Contain This: The Latest in Global Health Security

Marking World Tuberculosis Day with Dr Mel Spigelman, Dr Margaret Kal from PNG and Dr Philipp du Cros

March 22, 2022 Indo-Pacific Centre for Health Security: Department of Foreign Affairs and Trade Season 2 Episode 18
Contain This: The Latest in Global Health Security
Marking World Tuberculosis Day with Dr Mel Spigelman, Dr Margaret Kal from PNG and Dr Philipp du Cros
Show Notes Transcript

This Thursday, 24 March is World Tuberculosis Day. An estimated 9.9 million people fell ill with TB in 2020 and 1.5 million people died from the disease. 

TB continues to be a blight in the Indo-Pacific region, particularly in Papua New Guinea, Indonesia, Kiribati and the Republic of the Marshall Islands. Papua New Guinea bears the largest burden of disease in the Pacific, including a heavy burden of multidrug-resistant TB. In 2020 almost 30,000 cases were notified there, including 600 cases of multidrug-resistant and extensively drug-resistant TB.

But TB is preventable and curable. So why is it still one of the most infectious and deadly diseases on the planet? 

On today’s episode we are joined by three experts who are on the front line of trying to bring an end TB.

Dr Mel Spigelman is the President and Chief Executive Officer of the Global Alliance for TB Drug Development – the TB Alliance – and a Member of its Board of Directors. In his time at the TB Alliance, Dr Spiegelman has been a leader in developing a regimen-based paradigm of TB drug development and leading the TB drug research field.

Dr Margaret Kal is the director of the PNG National TB Program (NTP). In this role, Dr Kal is responsible for the development of all national TB guidelines, policies, research, national program reviews and all other plans and policies for TB prevention and care in PNG. Australia’s Department of Foreign Affairs and Trade supports the work of the NTP.

And finally, Dr Philipp du Cros is an Infectious Diseases Specialist in TB Elimination and Implementation Science at the Burnet Institute. He has extensive experience in the management of TB/HIV programs and has worked with MDR TB programs across Tajikistan, Uzbekistan, India, Myanmar, Uganda, Swaziland and Zimbabwe.

The theme of World TB Day 2022 - ‘Invest to End TB. Save Lives.’ We talk to all of our guests on this episode about practical ways the global community can invest to end TB and the urgent need to invest resources to ramp up the fight against TB.

We hope you learn something from the conversation and join the fight to end TB @TBAlliance @CentreHealthSec

Camilla Burkot 0:01

Hello, and welcome to Contain This. My name is Camilla Burkot and I'm a Technical Advisor at the Indo-Pacific Centre for Health Security. This Thursday 24th March is World Tuberculosis Day. In 2020, while most of us were understandably preoccupied with the COVID-19 pandemic, an estimated 9.9 million people around the world fell ill with TB, and 1.5 million people died from the disease. These figures represent a significant decline from previous years in the number of people who were diagnosed with TB and an increase in the number of people who died of TB as a result of reduced or delayed access to diagnosis and treatment. This thousand year old disease remains one of the most infectious and deadly diseases in the world, despite it being a preventable and curable infection. 

On today's episode, we're joined by three experts who are on the frontline of trying to bring an end to TB. We speak first to Dr Mel Spigelman. Dr. Spigelman is President and Chief Executive Officer of the Global Alliance for TB Drug Development, the TB Alliance, and a member of its Board of Directors. I asked Dr Spigelman why TB is still ravaging so many countries around the world, and what the TB alliance is doing, including with the support of donors and governments like Australia, to end this pandemic. 

We then speak to Dr Margaret Kal and Dr Philipp du Cros. Dr Kal is Director of the PNG National TB Programme and talks to us about why it is so challenging to prevent, detect and treat TB in Papua New Guinea. Dr du Cros is an infectious diseases specialist in TB Elimination and Implementation Science at the Burnett Institute. He speaks to us about his experiences across the Asia Pacific, one of the region's most affected by TB and helps us to understand how the COVID-19 pandemic interacted with the TB pandemic, worsening the rates of TB infection and mortality across the world. 

