Thanks for joining us again at the Canadian Breakpoint, a Canadian infectious diseases
podcast by Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal, pediatric infectious diseases specialist
from Saskatoon.
For this episode, we welcome Dr. Rachel Dwillo, pediatric infectious diseases specialist from
Winnipeg to discuss the current landscape of tuberculosis in Canada.
Dr. Purewal.
All right, welcome everyone to another episode of our podcast at the Canadian Breakpoint.
So today we have a very special guest with us, Dr. Dwillo.
So I would like to welcome Dr. Dwillo.
Dr. Dwillo is a fellow of the Canadian Royal College of Physicians and Surgeons in general
pediatrics and pediatric infectious diseases.
During her infectious disease fellowship training, she completed additional training in pediatric
tuberculosis at the University of Stellenbosch in Cape Town, South Africa.
She has worked extensively with TB effective populations in remote low resource settings.
Her current roles at the university include clinical lead for pediatric TB services, medical
lead for the Winnipeg Regional Health Authority TB program, and the TB consultant for the
Kivilek region of Nunavut, Canada.
She's the lead author of the pediatric chapter in the most recent edition of the Canadian
TV standards.
Welcome.
Thanks so much for having me.
I usually go by Dr. Rachel or Rachel.
So Dr. Dwillo seems too formal.
Totally fine.
We'll go with Rachel or Dr. Rachel today.
Yeah.
Perfect.
All right.
Well, a little bit of a disclaimer.
Dr. Rachel was my attending physician and fellowship as well.
So we've worked closely together.
We've had some TB discussions, but I think things are a little bit different in Canada
for sure and around the world.
So why don't we start off by talking a little bit about the current situation of TB in Canada,
just for our listeners to have an overview of what's changed, what are the outbreaks
like and what's going on in your world?
Yeah.
So, you know, I come from a Manitoba and Nunavut perspective.
So I don't know what's going on actively in other provinces over the last couple of years,
but I can say certainly in the standards that the first chapter definitely does a nice job
of describing the situation up until about 2000.
And so Canada is really quite obviously the Canadian population on a general basis.
It's considered a low incidence setting for TB.
So we've been like fairly stagnant around five per 100,000 cases, the incidence rate.
But again, you know, that doesn't describe the entire picture, as I'm sure you know,
having spent some time here in Manitoba.
And you know, there's it's heterogeneous across Canada as to who's affected.
But the general population groups at highest risk that we've seen in terms of what our
EPI data tells us is that this is a disease in Canada of those who are foreign born or
have foreign born relatives or live in the houses of foreign born people.
And specifically, as the data shows, higher risk from from the South Asia region, which
makes sense.
High burden countries there, as well as the African region.
Again, also not surprising, I think, for anyone that's done any work in the areas, and then
indigenous.
And so indigenous includes both Inuit, First Nations and Métis.
And so depending where you are on the country, you actually get a really different patient
population.
So my population is very different in terms of who is affected than say in Ontario or
say in BC versus Nunavut.
So again, it depends where you are in the country.
I know, at least in Manitoba over the last couple of years COVID did.
There was a decrease in case count.
Definitely, while COVID was happening.
As to the reason why, I don't know.
I don't know if we actually know or have data on that.
But this year, it's come back with a vengeance.
We're getting late cases, we're having more cases.
And there are concerns with certain communities that again, I won't name them, but they're
definitely struggling right now.
And I would say globally, that's been the case too.
We saw cases go down.
Cases go up from TB.
So I think probably this is just a trend of what's happened with COVID and a lot of other
diseases as well.
I agree.
Yeah.
So I guess for timing wise, I mean, the new addition for Canadian TB standards came out
just in May here.
So I think timing wise, I think it's very pertinent information and actually reviewing
the guidelines myself came across a lot of changes that I might not have been aware of
previously.
And so I think in general, just kind of discussion around like, was there a reasoning behind
the new release or was it just time due for this to come out?
I don't entirely know.
I was a later addition to the group.
I know they had tried to do it right around the time COVID started.
I think, so it's Dick Menzies that leads the whole group.
I think his goal was to update it every five years, but obviously I guess that didn't happen.
