feasible, scalable nationally, and aligns with UNHLM targets.

A qualitative exploration of factors that influence the uptake of tuberculosis services by low-skilled migrant workers in Singapore

IntroductionSingapore relies heavily on migrant workers to build its country and harbours a relatively large population of these workers. Importantly, tuberculosis (TB) remains a pernicious threat to the health of these workers and in line with the United Nations High-Level Meeting in 2023, this paper aims to uncover the qualitative discourse facing migrant workers’ uptake of TB services and provide policy recommendations to enable more equitable access to TB services for this population.MethodsIn-depth interviews were carried out with the migrant worker population recruited from a non-governmental organisation in Singapore that serves migrant workers through the provision of primary healthcare services, counselling, and social assistance. Interviews stopped once thematic saturation was achieved and no new themes and subthemes were found.ResultsA total of 29 participants were interviewed, including 16 Bangladeshis and 13 Chinese, aged between 22 and 54 years old, all worked in the construction sector. Four key themes emerged. They are (1) General TB knowledge: Misconceptions are prevalent, where we found that participants were aware of the disease but did not possess a clear understanding of its pathophysiology and associated health effects, (2) Contextual knowledge and perception of associated policies related to TB in Singapore: low awareness among migrant workers as participants’ accounts depicted a lack of information sources in Singapore especially on issues related to healthcare including TB, (3) Attitude to towards TB: Motivation to seek treatment is underpinned by ability to continue working and (4) Stigma: mixed perception of how society views TB patients. The gaps identified in migrant workers’ TB knowledge, their attitude towards the disease and their perception of the availability of TB-related services is despite Singapore’s efforts to curb community spread of TB and its proactive initiatives to reduce the prevalence.ConclusionOur study illuminates the various aspects that policymakers need to home in on to ensure this vulnerable group is sufficiently supported and equitably cared for if they develop active TB during their stay in Singapore as they contribute to the nation’s economy. Leveraging the COVID-19 pandemic as a window of opportunity to improve overall healthcare access for vulnerable groups in Singapore can be a starting point.

Bridging the "Know-Do" Gaps in Five Non-Communicable Diseases Using a Common Framework Driven by Implementation Science.

According to the United Nations High-Level Meeting 2018, five non-communicable diseases (NCDs) including cardiovascular diseases, chronic respiratory diseases, diabetes mellitus, cancer, and mental health conditions accounted for two-thirds of global deaths. These five NCDs share five common risk factors including tobacco use, unhealthy diets, physical inactivity, alcohol use, and air pollution. Low- and middle-income countries (LMICs) face larger burden of NCDs than high-income countries (HICs), due to differences in ecological, technological, socioeconomic and health system development. Based on high-level evidence albeit mainly from HICs, the burden caused by NCDs can be reduced by affordable medicines and best practices. However, "know-do" gaps, ie, gaps between what we know in science and what we do in practice, has limited the impact of these strategies, especially in LMICs. Implementation science advocates the use of robust methodologies to evaluate sustainable solutions in health, education and social care aimed at informing practice and policies. In this article, physician researchers with expertise in NCDs reviewed the common challenges shared by these five NCDs with different clinical courses. They explained the principles of implementation science and advocated the use of an evidence-based framework to implement solutions focusing on early detection, prevention and empowerment, supplemented by best practices in HICs and LMICs. These successful stories can be used to motivate policymakers, payors, providers, patients and public to co-design frameworks and implement context-relevant, multi-component, evidence-based practices. In pursuit of this goal, we propose partnership, leadership, and access to continuing care as the three pillars in developing roadmaps for addressing the multiple needs during the journey of a person with or at risk of these five NCDs. By transforming the ecosystem, raising awareness and aligning context-relevant practices and policies with ongoing evaluation, it is possible to make healthcare accessible, affordable and sustainable to reduce the burden of these five NCDs.

Scaling Up TB Screening and TB Preventive Treatment Globally: Key Actions and Healthcare Service Costs.

