By Sophie Huddart, Emily MacLean & Madhukar Pai

New work from our group, out this week in Lancet Global Health, highlights the importance of the location of tuberculosis (TB) services in health care systems. The WHO estimates that 10.4 million new cases of tuberculosis occurred in 2015. More than 4 million of these patients were either not diagnosed or not connected to the tuberculosis programs in their countries. These losses mean we’re failing patients and failing to curb the epidemic.

In order to treat as many patients as possible, we must have diagnostics and treatments available wherever a patient may need them. In particular, we need TB care services in places where patients often seek healthcare. Our recent survey of 14 countries, however, shows that in countries with severe tuberculosis epidemics, many patients do not have access to the appropriate services at decentralized and primary care settings (Graphic). At best they may be offered a sputum smear microscopy at such levels of healthcare. Sputum microscopy, is a 100-year-old test that fails to diagnosis many TB patients.

Drug-resistant tuberculosis is increasingly common around the world. Patients with drug-resistant TB need specialized tests to determine which medications are going to work against their infection. In most of the countries we surveyed, these tests were only available in district and referral hospitals. In some countries, the two-year treatment for drug-resistant TB could only be completed at these referral centers as well.

Tuberculosis can also exist in the body in a latent stage before it manifests as active disease. Tests and treatments for latent TB exist but testing and treatment for this condition have very poor availability in the highest burden countries. Our survey shows that some countries do not have treatment for latent TB available at all.

In order to end the TB epidemic, we must diagnose and treat every TB patient including those with drug resistant and latent TB. We cannot continue to lose patients who are unable to reach specialized medical centers; instead we must take TB services to these patients in their communities. We must ensure that the services they need are available closer to home.

Our data also suggest that services for tuberculosis care in many countries might not be fully integrated into general health-care services. As countries work towards universal health coverage, it is crucial to not only strengthen tuberculosis services, but also ensure greater integration with primary health care. In parallel, we need to develop simpler methods (e.g., non-sputum based biomarker tests) and drug regimens (e.g., a universal drug regimen that does not require extensive drug-sensitive testing) that can be implemented closer to patients.

Sophie Huddart and Emily MacLean are doctoral candidates in epidemiology at McGill University, Montreal, Canada. Madhukar Pai is a professor of epidemiology, and Director of McGill Global Health Programs.