It's a lot of work to do something like this.
So I think it was just, it was on his plate, but on the back burner and then he had some
time and it was time to pull the trigger on it.
And again, there's been a lot of changes as I reflected there in terms of treatment and
diagnostics.
So again, it was very timely and probably overdue as well.
Right.
All right.
So kind of, I guess, digging right into the guidelines, because most of our listeners,
we've actually had a lot of requests for this episode.
Yeah.
And so I know which is good.
I like it when people are interested in this.
That's great.
Yeah.
I like it's because clinicians are seeing a lot of tuberculosis in their communities
and our listeners are, they're international, but we do have a lot of listeners from North
America and especially in smaller communities, we're going to see outbreaks, things like
presentation, right?
So maybe we can talk a little bit about, because I know in the guideline that was a recent
addition, as well, kind of comparing how like children may present very different from kind
of our typical adult presentation that we see of tuberculosis.
So why don't we touch on a little bit about that and then you can give us an overall kind
of overview as to an outsider from my standpoint, like what should I be looking in the guidelines
and what are the new things?
Yeah.
So again, you know, those of us who've studied pediatrics, children aren't little adults,
as we all know, and again, manifest things very differently.
I think the younger of the child, so an infant is very different than say a teenager with
TB.
So I would say the more adult type symptoms, which are fever, weight loss, hemoptysis,
prolonged cough, night sweats, you do see that in the more, I would say teen to preteen
as to the age cutoff, like there's no hard minimum age for that.
So but if you get when you get into the infants, the big thing is, I would say to focus on
is the epi link or epi contact.
So when I see an infant and I'm thinking about TB, like who do they live with?
Who are they exposed to?
Do they fall into one of the risk groups that we know has a higher incidence in Canada?
So again, recently immigrated to Canada from a high burden country or one of our Indigenous
populations again, not all are affected equally in Canada and definitely it depends which
region you're from.
So when I think of the epi link, then again, we also use the TST or the I-GRAA depending
on the age.
Again, it's not to diagnose TB disease.
So TB, when you're sick with TB, it's for TB infection.
So when we're using that in terms of making a diagnosis of active TB in somebody, again,
it doesn't tell me about TB disease, it tells me about immune response to tuberculosis antigens.
So then if my immune system or their immune system is responding, therefore that implies
exposure, therefore that implies risk.
And that's how I like to think about it.
So once those two things are thought about, then you move on to like clinical signs and
symptoms.
And again, I see a lot of kids with just Hyalur disease or perihyalur disease, mediastinal
disease I should say.
So lymph nodes in the chest, which is very classic of pediatric TB.
And actually a lot of times they're minimally symptomatic.
But again, you have to think about other things that cause that.
And so if you have that epi link, that to me is a diagnosis.
I would say a child who's more sick.
So you always ask about the TB symptoms, but you start getting into things like lethargy
and irritability.
And so weight loss or not interested in feeding, but not for short periods of time, for long
periods of time, like weeks.
And that's often what I hear when they're quite sick and you see the x-ray and you're
like, whoa, okay.
Yeah.
Okay.
Yeah.
So definitely a different presentation there.
And then in terms of, so obviously that's a little bit of touching on the clinical presentation
now kind of walking through.
You have that clinical presentation, talked a little bit about the TST and IGRA.
I know in the recent guideline, it was mentioned kind of the age group cutoffs, because I get
this a lot in my practice where everybody will ask, you know, like, what should I send
both?
Should I be sending TST and IGRA both or what should be really be telling experts out there?
Yeah.
So I would say amongst our group in our chapter, so the pediatric clinicians, lots and lots
of discussion around the IGRA and the minimum age range.
And so previous to this minimum age range, generally, you know, amongst my colleagues
was five years.
So five years and up for the IGRA.
And the reason for that is the immune system hasn't adequately developed.
And as to when it's adequately developed within the first five years, that's hard to say,
but you know, a chance of a false negative.
But there has been more evidence recently.
And there's a really nice, I think it's a table in the chapter talking about some of
the studies where they use some large cohorts and some like better evidence, I would say,
I'm not sure if it's the best, best evidence, but that the IGRA can be used in lower age
groups than five.
