Wake-up call: Lessons learned from Poland must reaffirm TB as an EU health priority
By Krzysztof Herboczek and Joanna Ladomirska
Over the last century, Europe — including Northern, Western, Southern and Central European countries — made remarkable progress in the near elimination of tuberculosis (TB) due to improved socio-economic conditions and advancements in research and development. However, a recent surge of TB in Europe, coupled with lack of structural preparedness within many European Union (EU) countries to address it, threatens to undo this hard-earned progress.
Figures released from the WHO Europe region on Thursday also show 7,000 excess TB deaths in Europe during the COVID-19 pandemic and that only 60% of TB patients were cured with first-line medication. The EU must put this forgotten disease back on its health agenda, and urgently address the testing, prevention, and access to treatment needs for people affected by TB and its drug-resistant forms.
Poland: A case study
Médecins Sans Frontières (MSF) began working with people with TB in Poland in 2022 in the context of the war in Ukraine, by supporting refugees from Ukraine and trying to ensure the continuity of their TB treatment in close collaboration with the Polish national health programme. Having worked with people with TB for more than 30 years in lower- and middle-income countries, we were shocked to note that the standards for testing, treatment and prevention of TB and its drug-resistant forms were outdated in Poland, and lacked an integration of the most up-to-date science — as outlined in the World Health Organization’s (WHO) guidelines — into its national health policy.
People with drug-resistant TB (DR-TB) had to stay in hospital for the entire duration of their treatment, which consisted of old, toxic and less effective regimens lasting at least 18 months and including dozens of daily pills and painful daily injections that are known to cause devastating side effects.
That there was no access to the newer, more effective TB drugs that have been available elsewhere for the past decade, hindered the use of the current WHO-recommended shorter, oral regimens that are adapted for everyone, including children. The lack of access and registration of child-friendly, water soluble formulations of TB drugs meant that children had to swallow crushed and bitter medicines without appropriate weight-based doses.
Additionally, people with drug-sensitive TB still have to take 11 pills per day even though the availability of fixed-dose combinations has reduced the pill burden to around 3 pills per day in many of the lower- and middle-income countries where we work to treat TB.
Moving onto the right track
The ongoing national and international efforts by WHO, MSF, and many other organisations in the last two years have led to significant steps in the right direction, with the Polish government now bringing back attention to this forgotten crisis.
In a bid to offer continuity of treatment to Ukrainian refugees affected with TB, the Polish government started to prioritise the management of this disease in 2022 and has made notable progress since then. In a notable move, the government launched a pilot project in partnership with MSF and WHO for ambulatory treatment of DR-TB that has resulted in reduction in duration of hospital stay from several months to a few weeks. The government also established a system of reimbursement for hospitals to cover the testing and treatment of TB.
Poland’s co-chairmanship of the TB United Nations High Level Meeting in 2023 led to the adoption of a political declaration with strong commitments to urgently end the global TB epidemic, and signals a paradigm shift by bringing the disease to the forefront of its health agenda. We have to keep at it. While the Polish government has made important moves since 2022, we believe that further actions are further needed if the efforts to address TB are to succeed.
The government must establish a system to actively identify people affected with TB , initiate timely treatment, and effectively control transmission of the disease. Worryingly, an MSF internal analysis revealed that over half of the people affected by TB in 2023 remained undiagnosed and untreated whilst living in Poland for at least two years.
Prices of the newer drugs and regimens must be reduced. The WHO-recommended six-month treatment regimen for DR-TB, consisting of bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM), is still exorbitantly priced at €45,300 in Poland even though it is available at €380 in lower- and middle-income countries through the Global Drug Facility, an international procurement agency.
All TB drugs should be made available for prevention and individualised treatment, ensuring that people with TB — irrespective of their drug-resistance profile, age and other co-morbidities — have access to appropriate treatment.
Paediatric TB formulations and fixed-dose combinations of TB drugs for both adult and children, already available in many other countries, must be made accessible in Poland as well.
The Polish government should urgently establish a National TB programme adopting and implementing the current WHO treatment guidelines.
EU countries lag behind
Regrettably, the challenges we see in eliminating TB are not exclusive to Poland but are common in many EU countries. This affects not only access to services in-country, but also the continuity of care for people with TB crossing borders, especially during emergencies.
The EU must put TB back on the agenda as a health priority.
The case study of Poland is indicative of a more general lack of preparedness within the EU to combat this deadly infectious disease. Such a lack of preparedness has certainly been highlighted and challenged by the rapidly changing international geopolitical situation, to which the war in Ukraine has contributed, and should serve as a compelling wake-up call for the EU to advance its efforts to deal with TB in the region.
As Poland convenes a TB summit with international stakeholders this week to initiate discussions for re-establishing a national TB programme, we urge all countries in the region to proactively revitalise their TB policies and programs, prioritise people-centered care, and take urgent steps to ensure universal access and affordability of TB tests and newer, all-oral treatment regimens.
We also call on the European Commission and concerned departments, including the Health Emergency Preparedness and Response (HERA), and the European Medicines Agency (EMA) to immediately focus on enhancing access to all the medical tools needed to combat TB across the EU.
Only through our collective efforts can we hope to defeat this ancient, yet curable infection, and prevent unnecessary suffering and deaths.
Krzysztof Herboczek is a medical doctor who has worked for Médecins Sans Frontières (MSF) since 2006 in various positions in the past, including as a TB doctor, manager and adviser. Since 2023, he has been the medical referent for the MSF TB project in Poland.
Joanna Ladomirska is the Medical Coordinator for MSF in Poland. She is a nurse who has 16 years’ experience in humanitarian work, including in countries in Africa, South America, South East Asia and Europe. She has worked in response to epidemics, natural disasters and conflict as well as HIV and TB, and describes herself as “a mother, an activist, and a doer with a humanitarian heart”.
This article first appeared in Health Policy Watch, 21 March 2024.