The theme of World TB Day 2022 is "Invest to End TB: Save Lives." We talk to all of our guests on this episode about practical ways the global community can work to end TB, and the urgent need to invest resources to ramp up the fight against TB.

Thanks Mel for joining the conversation. I wanted to start by posing a really broad question, which is that we know that TB is an ancient disease. It's been with us for a really long time. Why is it still with us?

Dr Mel Spigelman 2:09

Camilla thank you very much for this opportunity. And, you know, part of the answer to that question is also related to why I'm thanking you for the opportunity. One of the reasons and I'll go into more detail, why it's still with us, is because in spite of the numbers, there's remarkably not a huge amount of interest on the part of so many people for the issue of TB. 

So with that, why is it still with us? It goes to the heart of what does it take to effectively eradicate or get rid of a disease? And it means that you've got to work in multiple areas, including diagnosing the disease, treating the disease, and preventing the disease. That usually is what it would take and you have to really be strong, so to speak in all of those modalities. 

But let me kind of focus in on treatment. The ability to treat TB as a component of getting rid of the disease depends on what medicines are available to treat it. It depends on the healthcare system in which it's being treated. And it also depends on a wide variety of what I think are most commonly called socio-economic determinants. So what are some examples of those for TB? Housing, ventilation, availability of food, just to name a few. I think a lot of us don't appreciate that the role those elements also play in the fight against the disease and especially in the fight against the disease, TB. 

Most of the modern treatments that we have, in spite of them being significantly better than what we had not that many years ago, it's still not as good as we could have and as we should have, in a large number of geographic areas around the world, where when we put in also the factors of the state of the health care systems, the living conditions, the other socio-economic factors, it's just not enough to truly get rid of the disease. 

TB is very heavily almost exclusively a disease of the poor. And so what does that mean? It's a disease of people who can't pay very much for either treatment, diagnosis. So on the one hand, it gets relatively minimal attention from the commercial sector, who realistically focus on, you know, having products that can generate strong monetary profits. But similarly, and to a great extent, again, because it's the poor, frankly, who are the most afflicted and diagnosed, there's not a huge amount of even appropriate political pressure, or what I would call political will, to devote the appropriate amount of public funds also, to eradicate this disease. 

Now, on the positive side, though, I have to say, in spite of all those shortcomings, and limitations, the progress that we and others have been able to make over the past 10 years or so has, I think, been nothing short of pretty phenomenal. The progress we could make, under different circumstances, that would really be mind blowing.

Camilla Burkot 6:08

I was curious as about whether there are estimates of what funding would be required? Do we have a sense of what what the gap is?

Dr Mel Spigelman 6:17

Let me start with the total funding for new products in for TB, for research and development. The total funding was about $680 million in 2020, when we have the last reasonably good numbers. Now, the Stop TB Partnership pulls together group of people, and they tried to estimate the gap. And their estimate was the gap is probably about one and a half billion dollars. Because the estimate and you know, based on the experts who came together is that you probably need about 2.2 billion a year instead of 680 million.

But when they put in the following factor, I asked the question, in two years, how much money was devoted to trying to get COVID vaccines over the last two years? Just vaccines. The answer to that is roughly $100 billion, probably more. So I think in with all due deference, I think my colleagues within, you know, TB, also very much underestimate this gap. 

Camilla Burkot 7:44

So in relation to costs, we talk a little bit about what, what are the costs of this of the treatments for TB? And do we have a sense of you may, this may or may not be a question that we can we can answer, but in most places, are patients able to access treatment for free? Or do we know something about what it costs patients to access treatment?