So pushing it down to around two is where we're at with that.
So I would say, you know, for sure down to age five, for sure down to age two, with some
caveats again, if you're an abnormal immune system, maybe not.
I don't think you necessarily need to do both, but I would say I would use it as well.
Consider more strongly using it in those who are BCG vaccinated.
Again, the TST obviously reacts to that.
So again, that's really also an emphasis, so BCG vaccinated should try and get an IGRA.
Not the end of the world if you have a TST, again, there's really good reasons to use
a TST.
Remote settings, because often IGRA is not even available outside of bigger centers.
So again, you know, TST is just fine and a good contact history and symptom history is
also what you need.
Okay.
And then just touching a little bit more on the workup.
And then the real area I want to talk about is the management, because I think a lot of
the updates are around there.
So in terms of, so do you want to just walk us through maybe, so we have a patient who
we're thinking we're suspecting TB, you know, we would do the initial workup.
So let's say it was somebody that you had high suspicion from clinical findings.
And so obviously as part of that, we talked about sending some of the diagnostic testing
as well, like taking IGRA.
And then what are some of the additional management criteria that we should be using?
So obviously initially it's a chest x-ray as well.
And really like TB clinicians who spend all their time doing TB are so anal about this
and I am so anal about this, is it's a good quality chest x-ray.
So you want to get the, that is one of your best tools.
And so because you're looking at the media stinum, you really need to have a great straight
on view, good inspiration, good penetration, any twisting or anything like that, again,
really affects what you're seeing.
And again, I've seen a kid who had a bad x-ray, bad quality as we would label it or how it's
known.
And then we brought them in, redid it.
Clearly TB disease.
So again, really want to emphasize the importance of that and the importance of a good one.
So there's that.
And again, because usually it's going to be pulmonary is the most common thing.
So that's where you start.
But again, you know, dictated on signs and symptoms.
So certainly if there are signs and symptoms outside of the respiratory system, obviously
imaging for that.
And then sputum.
But most of the time our kids can't cough on command like an adult.
So we use different ways to do it.
So I would say gastric are really popular around Manitoba and because we also blast
mycosis here.
So we use it for that.
And so we send gastric aspirates after a period of being a fasting, I would say probably four
hours or more.
Fasting in the morning is ideal, but I wouldn't necessarily admit someone to hospital just
to do it or a prolonged hospitalization just to do it.
And so send those for AFB PCR if it's available at least once, which we also really want.
We talk about that a little bit.
And that's talked about as well in the adult chapters.
And then obviously smears and cultures as well for AFB.
And the gold standard again is usually an AFB culture or MTB complex on culture or,
you know, PCR as well.
Positive PCR with compatible symptoms is also very appropriate.
We also do touch upon a technique used in more lower resource settings of getting sputum
induction on even on young kids.
And I think that probably relies on the experience of the nursing staff or the RT or whoever
is going to do it.
Because again, it has to be a good sample.
So you can do it on babies.
They do it in South Africa and India on babies.
So again, it depends on what you have and what resources you have.
But again, you can do it.
So you know, if you have that and that's all you have, do it.
Again, some sputum is better than none.
But you know, a lot of this, a lot of pediatric TB is, again, as a lot of you may know, is
a clinical diagnosis.
Again, we're really unlikely to have a positive smear culture.
So again, it's just a gestalt and epihistory.
And again, other surrogates like the TST or IGRA to make the diagnosis.
And I'm actually glad that you brought that up because there's a lot of times, I mean,
obviously dealing with like being an infectious disease specialist myself, there's a lot of
times when there's multiple things on your differential.
And I think reminding kind of the listeners as well, but what I do in my clinical practice
as well is to remind them that like a negative culture or a negative smear doesn't rule it
out.
Yes, definitely.
And that's a huge thing because...
Oh, and that's like, if you know, it's hard for sometimes I think that's challenging for
people to wrap their head around even, you know, here in our hospital.
Yeah.
Serial, serial follow up is actually super useful too.