The 2018 United Nations High-Level Meeting on Tuberculosis (UNHLM) set targets for case detection and TB preventive treatment (TPT) by 2022. However, by the start of 2022, about 13.7 million TB patients still needed to be detected and treated, and 21.8 million household contacts needed to be given TPT globally. To inform future target setting, we examined how the 2018 UNHLM targets could have been achieved using WHO-recommended interventions for TB detection and TPT in 33 high-TB burden countries in the final year of the period covered by the UNHLM targets. We used OneHealth-TIME model outputs combined with the unit cost of interventions to derive the total costs of health services. Our model estimated that, in order to achieve UNHLM targets, >45 million people attending health facilities with symptoms would have needed to be evaluated for TB. An additional 23.1 million people with HIV, 19.4 million household TB contacts, and 303 million individuals from high-risk groups would have required systematic screening for TB. The estimated total costs amounted to ~USD 6.7 billion, of which ~15% was required for passive case finding, ~10% for screening people with HIV, ~4% for screening household contacts, ~65% for screening other risk groups, and ~6% for providing TPT to household contacts. Significant mobilization of additional domestic and international investments in TB healthcare services will be needed to reach such targets in the future.

Shaping Global Health Law through United Nations Governance: The UN High-Level Meeting on Pandemic Prevention, Preparedness and Response.

The United Nations (UN) General Assembly High-Level Meeting (HLM) on pandemic prevention, preparedness and response (PPPR) was a missed opportunity to bring high-level commitment and momentum to the global governance of health emergencies. Intended to bring much-needed attention to a policy issue that is rapidly slipping down the international agenda, the fraught diplomacy among member states, lack of consensus on key issues, and weak UN Political Declaration in New York foreshadow a difficult road ahead for upcoming negotiations under the World Health Organization (WHO) in Geneva. This column chronicles the evolving engagement of the UN in global health governance, examines the diplomatic process leading to the UN HLM on PPPR, and assesses the contributions and missed opportunities of its resulting Political Declaration.

Retrospective Analysis of Drug Resistant Tuberculosis and the Associated Treatment Outcomes in Kenya

Tuberculosis is the world's deadliest infectious disease and kills up to 1.4 million people a year. The latest diagnostic tests can rapidly and accurately diagnose T.B. New medicines can help prevent and cure T.B. Yet two years after a United Nations High-Level Meeting on T.B. in 2018, people are still dying of a disease that should have been eliminated decades ago.

Tuberculosis recovery in Georgia: implementing more by 24

The 2022 Global Tuberculosis Report released by WHO again contained more bad news: diagnoses are not slowing enough to meet WHO's End TB strategy, and deaths from the disease continue to increase.1 Although the COVID-19 pandemic has adversely affected global efforts to eliminate tuberculosis, even before the pandemic the tuberculosis community was not on track to meet any indicators set at the 2018 United Nations High-Level Meeting on Tuberculosis.2

Carbon Emission Factors Identification and Measurement Model Construction for Railway Construction Projects.

Carbon emissions have become a focus of political and academic concern in the global community since the launch of the Kyoto Protocol. As the largest carbon emitter, China has committed to reaching the carbon peak by 2030 and carbon neutrality by 2060 in the 75th United Nations High-level Meeting. The transport sector needs to be deeply decarbonized in China to achieve this goal. Previous studies have shown that the carbon emissions of the railway sector are small compared to highways, waterways, and civil aviation. However, these studies only consider the operation stage and do not consider the carbon emissions caused by large-scale railway infrastructure construction during the construction stage. As an essential source of carbon emissions and the focus of emissions reduction, the carbon emission of railway construction projects (RCPs) is in urgent need of relevant research. Based on a systematic literature review (SLR), this paper sorts out the carbon emission factors (CEFs) related to RCPs; combines semi-structured expert interviews to clarify the carbon emissions measurement boundary of RCPs; modifies and calibrates CEFs; constructs the carbon emission measurement model of RCPs including building material production stage, building material transportation stage, and construction stage; and conducts empirical analysis to validate carbon emission factors and measurement models. This study effectively complements the theoretical research on CEFs and measurement models in the construction stage of railway engineering and contributes to guiding the construction of low-carbon railways practically.

The WHO Global Tuberculosis 2021 Report – not so good news and turning the tide back to End TB

ObjectiveTo review the data presented in the 2021 WHO global TB report and discuss the current constraints in the global response. Introduction and methodsThe WHO global TB reports, consolidate TB data from countries and provide up to date assessment of the global TB epidemic. We reviewed the data presented in the 2021 report. ResultsWe noted that the 2021 WHO global TB report presents a rather grim picture on the trajectory of the global epidemic of TB including a stagnation in the annual decline in TB incidence, a decline in TB notifications and an increase in estimated TB deaths. All the targets set at the 2018 United Nations High Level Meeting on TB were off track. Interpretation and conclusionThe sub-optimal global performance on achieving TB control targets in 2020 is attributed to the on-going COVID-19 pandemic, however, TB programs were already off track well before the onset of the pandemic, suggesting that the pandemic amplified an already fragile global TB response. We emphasize that ending the global TB epidemic will require bold leadership, optimization of existing interventions, widespread coverage, addressing social determinants of TB and importantly mobilization of adequate funding required for TB care and prevention.