Dr Mel Spigelman 8:08

So it's, it's really fascinating, if you look at the costing dynamics within the TB marketplace. With the one of the benefits of the 50 year old treatments is that these are all generic drugs, that are manufactured by a large number of generic manufacturers who compete with each other because there are no patents, there are no restrictions really on manufacturers being able to make these drugs. 

Um, and that coupled with the fact that millions of people have TB, which is also a prime determinant of cost of a drug is how widespread is the market, so to speak, for the drug because there's a direct correlation. If a manufacturer can make drug for a million people, in tonnes of drug, it costs much, much less than if the manufacturer is making drug for 100 people or 1,000, or even just one, you know, a few 100,000. So if you look at the cost for these old regiments, because they're made, and they service millions of people, and they have a lot of generic competition. The cost is actually, I think, relatively modest, $25 / $30 US for a course of treatment. 

And it highlights frankly, in my opinion, that the generic marketplace, when it functions for a large number of people, actually drives down costs when it's truly competitive, and behaving, so to speak, like it was intended to behave. And that when you ask about BPaL, is exactly the approach that we took. 

The other thing that we have to take into consideration, not only the cost of the drugs, it's the cost of the healthcare system to the patient being out of work to the family, all of those other socio-economic determinants that enter into it. And the approach we took from for that was for the drug drugs that we could control, we are trying it's an experiment perhaps but it's one that we think will work that we licence that to multiple manufacturers who could compete with each other to bring the generic the highest quality generic manufacturers who would then compete with each other like the generic marketplace is supposed to do and bring the cost down to the lowest price that would be both affordable but the other issue is also sustainability because a company you know the people we licence too, if they don't make some profit, they're not going to do it, plainly stated. 

But just to cut to the chase, the treatment of these highly resistant patients now has come down from, you know, $10,000 - $20,000 per treatment for just the drugs in many locales to under $1,000. If we take just the one example of the BPaL or the BPaL regimen for highly resistant TB, we're talking about patients who now can be cured with six months instead of two years of treatment. They can, they also feel better, much more quickly. So that in fact, they can do things like go back to work, be with their families, etc, much more quickly. The cost is much lower. 

Camilla Burkot 12:13

I was just thinking a bit about cohorts like children and how they're affected and what sort of treatment they're that treatments available to them?

Dr Mel Spigelman 12:22

Special populations are a major problem for two reasons. One is that it's very difficult and expensive to develop a drug and test it in these populations. About six years ago, when we looked around at the situation for children with even drug sensitive TB to drugs that have been available for 40 years. How are people how are kids being treated back then, they were basically being treated by taking adult pills, either breaking them in a half or a quarter or whatever, a caregiver thought, would wind up with the appropriate dose. 

Then with the combination of funding from UNITAID, and other donors, FCDO and you know, a whole variety of other funders, DFAT in Australia, we undertook a project to come up with a really good formulation at the right dosage, which meant manufacturing pills that would be dispersed in water, so that you only had to drink it, they were the right dose for the right ages of the different children. They had a good taste. And also again, because there are probably over a million children a year who are afflicted with TB, the price for the treatment with those state of the art dispersible tablets for children is about $16 for a total course of six months of treatment.

So this sort of progress, it can be made. It can be made, if one can get the appropriate resources and the appropriate, you know, people behind it and just do it.

Camilla Burkot 14:30

It's I know it's made a huge difference for lots of kids having those those treatments that are actually designed for them. 

Dr Mel Spigelman 14:38

Our goal is if we can get to the point where we have a universal regimen, and by that I mean a treatment that applies to as soon as you diagnose TB, you don't have to worry, for all intents and purposes about whether it's sensitive or drug resistant, you can just give them the pills. And frankly, if we can get down to the order of days, and tell them take these for a week, and you will be fine. It's it, I think it's unbelievably huge difference that something like that would make in the lives and the structure of the health care systems, if we can get to that. And if we look at the progress that's been made in other fields of science, I think it can be done. 