So if again, you're not sure the kid's healthy, there's minimal disease or whatever is going
on in the chest, a follow up four weeks later, that's okay.
As long as they have a reliable caregiver.
Sometimes when I'm really on the fence, because again, treating someone for TB and especially
young children is a very big deal.
It's a lot of investment and resources.
And so really good short-term follow up again, can sometimes help clarify things with another
X-ray.
And again, if it's TB, it's going to be there.
So yeah, that's the approach I use when I'm on the fence.
That's good.
Yeah.
Serial follow ups.
I think that's really important to kind of reiterate too.
So, okay.
So I think in terms of our listeners should have like a bit of a grasp on, you know, because
there hasn't been too many changes around that.
I know that there's in the guidelines, more comments on age groups and cutoffs and volumes
and that type of thing.
So I think that's something that we can all refresh our knowledge about.
I think the area that was, I think, very, I guess, intriguing for me was where the guidelines
kind of emphasize more talking about, first of all, just like drug susceptible TB.
And so maybe we can talk a little bit about things that have changed in the pediatric
world as well, but also in the adult world with LTBI.
So TB infection management.
So maybe what's the most common regimen you can touch on that?
Yeah.
You know, and so that's actually a really great point you brought up.
I would say the most changes in terms of treatment in the standards is around TB infection and
even the name TB infection is different from latent TB infection.
Just because I think we, you know, could talk about this longer.
But again, TB infection is actually like a broad spectrum of things that we don't understand.
So again, that concept itself is changing.
And so really, I mean, globally, I think lots of low and middle income countries are actually
farther ahead than we are on because they have better drug access.
That's just simply because again, there's a bigger market.
But really what we're the focus in children and adults is the rifamysin-based regimens.
So anything with a riff in it is better than INH itself.
And purely better, it's not that it's like there's an efficacy difference.
It's that in the real world, people are more likely to finish a shorter regimen and rifamysin-based
regimens are definitely associated with less side effects than traditional kind of longer
INH regimens.
So people like that.
So that gets us into the two ones that are spoken about, which is the 3-HP regimen.
So that's the three months of high dose isoniazidine and rifapentine.
So once a week, 12 weeks.
And then there's the 4-R regimen, which is four months of daily rifampin, which again,
because it's daily, it's considered reasonable to have that done self-administered.
So again, in resource limited settings for whatever reason, there's no DOT worker to
monitor intermittent therapy.
So therapy that's not every day.
Then 4-R or daily rifampin is totally acceptable and has better completion rates than INH or
9-INH, nine months of isoniazid.
3-HP is where it's at.
So if you're over the age of two, and obviously there's no drug interactions or anything like
that, again, that's also a limitation of using rifamycin based therapy is lots of drug-drug
interactions.
So you have to be careful with that.
But again, that's 12 weeks of once a week is 12 doses total versus 4-R is 120 doses.
So completion is great, but rifapentine is not available everywhere yet.
It's considered special access by Health Canada, but we've been lucky here in Manitoba.
And I know what the Nunavutab app had access to it.
So I use it whenever it's appropriate.
That's good to hear.
Perfect.
It's great.
And then going into more, I guess, management of TB disease.
So are there any recent updates in terms of management change?
I know that there's definition changes or there's like addition of definitions for resistant
TB.
Yeah.
I would say the big thing to focus on because DRTB or drug-resistant TB is very small proportion.
And I would say that encourage anyone again, who's dealing with someone who has the possibility
of having that or has that to reach out to their tertiary care center, because it's very
complex management, side effect wise, prolonged therapy.
So again, I wouldn't do that on one's own.
So in terms of drugs susceptible TB, obviously susceptible to all first line drugs, just
isoniazid, rifampin, paracetamide, ethambutol.
So really what is being spoken about mostly is the standard six month regimen, which again,
hasn't really changed that much.
So you have the two months of the four drugs and then four months of two drugs.
And then again, what's being brought up is to being a little bit more, I guess, less
paternalistic about DOT, so directly observed therapy.
It's felt, I think in some jurisdictions to be really restrictive to people and maybe
even bordering on infringement of their rights.
And so, you know, I think people are trying to back away from that and think about it
more as treatment support, actually.
