Breath for Life: The Johnson & Johnson Program That's Helping Eradicate Tuberculosis in Vietnam

Le Van Giang doesn’t know if his family would be alive today were it not for an observant health worker at his local clinic.

In 2016, on a visit to get a persistent cough checked out, she suspected that Giang might have tuberculosis (TB)—a disease that has seriously burdened the healthcare system in Vietnam, with over 100,000 new cases identified in the country in 2016 alone.

She urged Giang to make the journey to the Provincial Tuberculosis and Lung Disease Hospital for further examination, and it was not a moment too soon—once there, he was diagnosed with active TB and hospitalized. Concerned that his family might also be at risk of the highly contagious disease, the local clinic sent them for TB screening, too.

The results: His wife, Nguyen Thi Ly, and 5-year-old son, Le Nguyen Van Khang, were in the clear. But not his 8-year-old son, Le Nguyen Van An, who was hospitalized immediately.

While Van An had shown many of the symptoms TB patients tend to experience—coughing, weight loss, fever and chills—his parents assumed he just had a cold. Were it not for the specialized training his health worker had received through a unique new program called Breath for Life (B4L), Giang and his son might not be here to recount the tale.

A Lethal Pediatric Epidemic Calls for a Groundbreaking Partnership 
Despite being preventable and curable, TB remains the leading cause of mortality among all infectious diseases in Vietnam. It is spread through coughing, talking, sneezing and even breathing—and usually affects people living in crowded conditions. Children are particularly vulnerable because TB progresses more rapidly in this population, plus it's harder to detect in kids than in adults.

For children under the age of 5, a treatment known as isoniazid preventive therapy (IPT) can help reduce the risk of developing the disease. But due to a lack of resources for training local health workers on IPT, less than 50% of at-risk children in Vietnam have received it.

To help address this public health crisis, the global health nonprofit PATH has been working to improve TB detection and treatment in Vietnam, and in 2016, formed a unique partnership with Johnson & Johnson known as Breath for Life.

The goal: combine the collective support of PATH, the National TB Control Program (NTP), the Nghe An Provincial Health Department (PHD) and the Nghe An Provincial Tuberculosis and Lung Disease Hospital (PTLH) to improve the detection, diagnosis and management of TB in one of Vietnam’s most heavily burdened areas—Nghe An.

Vietnam is divided into 63 provinces, each of which is broken down into districts, and even further into communes. Nghe An is the 10th most TB-affected province, so it seemed a fitting region in which to implement a two-year B4L pediatric TB pilot project in four districts of the province.

“The Johnson & Johnson/PATH relationship was quite different from most donor-grantee relationships,” says Kim Green, program director of the HIV/TB and Noncommunicable Diseases (NCD) Program in the Mekong Regional Program at PATH. Typically, the structure of such a project is designed entirely by the grantee, such as PATH. “But Johnson & Johnson and PATH shared such strong values that we leveraged our mutual assets to design something truly meaningful together,” she adds.

For Johnson & Johnson, which, in 2012, had introduced the first new TB drug in the U.S. with a novel mechanism of action in more than 40 years, the partnership spoke to the company's long-standing commitment to helping advance health for humanity around the globe—a core tenet in its company mission statement, known as Our Credo.

“Given the progress made in reducing the HIV burden around the world, TB has become the single largest infectious disease killer that we have on the planet these days,” says Ross Underwood, Global Access and Commercial Leader, Johnson & Johnson. “According to the Credo we follow, Johnson & Johnson had every reason to invest in a global public health solution in Southeast Asia, which has been heavily hit by the disease.”

What a Difference Just Two Years Can Make: A Near Zero Mortality Rate 
To achieve its lofty mission, B4L focused on these main strategies: decentralizing the way pediatric TB is detected and diagnosed (that is, empowering clinics and hospitals to do so not just at the provincial level, but also in districts and communes); developing training programs to enable health workers at the commune level to administer IPT programs and introduce systematic screenings for children at risk at the commune level; and creating and distributing educational materials to improve TB awareness.

And the program has already made quite the impact.

Based on World Health Organization (WHO) estimates, Vietnam should be detecting approximately 11,000 new active TB cases in children younger than 14 every year. In reality, just 1,338 cases were detected and managed in 2014, and 1,545 in 2015, so that means almost 90% of cases were going undetected—and untreated—annually.

In just one year, B4L saw the number of pediatric TB cases detected in Nghe An almost double—from 252 in 2015 to 425 in 2016—and the number of eligible children enrolled in IPT increase from 45% in 2015 to over 76% in 2017. Meanwhile, over 200 health workers had also received specialized training in pediatric TB detection and treatment, thanks to B4L.

Health Station Chief Nguyen Thi Tho, who has worked at Nghe An’s Hung Tien commune health station for 26 years, says she has seen extraordinary changes since the program kicked off.

“The possibility of someone dying from undetected TB in Nghe An is now near zero; five or 10 years ago, this would not have been the case,” she says. “It’s because patients are now proactively bringing themselves or their children to the health center, which they never would have done in the past.”

And that’s due to two reasons, she says: “One, they know health workers’ skills and expertise have improved. Two, people are now able to identify the symptoms they are seeing in their children as signs of TB. People are also bringing their TB stories back home to their village and talking about it, so there’s not so much stigma surrounding it anymore.”

Awareness of the deadly disease has also grown significantly in the province through improved communication channels among health authorities, district and commune health workers, and the community. Information about TB is now regularly broadcast over loudspeakers in communes and hamlets—translated into the local dialect, so that no one is left out—and healthcare workers often go door-to-door in a bid to educate the uninformed.

The training materials developed by B4L are now used for continuing medical education at PTLH, and in March 2017, the hospital used its own resources to establish its first-ever dedicated pediatric department. In a colorful play area stocked with toys and books, donated by Johnson & Johnson and PATH staff, children hospitalized with TB are no longer forced to share overcrowded hospital wards with adult patients—a welcome relief for their already stressed parents.

Deputy Director of Nam Dan District Health Center Nguyen Thanh Lan agrees that progress against pediatric TB has been remarkable since the project began. In 2015, a mere 19 children in his district were enrolled in IPT. By 2017, there were 64 eligible children receiving the treatment.

“Although the project has only been implemented in four districts so far," he says, "it’s a perfect pilot and would work well anywhere else in the country."

Taking One Province's Life-Changing Results to the Rest of the Country 
Indeed, B4L is already having a ripple effect throughout Vietnam, with health workers, provincial governments and even private health facilities and pharmacies traveling to Nghe An to study the pilot program.

“The project triggered optimism from the Ministry of Health and the NTP, and the B4L team was invited to present our approach to other provinces so it can be integrated into their own TB control plans,” says Green.

The initial, two-year model is now being scaled out across the remaining 17 districts of Nghe An by Vietnamese health authorities, and the training curriculum has been made available to other provinces in the hope it will lead to sustainable change in countrywide management of TB.

“We will ultimately see the most success over the next five to 10 years, when the model is replicated elsewhere across the country,” says Thai Dinh Lam, M.D., Deputy Director of PTLH, grinning broadly at the prospect.

Key components of the B4L model are also being integrated into another Johnson & Johnson-supported project, the Zero TB Initiative, which is committed to ending TB in Vietnam by developing community-based interventions across different locations—starting with Ho Chi Minh City, Hai Phong and Hoi An—so that no child will have to die from TB again.

“The sustainability and success of our Global Public Health program comes from embedding ourselves into the local fabric of a community, making for healthier communities that ultimately will result in healthier patients,” says Underwood. “That’s our model in everything we do.”