Camilla Burkot 15:33

Thank you again for your time. I know there's a lot of there's a lot of work to do, as you described. So we're really grateful for you giving us so much of your time today.

Dr Mel Spigelman 15:43

Well thank you, Camilla.

Camilla Burkot 15:46

I'd like to ask Dr Kal if you could give us an overview of the TB situation in PNG? 

Dr Margaret Kal 15:53

TB is actually one of the huge health issues that the country is currently facing. We have been facing this problem for quite a while now, based on our notifications that go down to the National TB Programme. And really TB affects almost about 30,000 people every year. We estimated as more cases than this, but we have challenges in detection. So right now, we are only able to detect around 30,000 plus TB cases. 

So in terms of our drug resistant TB cases, we estimate more than 1,000 cases every year, but we can only treat that about half of that. So we have seen TB as huge burden in terms of affecting our health. 

When we look at causes of mortality and morbidity per hospital data. TB is among the top three causes of hospital admissions. So every year in almost all the provincial hospitals, and it's among the top five causes of TB in deaths that's reported from hospitals. 

In terms of the social implications of TB. We have seen, we have done patient cause survey recently in 2020, that showed that people and families in Papua New Guinea who have TB suffer huge catastrophic costs. We have seen a lot of people suffer because of TB, the poverty levels, you know, increase. So you know, people dropped below the poverty line, and those who are poor before become even more poorer, having TB or trying to access TB services, as well as loss of employment and so many other things.

In terms of the type of TB affected, the age group that's affected about most of the TB about TB affects around economically productive age group. So the bulk of the TB, around 70% - 80% of the TB is in the age group of 15 to 45 years. So that's the productive age group, the cream of the country. So this means it's affecting the earners the income enters that people are taking the payroll or payroll, the people who are looking after others. 

You know, they also there's also stigma discrimination due to a lack of understanding. So we see the implications of TB are huge in not just as a health issue, but also as a social issue. 

So where where does development happening in, you know, parts of the country like in Port Moresby, where a lot of people are coming in from the provinces into Port Moresby, we are seeing a lot of TB. So the top the hotspots of TB, in particular, among the urban dwellings, you know, across all the provinces, if you want to look province wise, but in terms of the country as a whole, we see 70% - 80% of the TB is actually in the urban setting. So we are seeing that it's a problem that we actually need to address not just from the health sector, but also with other sectors that are involved in social development as well. 

Camilla Burkot 19:08

You mentioned, one of the challenges is around detecting TB cases. I wonder if you could say a little bit more about that. And about any of the other sort of challenges around delivering TB health services in PNG.

Dr Margaret Kal 19:20

So when we look at detection challenges, we actually look at the quality of detection and also the accessibility of services. We would note that proportion of population that are actually accessing services, or they've actually been screened for TB is way below 1%. So we are seeing that not everyone in the population is have access to TB services. So in some settings, it's because their facilities aren’t there. In some settings, it's because the facilities are further away. In some settings where the services are there, it could be an issue of them no way, you know, there's communication about services are not there. So the community most of the community is not well aware. Now when we look at provincial health services to a suburbs to deliver this communication awareness, we see that they actually have issues around human resources, transportation, logistics, so they're not actually able to deliver this. 

Okay, now we look at training as well, most of that workers are not, we have not done refresher training, we have done a training site with the Global Fund support in the first grant we received in 2008 /2007 and then the second grant, but after that, that budget for training was reduced. And then the trained staff actually move on to other other facilities. So they move on to other better jobs. So now, there's, there's there's a need for training. So most of the staff are either trained some time ago or they have not been trained, and they're like learning from each other. So as well the training is also an issue that affects on the diagnosis as well. 

And then there's other issues around transportation. We have provided gene expert machines, but they're in the district facility in a more central facilities. So for other facilities to access, they actually need transportation support, and then logistics support, which currently they are unable to get within their own resources. Most likely, it's because it's not committed. Or it's not available. I mean, there's inadequate resources available. So that's one of the issues.