So people that are going to like, I know some families that want help, and I know some families
that are just fine.
So it has to be obviously a discussion and good follow up to make sure that those who
can like give them a bit more freedom.
And they do mention that daily therapy is preferred over intermittent.
There is some discussion about that, at least in the adult disease chapter.
But what's really exciting, and I forget if this was included or not, is there are studies
out there like clinical trials looking at even shorter than six months now.
So there's study 31, which is a rifapentine based treatment that looked at four months
of treatment.
And then there's the Shine trial in pediatrics that looked at four months as well for minimal
disease.
We're not there yet to prescribe it, you know, broadly, but it's, you know, people are working
on this because again, we recognize that some people don't need six months, but we have
to figure out who those are and what the right drugs are.
Right.
Yeah, no, that's fair.
So I think yeah, most of these kind of conventional treatments or standard treatments that we've
used for a long, long time haven't changed much.
But there definitely was mention about kind of our second line agents or agents when we
are dealing with drug resistance.
Now, obviously, in terms of everything we talk about today, even if we are clinicians,
it's not medical advice and it doesn't, you know, it's really for discussion purposes
and knowledge purposes.
But touching on kind of what availability.
So I mean, some of them are very available, like for a point of loans, for instance, we
all have access to those.
Are there certain drugs that are a little bit more difficult to access for second line
that we should be aware of that, you know, we should be thinking about ordering sooner?
Yeah.
So, you know, that gets really complicated.
It's a complicated question here and again, I don't have any.
I've only had my mono resistance in my practice here.
Meaning I said, I said, or a famine or pure cinnamide.
So we're not getting into the second line agents there really.
But definitely, at least here, things like the laminated and bedaquiline or special access
only, but they're great drugs.
They're oral.
It's unfortunate.
The availability is is what it is.
But I would say in terms of choosing regimens, go to WHO's great publication and update on
what is considered good regimens based on the group the medications fall in.
So that's group A, group B, group C. Right.
And they do touch on that in the in the standards.
And I would also say, I don't know if we can readily accomplish this yet.
It depends probably on jurisdiction and drug availability is we are trying to get away
from amino glycosides or injectable.
That's really being pushed globally as all oral regimens for drug resistant TB.
Because again, amino glycosides are super toxic and and, you know, people have hearing
loss from them.
And you know, it's a really tragic thing.
And so again, that's really being discouraged globally.
I think in some circumstances, we do have to use them because they work simply because
we don't have access to all the other oral agents that other countries do.
So yeah.
So talking about your practice, then with like the mono resistant.
So if you have a patient who's like isoniazid resistant, like obviously, we just talked
about the regimen having those four drugs and then the duration.
So what how does that change kind of?
Yeah, so it changes agents and it changes like so you can't use isoniazid then and it
also changes duration.
But again, it depends on which drug you drop.
And again, they do talk about I believe they talk about mono resistance and different treatment
strategies.
And that's definitely super widely available in the literature.
And you know, often you have to go to nine months, even if it's pulmonary.
Again, and also depends on how extensive the disease is as well.
Right.
Which again, more extensive, more prolonged.
But again, there's lots of great resources out there for mono resistant TB like the Curry
Center as well as a great resource from the US.
They do really great education out of San Francisco and lots of their stuff's available
online.
That's really good.
And then in terms of since you see TB and you manage these patients, what intervals
are we looking at, for instance, like side effect monitoring and that type of thing?
Maybe we can touch a little bit about that.
Yeah.
I mean, so I'm not going to be prescriptive myself about that.
But I would say follow the standards.
And I would say generally speaking, because I do a lot of remote medicine and things are
simply just not available.
I can't do it.
But I would say children, teenagers really don't need a lot of blood work, if any at
all after kind of the first bit, if they do not have side effects.
It's a little bit different in adults with comorbidities on medications or hepatitis
or whatever, where you're worried about liver toxicity, which is the big, big thing you
worry about with three of the first line agents.
So again, we really don't do a lot of blood work regularly.
But I would say really it's important in terms of monitoring is just talking to the patient
about side effects and talking to them about things like signs of early hepatitis, which
again is the thing that's going to kill someone.