Clean problems: Simplicity, complexity and the contemporary history of global noncommunicable disease prioritisation

In this paper, I first explore the actors, events, evidence and arguments that enabled noncommunicable diseases (NCDs) to be constructed, from the 1990s onwards, as a ‘global epidemic’ and ‘global crisis’ that threatened social and economic development. I then examine how two decades of action since the Global Strategy on the Prevention and Control of Noncommunicable Diseases (World Health Organization, 2000) has revealed the limits to that problematisation. In so doing, I actively trace the purposeful and inadvertent interplays between simplicity and complexity that have characterised the path of the NCD agenda since the early 1990s. As I argue, ‘clean problems’ may be deeply oxymoronic, but they are also a way of parsing complexity and simplicity and for key actors to explain why other disease constituencies have been relatively more successful in attracting global health funding. To support these arguments, I draw on interviews with forty key actors from the global ‘NCD community’ identified as playing an essential role in working towards the achievement of the first United Nations High Level Meeting in 2011. In critically exploring the oscillations of complexity and simplicity that characterise three decades of NCD advocacy, this paper brings analytical depth and qualitative rigour to a fascinating period of contemporary public health history.

Situational analysis of 10 countries with a high burden of drug-resistant tuberculosis 2 years post-UNHLM declaration: progress and setbacks in a changing landscape

ObjectivesGlobally, drug-resistant tuberculosis (DR-TB) is the leading cause of death globally related to antimicrobial resistance, affecting 500,000 emergent cases annually. In 2018, the first United Nations High-Level Meeting (UNHLM) on tuberculosis declared DR-TB a global public health priority. Bold country targets were established for 2018–2022. This study reviews the DR-TB situation in 2018, and the UNHLM target accomplishments in 10 high-burden countries (HBCs). MethodsAn ecological descriptive analysis of the top 10 DR-TB HBCs (Bangladesh, China, India, Indonesia, Myanmar, Nigeria, Pakistan, Philippines, Russian Federation, and South Africa), which share 70% of the global DR-TB burden, was undertaken, complemented by a cascade-of-care analysis and a survey gathering additional information on key advances and setbacks 2 years after the UNHLM declaration. ResultsMost countries are showing historic advances and are on track for the 2018 and 2019 targets. However, according to the cascade-of-care, none of the countries are capable of providing effective care for 50% of the estimated patients. Increasing levels of fluoroquinolone resistance and access to timely susceptibility testing can jeopardize ongoing adoption of shorter, all-oral treatment regimens. The programmatic management of DR-TB in children remains minimal. Achievements for 2020 and beyond may be affected significantly by the coronavirus disease 2019 (COVID-19) pandemic. ConclusionTriggered by the COVID-19 pandemic, there is a global risk of recoil in DR-TB care with long-term consequences in terms of deaths, suffering and wider transmission. Investment to support DR-TB services is more important now than ever to meet the aspirations of the UNHLM declaration.

Urgent need to address the slow scale-up of TB preventive treatment in the WHO South-East Asia Region.

In September 2018, all countries made a commitment at the first ever United Nations High-Level Meeting (UNHLM) on TB, to provide TB preventive treatment (TPT) to at least 30 million people at high-risk of TB disease between 2018 and 2022. In the WHO South-East Asia Region (SEA Region), which accounts for 44% of the global TB burden, only 1.2 million high-risk individuals (household contacts and people living with HIV) were provided TPT (11% of the 10.8 million regional UNHLM TPT target) in 2018 and 2019. By 2020, almost all 11 countries of the SEA Region had revised their policies on TPT target groups and criteria to assess TPT eligibility, and had adopted at least one shorter TPT regimen recommended in the latest WHO TPT guidelines. The major challenges for TPT scale-up in the SEA Region are resource shortages, knowledge and service delivery/uptake gaps among providers and service recipients, and the lack of adequate quantities of rifapentine for use in shorter TPT regimens. There are several regional opportunities to address these gaps and countries of the SEA Region must make use of these opportunities to scale up TPT services rapidly to reduce the TB burden in the SEA Region.