And the other issue on diagnosis is that most of the clinicians diagnose based on clinical. So when the patients come, they don't send us spittoon, collect the spittoon, and send it for confirmation of diagnosis, they would diagnose based on the clinical examination and X ray and things like that. So it contributes to our challenges in terms of diagnosis. 

Okay, now, in regards to the drug resistant TB, we have a culture facility, PCR lab, but it has been down for the last one year, almost going to two years now, because it needed some maintenance, and we do not have maintenance budget in our, you know, recurrent government budget. So we've been unable to find support to actually improve that. So we've been in the past one year plus, max, we've been, you know, treating, just putting pharmacy resistant cases on treatment without the confirmation from culture. But we're working with our partners now to actually, you know, get a look for ways to support this culture facility to be back online. 

In terms of treatment, we have seen in the past that and even now that about 15 to 20% of our patients, most don't have follow up. Patients have been diagnosed with drug resistant TB as well as susceptible TB, but some of them actually lost follow up, they are not coming back for to commence treatment. 

And one of the main reasons is, is because I mean, there's a lot of reasons one of them is, as I've mentioned, is that catastrophic costs, this also is a challenge to treatment. You know, patients in the community, sometimes they cannot afford to, to, to actually pay for transportation and in other costs just to access the services, the drugs, or the diagnosis or date free of charge paid by the government by the people in the community cannot access it because of challenges with bus fares and other economic challenges as well. That is why like after a few treatments, they feel better, and they're probably not coming back. 

So we have been recently with the Global Fund support, and also DFAT support in the National Capital District, we're rolling out a volunteer programme where we have volunteers in the community, who are given incentives to actually support treatment as well as improve, look for cases in the suspect I'm presenting it because in a community and refer, bring them in for diagnosis and those that are diagnosed, supervise the treatment. We have seen that this problem is very helpful because it actually reduced our lost to follow up. And they also increased the number of people that are detected and diagnosed for TB. Unfortunately, this resource is incentive based. We tried to roll this out in most other provinces, but actually there was no incentive to push for these. So this is a very good programme and it's not been done. 

Camilla Burkot 24:54

So I wanted to ask you what impact you think new treatments could have in PNG?

Dr Margaret Kal 25:01

In regards around drug resistant TB right now, for us, we have been using the longer regimen, we are reaching all originals, but longer regimens. So if we have a new combinations or new drugs that would reduce the length of treatment, that would be helpful and useful for us. We already know there are sort of regiments available also regiments and our team actually working around to putting protocol together for that. So we see that when when we do have shorter regiments, it will improve all the treatment completion and outcome because right now, we the longer treatment regimens, a lot of people normally last follow up. So you know, so it would actually have a big impact on our treatments, you know, successfully treating patients, as well as, you know, avoiding patients from lost follow up, as well as making the treatment attractive and available to patients.

Camilla Burkot 26:05

If I could just turn to Phil now. I wonder if you could talk a bit about how PNG compares to other countries in the Asia Pacific or indeed further afield where you've worked? 

Dr Philipp du Cros 26:18

So there's a lot of similarities around TB with PNG and other countries where I've worked, and then also a lot of differences and I'll try and maybe just keep it brief. 

The maybe a couple of things to think of in the similarities. You know, TB continues to be a major challenge in the Asia, Asia Pacific region, and continues to have high rates in a number of countries. And even the countries who have lower rates, then issues with drug resistance, or how to continue to reduce the rates of TB continue to be a challenge. I guess the similarities are around, you know, the challenges with TB continue to be things like. Diagnosis of TB when it affects areas outside the lungs. So extra pulmonary TB can be particularly challenging to diagnose. TB mainly affects the lungs, but it doesn't always affect the lungs. The other challenges around how do we put more effort on preventing TB. Most countries in the region and globally have spent a lot of time trying to scale up diagnosis and treatment, but very little attention has been put to preventing TB and that means that there's a lot more that could be done in in that area. 