And again, knowing which agents to pull off and how to pull things off and how to reintroduce
things is, again, I touched on in lots of different resources.
So I would say it's key to ask about side effects in early nausea, early vomiting that's
persistent is hepatitis, until proven otherwise and jaundice, you've missed the boat.
So I always get a little bit at least that was what was always emphasized to me when
I was in Cape Town is any nausea and any vomiting that's again prolonged beyond 24 hours, you
really need to think about hepatitis.
So yeah, that's good.
Yeah, good point there for sure.
All right.
So yeah, I think we've touched on a lot of kind of the key points in the guideline.
I did see that there was some mention of I mean, you mentioned one of the trials, but
future.
So what is the future of TB prevention and treatment in Canada?
Is there something that is coming soon or anything that you'd like for our audience
to kind of be aware of?
Yeah, so I would say the couple of things we didn't touch on, which are kind of are
really kind of quite big, actually, which, you know, maybe those outside of our TB world
don't don't think they're that big.
But you know, they're things we've done for a long time that have changed.
So not in the treatment for adult chapter, that there's no max to refampin anymore.
Also, they make some BMI caveats in there.
But again, we probably really under dose people on refampin.
And so 600 daily shouldn't be the cutoff as to an absolute max.
Don't know, but they've been doing some really interesting things published that, you know,
with people with TB meningitis or extensive disease, like pushing it way beyond 10 milligrams
per kilogram, and people really tolerating it fairly well.
Based on, you know, monitoring blood levels and things like that.
So that's a really big change.
It's such an important drug.
So again, I would say, maybe that's actually more on the horizon, maybe we'll see even
greater dosing for that.
And I would say the other thing that's really, I think, was really important in this that
people talked a lot about was de isolation.
And at least that's a hot topic, I know, in Alberta, as well as in Manitoba.
Right.
And not being so restrictive about keeping people in for two or three weeks.
Again, we know that's horrible for people to go through, especially if they're from
a remote community and have to be brought somewhere else, away from family members,
you know, people who have jobs they need to go to.
Because again, there's lots of evidence out there that once you're on a regimen that
works for your TB, you're responding to it, you become non infectious actually, quite
quickly.
And so there's really nice review on that at the end of the standards.
I'm not going to make any recommendations on de isolation, because that's definitely
very controversial.
Yes.
But really controversial, but I would say give it some, you know, amongst public health
authorities out there, you know, consider, consider being less restrictive about it based
on smear status response, and responding and taking appropriate therapy.
So again, if you have to be drug susceptible, and on that therapy to respond, if you're
someone with drug resistant TB, you know, this is not this conversation probably doesn't
apply.
Right.
And again, for drugs susceptible TB, certainly, I think we can look at that and hopefully
make more progress on that in the future.
And I would say on the horizon, maybe not for like, I would say in terms of like, look
out for shorter course regimens, like as I mentioned before, I think definitely there's
lots of work being done on it globally.
So maybe maybe that's the future, but we'll have to see certainly.
And again, I think it's probably what's going to happen is you're going to probably stratify,
if I had to predict based on extent of disease will dictate length of treatment, how we do
that, I don't know yet, but maybe a more stratified approach is what's coming.
So
Okay.
And then currently, I guess, one of the things I wanted to ask just for my personal knowledge
as well, is there a database that's like look like, you know, nationally that we're following
or they're currently, are there Canadian trials that are currently on the way?
Yeah, I'm not up on that.
Well, I do know like Dick Menzies does a lot out of Montreal does a lot.
His main interest is TB infections.
So I imagine there's stuff going on there.
He does a lot of global work as well.
I know there were some rifapentine, rifampin, LCBI trials in the past.
I don't know if there's anything ongoing now.
But yeah, lots of stuff done.
But again, we're a low burden setting.
So it's our patient population is probably not a good bang for your buck.
So but I know lots of these people are on India and other places in the world doing
work on these types of things.
Yeah, that's there.
All right.
Perfect.
So before we kind of let the audience go here to is there anything else key in the guidelines
that we should be looking at as clinicians or key take home points, something that you're
dying to tell us that we should know for sure about TB?
