Introduction

Globally, tuberculosis (TB) remains a significant cause of ill health and is a leading cause of death due to an infectious agent (1). The TB epidemic is attributable to five main health-related risk factors globally, namely, diabetes mellitus (diabetes), HIV, smoking, undernutrition, and disorders due to alcohol use. The contribution of these risk factors to the global TB burden is reported annually in the WHO global tuberculosis report (1). For this operational handbook, a health-related risk factor is defined as a condition or action that increases the risk of TB disease (2). When they occur in people with TB, health-related risk factors are also considered comorbidities, and may lead to poor TB treatment outcomes, lower health-related quality of life, or other suboptimal health or social outcomes, such as increased out-of-pocket costs or TB-associated disabilities.

The impact of these risk factors for TB differs between and even within countries. Collectively, they account for just under half of the new TB episodes globally (1). Other significant health-related risk factors for TB disease include silicosis and disorders due to drug use. People with TB also frequently experience other comorbidities, including pulmonary and mental health conditions and viral hepatitis (2). Moreover, people with TB may develop chronic lung disease or other impairments (such as musculoskeletal or neurological), all of which require specialized care or rehabilitation during TB treatment and after TB treatment completion. People with TB may also have multiple comorbidities or health-related risk factors which require holistic people-centred care in the context of universal health coverage.

Addressing individual comorbidities, multimorbidity, TB-associated disabilities and health-related risk factors for TB are key elements of Pillar one of the End TB strategy, which focuses on integrated patient-centred care and prevention (3). The End TB strategy emphasizes that relevant comorbidities and health-related risk factors should be routinely assessed and managed for improved TB treatment and general health outcomes.

The political declaration of the 2023 United Nations High Level Meeting on the fight against TB reaffirmed the commitment to ending the TB epidemic globally by 2030, in line with the Sustainable Development Goals (4, 5). In the declaration, Member States committed to a comprehensive response that addresses TB and comorbidities, as well as social and economic determinants of the epidemic, and that protects and fulfils all people’s human rights and dignity (4). This commitment was echoed in the latest United Nations High Level Meeting declarations on noncommunicable diseases and on HIV in 2018 (6) and 2021 (7), respectively, in which Member States committed to assuring integrated people-centred services for TB, HIV, noncommunicable diseases and mental health.

Although global guidance on interventions to address TB and key comorbidities exists, its uptake has been variable. This operational handbook aims to support countries in scaling up people-centred care, based on the latest WHO recommendations on TB and key comorbidities, and drawing upon additional evidence, best practices and advice from experts, garnered through WHO processes.

This operational handbook is complementary to and should be used in conjunction with the WHO consolidated guidelines on tuberculosis. Module 6: tuberculosis and comorbidities (in press) and it also aligns with WHO’s Framework for collaborative action on tuberculosis and comorbidities (2). While the consolidated guidelines summarize WHO recommendations on TB and comorbidities and the evidence and processes behind them, this operational handbook provides practical guidance to aid in the implementation of these recommendations by country programmes. The Framework provides a structure and mechanisms for establishing and strengthening collaborative action across disease programmes and with relevant sectors outside the health system for the delivery of people-centred care for TB and comorbidities. It focuses on actions in five key areas and is underpinned by six principles that are fundamental to implementation (2).

Objectives

The objectives of the operational handbook are to:

  • support Member States to implement and scale up WHO recommendations on TB, comorbidities and health-related risk factors for TB;
  • inform the development of national TB strategic plans and other relevant health strategies, guidelines and tools on integrated people-centred care for people with TB and comorbidities; and
  • contribute to high quality people-centred care for people at risk of TB or with TB disease, and for people with comorbidities and health-related risk factors, contributing to improved health, social and economic outcomes over the longer term.

Structure and evolution 

The first edition of the operational handbook on TB comorbidities focused entirely on mental health. In the second edition a section on HIV-associated TB has been added. Subsequent editions will include sections on diabetes and on undernutrition, respectively.

Target audience 

This operational handbook is intended for use by people working in ministries of health, particularly TB programmes and the relevant departments or programmes responsible for comorbidities and health-related risk factors such as HIV, diabetes mellitus and other noncommunicable diseases, mental health, lung health, undernutrition, substance use and tobacco use. The operational handbook is also targeted at relevant line-ministries, policymakers, international technical and funding organizations, researchers, nongovernmental and civil society organizations, as well as healthcare workers, including specialists and community health workers who support the response to TB and comorbidities in both the public and private sectors.

References for the introduction

  1. Global tuberculosis report 2022. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/363752).
  2. Framework for collaborative action on tuberculosis and comorbidities. Geneva: World Health Organization; 2022 (https://iris.who.int/handle/10665/361989).
  3. The End TB Strategy. Geneva; 2015 (WHO/HTM/TB/2015.19; https://iris.who.int/handle/10665/331326).
  4. Political Declaration on the High-Level Meeting on the Fight Against Tuberculosis “Advancing science, finance and innovation, and their benefits, to urgently end the global tuberculosis epidemic, in particular by ensuring equitable access to prevention, testing, treatment and care”. New York: United Nations; 2023 (https://documents-dds-ny.un.org/doc/UNDOC/GEN/N23/306/91/PDF/N2330691.pdf, accessed 17 January 2024).
  5. Resolution 70/1. Transforming our world: the 2030 agenda for sustainable development. Resolution adopted by the General Assembly on 25 September 2015. New York: United Nations; 2015 (A/RES/70/1; https://documents-dds-ny.un.org/doc/UNDOC/GEN/N15/291/89/PDF/N1529189.pdf?OpenElement).
  6. Resolution A/RES/73/2. Political declaration of the third high-level meeting of the General Assembly on the prevention and control of non-communicable diseases. Resolution adopted by the General Assembly on 10 October 2018. New York: United Nations; 2018 (https://digitallibrary.un.org/record/1648984?ln=en).
  7. Resolution A/RES/75/284. Political declaration on HIV and AIDS: ending inequalities and getting on track to end AIDS by 2030. Resolution adopted by the General Assembly on 8 June 2021. New York: United Nations; 2021 (https://digitallibrary.un.org/record/3928975?ln=en).

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