I guess some of the the challenges that are unique to PNG, compared to some of the other countries in the region is, you know, PNG is a very mountainous country that has very few roads to certain areas. And so the geography and the logistics, makes the running of an effective TV programme very challenging. And I think the other thing that Dr Kal touched on is, you know, the lower numbers of the medical workforce compared to the amount of medical needs that there are means that it's very challenging for the staff. If the doctors are looking after the TB programme, but also the HIV and all the other infections as well as treating non communicable diseases, it can be a big challenge. 

I think we also need to not just think about things in terms of the TB epidemic, but we need to think about overlapping epidemics or so called, you know, syndemics. For example, in many countries in the region, we see, rising rates of diabetes, and diabetes can contribute to an increased risk of getting active TB, and certainly make the challenges of caring for for TB more difficult. The other things to think about is, have we achieved access to HIV care appropriately in the countries in the region, and there's still work to be done there. Giving HIV treatment can reduce people's risk for developing active TB. And so it's a very effective strategy, both for HIV improved care and for for TB. 

We also need to maybe think a little bit beyond just the TB itself and look at things like the social challenges of alcohol use and smoking, which can on a population scale will contribute to increased rates of TB. And then also issues like crowding. So, you know, Dr Kal was talking about rates in the urban areas. And in PNG, in parts of PNG, there's a lot of crowding, and that can be crowding within where people gather, but also crowding within households and with levels of poverty, meaning that lots of people can be sleeping in the same room. So there's easy transmission of respiratory diseases such as tuberculosis. 

So you know, PNG has some of those challenges a little bit more than other countries but shares them within the region. 

I guess one of the the key similarities that we've seen across the region with TB over the last two years and with COVID is that COVID has really stretched health systems. And so in the emergency response for COVID and the preparatory response, then a lot of the TB system has been leant on to help support that. So use of the diagnostic capacity, either the staff or the gene expert machines for COVID testing. Use of TB wards for isolation for COVID, meaning that there may not be wards available for for TB isolation when needed. And also the contact tracing teams shifted from TB to COVID. The end result has been that across the region, there's been more than a 20% reduction in the diagnosis and notification of TB. And, and really what we're seeing globally now is an increase in the mortality from TB. So the rates in 2020 of estimated deaths from TB is 1.5 million so and the first increase for over a decade. And the the modelling or the predictions suggest that with the reduction in case numbers diagnosed that we're going to continue to see increased numbers of TB cases within the region, including within PNG, increasing transmission and increasing mortality. So I think there's an important message there around thinking through when we're responding to one epidemic, how we might strengthen the continued response to tuberculosis.

Camilla Burkot 32:31

I want to ask a big question, which is, is it possible to eliminate TB?

Dr Philipp du Cros 32:38

Yes, that's a very big question. And I'm going to answer it with a dual answer. I'd say yes, and no. And let me clarify that. So there are definitely examples in history where TB elimination has been achieved in certain locations, with an appropriate strategy that deals with searching actively for cases, and looking to treat effectively and looking at prevention. So examples would include parts of Alaska and also in Greenland. 

But I think the the reason why I'm hesitant around the no is that you require appropriate financial and resources to scale up the things that we already have, that we know that work. And I think, in addition to using what we know, that already works, we also need to seek evidence on how we can do things better, how we can do things, slightly more cost effectively, as we scaled them up to cover whole countries with these kinds of strategies. So what sort of strategies am I talking about? Well, in in Australia, if you went back sort of 50/60 years, we used to have mobile chest X-rays that were available free for people to be able to get screened for TB. This is a strategy that we're now investigating, with renewed energy in in other countries in the region. So we've partners at the University of Gadjah Mada in Yogyakarta in Indonesia, we're looking at mobile chest X ray linked with artificial intelligence software that automates the readings. So we don't need a doctor tied up with the team to read the chest X rays. And this can help screen a large number of people who are at risk for TB and and then determine who needs further testing. So I think those strategies could be very helpful. 