Situational Analysis of the 10 High Drug Resistant Tuberculosis Burden Countries Two Years Post-UNHLM Declaration: Progress and Setbacks in a Changing Landscape

Drug-resistant tuberculosis (DR-TB) is the greater exponent and, leading global cause of death related to antimicrobial resistance comprising close to 500,000 cases per year. In 2018 the first United Nations high level meeting (UNHLM) on tuberculosis was held, declaring TB and, its resistant forms a first order world public health concern. Bold country targets were established for 2018-2022. Currently 10 countries account for the 70% of the global DR-TB burden (Bangladesh, China, India, Indonesia, Myanmar, Nigeria, Pakistan, Philippines, Russian Federation, and, South Africa). The present study reviews these 10 countries situation in 2018, the levels of DR-TB related UNHLM target accomplishment and, it is complemented with a survey to ascertain key advances and, setbacks at 2 years from the UNHLM declaration. Although most countries are showing an historical advance and, were on track for the 2018 and, 2019 targets, according to the DR-TB country cascade of care, no country is capable of providing care for even 50% of the estimated patients. Increasing levels of fluoroquinolone resistance and, the difficulties in obtaining timely susceptibility results can jeopardize ongoing adoption of shorter, all-oral regimens. Proportions of diagnoses and, enrolled on treatment of children with DR-TB remain minimal. Achievements for 2020 and, beyond are going to be affected by COVID-19 pandemic and, the measures to contain it.Triggered by COVID-19 pandemic, there is a risk of a step back in DR-TB care, with long-term consequences in deaths, suffering and, antimicrobial resistant transmission. Investing in and, supporting DR-TB services is more important than ever to meet the UNHLM aspirations.Funding Information: The study was funded by a GDI initiative with no involvement of any pharmaceutical company or, other agency.Declaration of Interests: No author declared any conflicts of interest.

Epidemiology of Tuberculosis and Progress Toward Meeting Global Targets - Worldwide, 2019.

Although tuberculosis (TB) is curable and preventable, in 2019, TB remained the leading cause of death from a single infectious agent worldwide and the leading cause of death among persons living with HIV infection (1). The World Health Organization's (WHO's) End TB Strategy set ambitious targets for 2020, including a 20% reduction in TB incidence and a 35% reduction in the number of TB deaths compared with 2015, as well as zero TB-affected households facing catastrophic costs (defined as costs exceeding 20% of annual household income) (2). In addition, during the 2018 United Nations High-Level Meeting on TB (UNHLM-TB), all member states committed to setting 2018-2022 targets that included provision of TB treatment to 40 million persons and TB preventive treatment (TPT) to 30 million persons, including 6 million persons living with HIV infection and 24 million household contacts of patients with confirmed TB (4 million aged <5 years and 20 million aged ≥5 years) (3,4). Annual data reported to WHO by 215 countries and territories, supplemented by surveys assessing TB prevalence and patient costs in some countries, were used to estimate TB incidence, the number of persons accessing TB curative and preventive treatment, and the percentage of TB-affected households facing catastrophic costs (1). Globally, TB illness developed in an estimated 10 million persons in 2019, representing a decline in incidence of 2.3% from 2018 and 9% since 2015. An estimated 1.4 million TB-related deaths occurred, a decline of 7% from 2018 and 14% since 2015. Although progress has been made, the world is not on track to achieve the 2020 End TB Strategy incidence and mortality targets (1). Efforts to expand access to TB curative and preventive treatment need to be substantially amplified for UNHLM-TB 2022 targets to be met.

The critical role of health promotion for effective universal health coverage

The Political Declaration from the United Nations High-Level Meeting on Universal Health Coverage: Moving Together to Build a Healthier World (2019) provided important reaffirmation of health as a precondition for sustainable development and equity, as well as of the role for primary care as a cornerstone of universal health coverage. Health promotion, prevention and sustainable healthcare go hand in glove. Health promotion can enable more effective use of health resources by reducing demand for expensive health services and reducing hospital admissions. Promoting mental and physical health, and addressing health literacy and the social determinants of health, enables governments and departments of health to (i) empower citizens and communities to take control of their health, and (ii) better support innovative and financially sustainable healthcare. Without the bedrock underpinning of effective health promotion, treasuries and health systems will struggle to meet the rising costs and burden of ill health.

Framework for the evaluation of new tests for tuberculosis infection.