Yeah, what what if I had to say something?
That's a good question.
I actually hadn't like totally thought about it.
That question specifically.
Yeah, so I would say
Well, pediatric TB always requires a high index of suspicion.
And again, your history is crucial.
And looking for signs outside of the classic adult signs are really what's key.
And I would say for you know, I think a lot of people felt very strongly about is that
TB is more than just TB disease, and the families we see is more than just the medical treatment.
There's a lot of other social issues that go along with it.
You know, housing and food insecurity and and things that have to be addressed.
And you know, all of us would love to have a social worker as well.
All of us would have loved to have better access to all of these drugs being used in
other places in the world.
So just an appeal to anyone who's listening, more money, more availability.
And again, I think that's probably the state of TB in the world in general.
It's a huge problem.
Maybe not as much in Canada, but still requires a lot of time and a lot of money to if we
want to eliminate it.
So yeah, I think that's what I that's that's my message.
That's really great.
I mean, it's always nice to hear from somebody who's kind of managing TB daily, you know,
like even though a lot of us listeners are clinicians or pharmacists and nurses that
are seeing TB, you know, there's there's many angles to this.
And yeah, it's it's definitely just beyond the physician and the nurse.
There's people giving people meds in the community that do such grueling work and find patients
who are hard to find and and, you know, public health, public health is also a key ally.
Speak to them all the time.
And again, you know, implementing our programs and things like that.
So it's a vast network of people just beyond me that deal with the patients that I see.
So, you know, very thankful again, as well, all the people who just really love to work
in this in this area and do so much so for so so very little, actually.
So I think it's also very helpful.
I mean, we're really grateful for yourself as well, like authors like you that have been
able to kind of change up guidelines, current guidelines and updates for us, because obviously
if we're not seeing TB cases as often, we're not really familiar with the current practice.
Yeah, exactly.
It's all about.
It's all about volume.
As I say, like you just like anything in infectious diseases, once you see it 10 times, it looks
like that.
Yeah.
But you know what?
You know, I also want to put a shout out out there.
That's very nice and generous of you for the thanks.
But to Ian Katai and Dick Menzies as well.
They're out there in the world.
But we're very I was very fortunate to be given this opportunity.
And it was a collaborative effort.
I learned so much.
And these are experts and wonderful people.
So again, you know, always phone a friend if they know more than you.
I do that for other things.
So I'm always happy to provide advice as well.
That's great.
Yeah, yeah, there's been multiple times I've been in touch with you.
So it's great.
Anytime.
I love to talk about it and other things too.
But yeah, yeah.
So I think reiterating that the TB standards are the reason I wanted to do this episode
was just remind everyone that there are updated guidelines and those standards.
And again, and again, it's meant to be an accessible document, right?
It's not meant to be a super scientific thing.
So again, that was the as I think we spoke about before, that was the main goal.
It landed up being much larger because everything was so important to all of us.
So I hope I hope it's useful to people I really do.
And that people use it and give good care to these patients.
Awesome.
Yeah.
And there's actually a lot of information about kind of drug resistant TB in there.
I know some of our listeners had asked for some elaboration in there.
But I think the guidelines actually after reviewing them are fairly straightforward
there and then remembering that reach out to your experts.
Yeah, I would say yeah, you know, even in places like South Africa, I'm on a group talking
about some pregnancy and newborn stuff like, yeah, if you're on the community, this is
you should not be managing that alone.
It's complicated.
It depends what's available.
And there's usually someone within your network that that does this and you should reach out
to them and not be afraid to.
I know I know certainly that's at least the philosophy with the people I learned from.
So again, you know, you're not alone out there.
So again, and all of us again, it's all TB is a team and a collaborative effort.
So none of us minds, I think.
So I would reach out.
Awesome.
Perfect.
Well, thank you so much, Dr. Rachel or Dr. Dwillow.
Just Rachel.
Yeah, no problem.
Thanks for having me and listening.
Yeah, it was awesome.
All right.
Thanks.
Take care.
Thank you, Dr. Dwillow for joining us.
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