I think where we also need to, you know, we need to scale up things like our preventive treatment. So COVID has put renewed attention on infection control. Infection control for COVID would also be very helpful for TB. So we should strengthen those things across diseases, both in healthcare facilities, but also thinking about where transmission is most likely to occur in communities and how we can improve things like ventilation and preventive strategies in the community as well. 

But then thinking in TB, we can also think about prevention. With preventive treatment, I think we need better tools on how to know who to target who's at highest risk. The tests that we have at the moment, are easily available. However, they're they're not good at picking the people who are most at risk. So if we could get more targeted tests, we would have less people to treat with preventative treatment, the current tests would diagnose about one in four people in the world with with TB, latent infection, or what so called sort of sleeping TB. And that's probably to large a population in the world to try and treat. So we need to be a little bit more more targeted. 

And then I guess thinking towards the future, there is ongoing research on TB vaccines, there are some promising candidates in the pipeline. And so if we were to get a TB vaccine, and maybe with some of what's been learned around COVID vaccines, whether some of that technology and could be applied to TB vaccines may help us get an effective TB vaccine that maybe might be an added tool to really help bring down the rates of TB much quicker. 

Camilla Burkot 36:36

Thanks, Phil. Yeah, I think it's a really, it's, it'd be really interesting time to watch next few years, whether this sort of other developments around mRNA vaccines for a whole range of infectious diseases that have come about through COVID, whether that, yeah, we'll have, we'll see more and more applications of that. 

Dr Margaret Kal 36:57

I would like to take this opportunity to also mention that in, in our TB program, and the way we see it, we see that a lot of participants is actually improved. TB control has you know, we are getting more people more partners to take part but speeding in TB activities are in controlling TB. And in regard to that, as we know, this Year's World TB Day theme is "invest in TB" and so we save lives in this TB epidemic. 

So that now is a call for you know everyone at all levels, whether it's donor partners, implementing partners, technical partners, that the community. So we actually see that the if mentioned about the TB elimination, we've the COVID has taught us a lot of things that if you know the same determination, and passion and investment can be done in TB, and then there's involvement and participation across all our partners. I believe that TB is something that we can make history and can eliminate. So I would like to also mention that partnership at all levels is very important. So for for us from the National TB program, we appreciate all partners, including DFAT and other donor and development partners. And I would like to thank all of you. Thank you.

Camilla Burkot 38:16

Thanks very much, Dr Kal. And yes, definitely partnership is at the core of everything, isn't it? 

Dr Philipp du Cros 38:22

I think that's a nice note to end on from Dr Kal. It's a very important point.

Camilla Burkot 38:28

Thank you for joining us for today's episode of Contain This to mark World Tuberculosis Day. I'm Camilla Burkot, Technical Adviser to Australia's Ambassador for Regional Health Security and Principal Health Specialist at the Indo-Pacific Centre for Health Security. You've been listening to my conversation with Dr Mel Spigelman, President and CEO of the TB Alliance, Dr Margaret Kal, Director of the PNG National TB Programme, and Dr. Philipp du Cros, an Infectious Diseases Specialist in TB Elimination and Implementation Science at the Burnet Institute. 

TB continues to be a blight in the Indo-Pacific particularly in Papua New Guinea, Indonesia, Kiribati and the Republic of the Marshall Islands. Papua New Guinea bears the largest burden of disease the Pacific, including multi-drug resistant TB. In 2020 almost 30,000 cases were notified in PNG, including 600 cases of multi-drug and extensively-drug-resistant TB. As our guests noted, it will take political will as well as scientific advances to end the scourge on our region and the world. We hope this conversation prompted you to join the fight to end TB. We encourage you to join the conversation online using the #investtoendTB and by following @CentreHealthSec and @TBAlliance and @BurnetInstitute.