The scale-up of tuberculosis (TB) preventive treatment (TPT) must be accelerated to achieve the targets set by the United Nations High-level Meeting on TB and the End TB Strategy. The scale-up of effective TPT is hampered by concerns about operational challenges to implement the existing tests for TB infection. New simpler tests could facilitate the scale-up of testing for TB infection. We present a framework for evaluation of new immunodiagnostic tests for the detection of TB infection, with an aim to facilitate their standardised evaluation and accelerate adoption into global and national policies and subsequent scale-up. The framework describes the principles to be considered when evaluating new tests for TB infection and provides guidance to manufacturers, researchers, regulators and other users on study designs, populations, reference standards, sample size calculation and data analysis and it is also aligned with the Global Strategy for TB Research and Innovation adopted by the World Health Assembly in 2020. In addition, we briefly describe technical issues that should be considered when evaluating new tests, including the safety for skin tests, costs incurred by patients and the health system, and operational characteristics.

Building a tuberculosis-free world while responding to the COVID-19 pandemic

Building a tuberculosis-free world while responding to the COVID-19 pandemic

Leveraging differentiated HIV service delivery to expand tuberculosis preventive treatment: a call to action.

Tuberculosis (TB) is the leading cause of death among people living with human immunodeficiency virus (PLHIV), and sub-Saharan Africa has a particularly heavy burden of HIV-associated TB. Although effective TB preventive treatment (TPT) has been available for decades and shorter regimens are newly available in some settings, TPT coverage among PLHIV is suboptimal, leading to preventable illness and death. In 2018, the United Nations High-Level Meeting on Ending Tuberculosis called for ambitious new targets for TPT coverage among PLHIV and many countries in sub-Saharan Africa have redoubled their efforts to take TPT to scale. Importantly, however, this push to expand TPT among PLHIV is taking place in the context of a changing HIV treatment delivery landscape. Countries in sub-Saharan Africa are at the forefront of innovative changes in HIV program design, including a shift towards less-intensive differentiated service delivery (DSD) models for stable patients doing well on antiretroviral therapy. Understanding the opportunities and challenges that DSD presents for TB diagnosis, prevention and linkage to care among PLHIV will be critical to success.

Realizing the "40 by 2022" Commitment from the United Nations High-Level Meeting on the Fight to End Tuberculosis: What Will It Take to Meet Rapid Diagnostic Testing Needs?

The potential gains from full adoption of World Health Organization (WHO)-recommended rapid diagnostics (WRDs) for tuberculosis (TB) are significant, but there is no current analysis of the additional investment needed to reach this goal. We sought to estimate the necessary investment in instruments, tests, and money, using Xpert MTB/RIF (Xpert), which detects Mycobacterium tuberculosis (MTB) and tests for resistance to rifampicin (RIF), as an example. An existing calculator for TB diagnostic needs was adapted to estimate the Xpert needs for a group of 24 countries with high TB burdens. This analysis assumed that countries will achieve the case-finding commitments agreed to at the recent United Nations High-Level Meeting on the Fight to End Tuberculosis, and that countries would adopt the WHO-recommended algorithm in which all people with signs and symptoms of TB receive an Xpert test. When compared to the current investments in these countries, this baseline model revealed that countries would require a 4-fold increase in the number of Xpert modules and a 6-fold increase in the number of Xpert test cartridges per year to meet their full testing needs. The incremental cost of the additional instruments for these countries would total approximately US$474 million, plus an incremental cost each year of cartridges of approximately $586 million, or a 5-fold increase over current investments. A sensitivity analysis revealed a variety of possible changes under alternative scenarios, but most of these changes either do not meet the global goals, are unrealistic, or would result in even greater investment needs. These findings suggest that a major investment is needed in WRD capacity to implement the recommended diagnostic algorithm for TB and reach the case-finding commitments by 2022.

Quality matters: Redefining child TB care with an emphasis on quality

Children have been neglected in the fight against tuberculosis (TB) for decades. Despite being the number one infectious disease killer, TB does not feature on the child survival agendas partly due to absent and inaccurate data. Quality is a missing ingredient in TB care in children, yet high rates of unfavorable TB outcomes highlight its importance in this age group. Quality care is particularly important for TB affected children in the absence of a point of care sensitive and specific diagnostic test. Using the current models of child TB care, it will take another 200 years to end TB. Without focusing on the quality of child TB care, the ambitious country specific United Nations High Level Meeting for TB targets will carry minimal impact. High TB burden countries must also adopt Universal Health Care (UHC) and ensure that quality TB care is made free and equitable for all children, adolescents and their affected families. We advocate for the importance of evaluating the quality of child TB care, and provide a basic framework for quality in child TB with special attention given to creating differentiated service delivery models for children and families affected by TB.