2022 年世界結核病日：調整 COVID-19 和結核病之創新以挽救生命和終結結核病
資料來源：www.thelancet.com/infection Vol 22 April 2022；財團法人台灣紅絲帶基金會編譯
在過去的兩年裡，全世界的注意力都完全地集中在了 COVID-19 上，這是一個多世紀以來最致命的流行病，它擴大了全球呼吸道感染的巨大花費。 COVID-19 仍然是全球傳染病死亡的首要原因，並將結核病排擠在第二位。在結核病高度流行的地區，匱乏的資源已被轉移到 COVID-19 應對措施中，這破壞了結核病檢測和治療計畫。 COVID-19 對全球結核病控制工作的影響是災難性的，這使得在 2030 年實現世衛組織終結結核病策略目標方面所取得的任何進展都倒退了好幾年。自 2015 年以來首次出現，結核病的年度死亡人數已開始增加，2020 年有超過 150 萬人死於結核病。此外，COVID-19 對衛生服務的干擾阻礙了任一不論是活動性結核、耐藥性結核、耐多藥或廣泛耐藥性結核、潛伏性結核、結核和 HIV 之合併感染等的診斷和治療，以及結核病藥物、諮詢和追蹤等服務的取得，並降低治療順從性。這種阻礙反過來促進了耐多藥結核病菌株的發展並增加了治療的失敗率、痛苦和死亡。因此，在可預見的未來，結核病將繼續對結核病高負擔國家本已脆弱的衛生系統構成多重挑戰和負面影響。
今年世界結核病日的主題是「投資終結結核，拯救生命」。儘管這一主題適合將注意力從 COVID-19 重新轉移到結核病，但這是一項難以達成的任務。呼籲捐助者增加投資以終結結核病的呼籲再次遺憾地令人感到熟悉，惟至關重要，因為自世衛組織於 1993 年宣布結核病為全球緊急情況以來，要求政府負責並倡導增加投資的策略早已到位。鑑於全球經濟形勢不佳，對全球結核病控制方案的主要財政承諾不可能即將到來。然而，在結核病社區等待財政承諾的同時，可以透過更具創造性和創新性的衛生服務提供方式來將絕望轉化為希望。
我們業已擁有實現全球結核病控制目標所需的所有工具，甚至更可透過新的工作方式、創新策略和最大限度地利用現有資源來實現。在過去 2 年中，許多在結核病和 COVID-19 的篩查、診斷和管理上已取得具有新進展希望的方法，如果能夠巧妙地使用、聯合和協同，將可以克服 COVID-19 對空氣傳播傳染病造成衛生服務中斷的負面影響。從 COVID-19 應對措施中汲取的一些經驗教訓，包括創新的衛生服務工作方式，也為具有重疊臨床症狀和病徵的呼吸道傳染病之管理提供了一種新方法。許多實際步驟，使用最近更新的 COVID-19 和結核病診斷、治療、患者追蹤和社區照護指南， 如果立即採取行動，可能會產生協同、增強和加乘效應。因此，應以 COVID-19 應對措施中的 COVID-19 計畫之創新和調整為基礎，強化整合鍵接，建立以患者為中心的綜合結核病服務（圖）。
富裕國家正在進行的 COVID-19 大規模篩檢測試和疫苗接種推廣，是前所未有的金融投資、快速研發、科學協作和交付系統創新的結果。影響較富裕國家的疾病會立即得到關注，並迅速提供所需的資金。然而，結核病的歷史，以及新的 COVID-19，是一種科學和醫學進步，同時伴隨著政治上未能適當投資以將其推廣至所有具需要的人。對非洲COVID-19 疫苗分配上的不公問題以及較富裕國家未兌現承諾的問題突顯出，各國政府需要更有遠見的領導力，再加上大量的投資，讓結核病負擔高的國家能自力更生。由於缺乏政治上之意願而持續在非洲減少對結核病和 COVID-19 的投資是無法被接受的。
結核病本土高度流行的國家對導致結核病流行之社會、經濟和執行上的決定因素方面，擁有所有經驗和知識。結核病高度本土流行的國家迫切需要擺脫對捐助者的依賴，並應投資於有彈性和可永續的衛生系統上。在COVID-19這個前所未有的不確定時代，這將為所有結核病利益關係者提供保證。結核病流行國家應側重於改進衛生服務，重新調整它們，並使衛生部門更加包容所有世衛組織宣布的其他全球緊急情況。現在時機也成熟了，結核病流行國家應在當前全球對 COVID-19 的關注基礎上建立善意，以更好地去解決現有的結核病照護模式、預防未來人畜共通傳染病大流行的 One Health 方法，以及日益嚴重的全球抗生素耐藥性問題。
Francine Ntoumi、Jean B Nachega、Eleni Aklillu、Jeremiah Chakaya、Irina Felker、Farhana Amanullah、Dorothy Yeboah-Manu、Kenneth G Castro、*Alimuddin Zumla a.zumla@ucl.ac.uk
剛果醫學研究基金會，布拉柴維爾，剛果共和國（FN）；熱帶醫學研究所，圖賓根大學，圖賓根，德國（FN）；公共衛生研究院流行病學系 (JBN) 和傳染病與微生物學系 (JBN)，匹茲堡大學，匹茲堡，賓夕法尼亞州，美國；醫學與健康科學學院傳染病學部（JBN），斯泰倫博斯大學，開普敦，南非；彭博公共衛生學院流行病學系 (JBN) 和國際衛生系 (JBN)，約翰霍普金斯大學，馬里蘭州，美國；卡羅林斯卡大學醫院-哈丁格卡羅林斯卡醫學院檢驗醫學系臨床藥理學部(EA)，斯德哥爾摩，瑞典；醫學、治療學、皮膚病學和精神病學系 (JC)，肯雅塔大學，奈洛比，肯亞；英國利物浦熱帶醫學院臨床科學系 (JC)；亞新西伯利亞結核病研究所科學部（IF），新西伯利，俄羅斯；兒科、印度河醫院和健康網絡和阿迦汗大學(FA)，卡拉奇，巴基斯坦； Noguchi 醫學研究紀念學院，迦納大學，萊貢，迦納 (DY-M)；埃默里結核病中心羅林斯公共衛生學院，埃默里大學，亞特蘭大，喬治亞州，美國(KGC)；臨床微生物學中心感染和免疫學部和倫敦大學學院醫院 NHS 基金會信託基金 NIHR 生物醫學研究中心，倫敦大學學院，倫敦，英國(AZ)
圖：推進 COVID-19 創新以終結結核病
DOTS=短程直接觀察治療。DR-tuberculosis=耐藥結核病。MDR-tuberculosis =耐多藥結核病。
NAAT=核酸擴增試驗。 XDR=廣泛耐藥
World Tuberculosis Day 2022: aligning COVID-19 and tuberculosis innovations to save lives and to end tuberculosis
For the past 2 years the world’s attention has rightly been focused on COVID-19, the most lethal pandemic seen for over a century that has amplified the enormous global toll of respiratory tract infections. COVID-19 remains the top cause of death from an infectious disease worldwide, shifting tuberculosis to second place. In areas highly endemic with tuberculosis, scarce resources have been moved to the COVID-19 response, which has undermined tuberculosis testing and treatment programmes. The effects of COVID-19 on global tuberculosis control efforts have been catastrophic, setting back by several years any progress being made in achieving the WHO End TB Strategy targets by 2030. For the first time since 2015, the annual numbers of tuberculosis deaths have started increasing and more than 1·5 million people died of tuberculosis in 2020. Furthermore, COVID-19 disruptions to health services have impeded diagnosing and treating everyone with active tuberculosis, drug resistant tuberculosis, multidrug-resistant or extensively drug-resistant tuberculosis, latent tuberculosis, and tuberculosis and HIV co-infection, as well as access to tuberculosis medicines, counselling and follow-up, and lowered treatment adherence. This impedance in turn promotes the development of multidrug-resistant strains of tuberculosis and increases treatment failure rates, suffering, and death. Thus, in the foreseeable future, tuberculosis will continue to pose multiple challenges and negatively impact on already fragile health systems in countries with a high burden of tuberculosis.
The theme for this year’s World Tuberculosis Day is “Invest to End TB. Save Lives’”. Although this theme is appropriate to refocus attention from COVID-19 to tuberculosis, it is a difficult task to achieve. The call for donors to invest more to end tuberculosis is again sadly familiar, yet essential because strategies for holding governments accountable and that advocate for increased investments have been in place ever since WHO declared tuberculosis a global emergency in 1993. It is unlikely that in light of the poor global economic situation, major financial commitments to global tuberculosis control programmes will be forthcoming. However, while the tuberculosis community awaits financial commitments, despair can be turned to hope through more creative and innovative ways of health services delivery.
We already have all the tools required to achieve global tuberculosis control targets, and much more can be achieved via new ways of working, innovative strategies, and using existing resources maximally. Over the past 2 years, several promising new developments in approaches to screening, diagnosis, and management for both tuberculosis and COVID-19, if skilfully used, aligned, and synergised, could overcome the negative effects of COVID-19 disruptions in health services for airborne infectious diseases. Several lessons learnt from COVID-19 responses, including innovative new ways of health services working, also provide a fresh approach to management of respiratory infectious diseases with overlapping clinical symptoms and signs. Several practical steps, using recently updated diagnostics, treatments, patient follow-up, and community care guidelines for both COVID-19 and tuberculosis if immediately taken forward, could have a synergistic, enhancing, and multiplier effect. Thus, COVID-19 programme innovations and adaptations from within the COVID-19 response should be built upon, to enhance access to integrated, patient-centred tuberculosis services (figure).
The ongoing COVID-19 mass testing and vaccination rollout in wealthy nations are the result of unprecedented financial investments, rapid research and development, collaborative science, and innovation in delivery systems. Diseases that affect wealthier nations receive immediate attention and the required funding is made available quickly. However, the history of tuberculosis, and now COVID-19, is one of scientific and medical advances, accompanied by political failure to invest appropriately in rolling them out to all in need. The issues of inequities in COVID-19 vaccine distribution to Africa and unfulfilled pledges by wealthier nations, highlights that more visionary leadership, coupled with serious investments, are required from national governments to make countries with a high burden of tuberculosis self-reliant. Continued disinvestments in Africa into both tuberculosis and COVID-19 resulting from lack of political will is unacceptable.
Countries that are highly endemic for tuberculosis have all the experience and knowledge on social, economic, and operational determinants that drive the tuberculosis epidemic. There is an urgent need for countries that are highly endemic with tuberculosis to move away from donor dependency and invest in resilient and sustainable health systems. This would provide reassurance to all tuberculosis stakeholders in this unprecedented COVID-19 era of uncertainty. Tuberculosis-endemic countries should focus on revamping health services, recalibrating them, and making the health sector more inclusive of all other WHO-declared global emergencies. The time is also now ripe for countries endemic with tuberculosis to build goodwill on the current global attention on COVID-19 to better address existing tuberculosis care models, One Health approaches to prevent future zoonotic pandemics and the burgeoning problem of global antimicrobial resistance.
Francine Ntoumi, Jean B Nachega, Eleni Aklillu, Jeremiah Chakaya, Irina Felker, Farhana Amanullah, Dorothy Yeboah-Manu, Kenneth G Castro, *Alimuddin Zumla a.zumla@ucl.ac.uk
Foundation Congolaise pour la Recherche Médicale, Brazzaville, Republic of Congo (FN); Institute for Tropical Medicine, University of Tübingen, Tübingen, Germany (FN); Department of Epidemiology (JBN) and Department of Infectious Diseases and Microbiology (JBN), University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA; Division of Infectious Diseases, Stellenbosch University Faculty of Medicine and Health Sciences, Cape Town, South Africa (JBN); Department of Epidemiology (JBN) and Department of International Health (JBN), Johns Hopkins Bloomberg School of Public Health, MD, USA; Division of Clinical Pharmacology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital-Huddinge, Stockholm, Sweden (EA); Department of Medicine, Therapeutics, Dermatology, and Psychiatry, Kenyatta University, Nairobi, Kenya (JC); Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK (JC); Scientific Department, Novosibirsk Tuberculosis Research Institute, Novosibirsk, Russia (IF); Department of Pediatrics, The Indus Hospital and Health Network and the Aga Khan University, Karachi, Pakistan (FA); Noguchi Memorial Institute for Medical Research, University of Ghana, Legon, Ghana (DY-M); Rollins School of Public Health, School of Medicine, Emory Tuberculosis Center, Emory University, Atlanta, GA, USA (KGC); Division of Infection and Immunity, Centre for Clinical Microbiology, University College London, and NIHR Biomedical Research Centre, University College London Hospitals NHS Foundation Trust, London, UK (AZ)
Figure: Advancing COVID-19 innovations to end tuberculosis
DOTS=directly observed therapy short course. DR-tuberculosis=drug-resistant tuberculosis. MDR-tuberculosis=multidrug-resistant tuberculosis. NAAT=nucleic acid amplification test. XDR=extensively drug-resistant