Doris Obinna
Tuberculosis (TB) is the world’s top infectious killer today. It is airborne and can affect any of us. Over 5,000 women, men and children still die each day from TB. The social and economic impacts are devastating, including poverty, stigma and discrimination. This disease is curable and preventable, yet global actions and investments fall far short of those needed to end the global TB epidemic.
TB is caused by bacteria mycobacterium tuberculosis (MTB) and is the most potentially serious infectious disease that often affects the lungs. Tuberculosis is curable and preventable. The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes.
Once rare in developed countries, tuberculosis infections began increasing in 1985, partly because of the emergence of HIV, the virus that causes AIDS. HIV weakens a person’s immune system so it can’t fight the TB germs.
In the United States, because of stronger control programmes, tuberculosis began to decrease again in 1993, but remains a concern.
Many strains of tuberculosis resist the drugs most used to treat the disease. People with active tuberculosis must take several types of medications for many months to eradicate the infection and prevent development of antibiotic resistance.
A survivor who has experienced the side effects of TB medication, the difficulties of undergoing treatment, the mental and psychological impact, and wants to raise awareness about this disease, including the importance of getting tested and adhering to treatment, is Oluwafunke Dosumu.
Narrating her ordeal, Dosumu said, “I am a mother, a health educator, I survived tuberculosis in 2015.”
According to Dosumu, it all started on February 28, 2015. “I started coughing and assumed it was a minor cough and was treating it as such. After two weeks of minor treatments, the cough persisted, so I visited the hospital for check-ups. Immediately, I was told to run some tests and when I got the results, I was told it was TB, a disease that affects the lungs.
“At first, I was scared and shocked that I had TB, but later I summoned the courage to go through every bit of the process, positive that I would definitely come out of it. I was placed on anti-TB drugs, which I had to take every day for six months.
“During the process, I lost a lot of weight due to loss of appetite; night sweats as well as fever and chest pain. I was also isolated from my immediate environment, family and children for some months to face my health squarely and prevent the disease from spreading.”
While her experience has turned her into a TB champion and advocate who works with communities to prevent stigmatisation of TB patients, she has called on the Federal Government to strengthen collaboration with partners to end the spread of the disease in Nigeria.
An estimated 418,000 new TB cases occurred in Nigeria in 2018 while 106,533 cases (25 per cent) of TB were notified in 2018, leaving a gap of 314,712 and 319,599 cases that are yet to be notified, respectively.
According to experts, tuberculosis generally affects the lungs, but can also affect other parts of the body. Most infections do not have symptoms, in which case it is known as latent tuberculosis. TB is spread from person to person through the air.
“When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected. About one-quarter of the world’s population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease.”
According to World Health Organisation (WHO), TB remains the world’s deadliest infectious killer and one of the top 10 causes of death worldwide. Each day, nearly 4,500 people lose their lives to TB and close to 30,000 people fall ill with this preventable and curable disease. Global efforts to combat TB have saved an estimated 54 million lives since the year 2000 and reduced the TB mortality rate by 42 per cent. To accelerate the TB response in countries to reach targets; Heads of State came together and made strong commitments to end TB at the first-ever UN High Level Meeting in September 2018.
It is estimated by the WHO that 30,000 children get TB in Nigeria each year. There are also 47,000 children that are eligible to receive preventative treatment that would help to prevent them from getting TB. However, only about 8,500 children actually receive this preventative treatment.
Nigeria has, however, started to use the new TB treatment for children. This is the treatment that is both dispersible and flavoured and so it makes it much easier for children to take.
New data on tuberculosis trends in 202 countries
The 2019 edition of the global TB report was released on October 17, 2019. The global TB report provides a comprehensive and up-to-date assessment of the TB epidemic, and progress in the response, at global, regional and country levels.
The report includes trends in TB incidence and mortality, data on case detection and treatment results for TB, multidrug-resistant TB (MDR-TB), TB/HIV, TB prevention, universal health coverage as well as financing. It presents progress towards targets set at the first-ever United Nations General Assembly high-level meeting on TB in 2018, that brought together heads of state, as well as the targets of the WHO end TB strategy and the Sustainable Development Goals (SDG).
The report also includes an overview of pipelines for new TB diagnostics, drugs and vaccines. Additionally, it outlines a monitoring framework that features data on SDG indicators that can be used to identify key influences on the TB epidemic at national level and inform the multi-sectoral actions required to end the TB epidemic.
Key facts
Tuberculosis (TB) is one of the top 10 causes of death worldwide.
In 2018, 10 million people fell ill with TB, and 1.5 million died from the disease (including 251 000 among people with HIV).
TB is a leading killer of HIV-positive people.
In 2018, an estimated 1.1 million children became ill with TB and 251 000 children died of TB (including children with HIV associated TB).
Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. WHO estimates that there were 484 000 new cases with resistance to rifampicin – the most effective first-line drug, of which 78 per cent had MDR-TB.
Globally, TB incidence is falling at about 2per cent per year. This needs to accelerate to a 4-5 per cent annual decline to reach the 2020 milestones of the ‘End TB Strategy.’
An estimated 58 million lives were saved through TB diagnosis and treatment between 2000 and 2018.
Ending the TB epidemic by 2030 is among the health targets of the SDGs.
About one-quarter of the world’s population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease.
People infected with TB bacteria have a 5-15 per cent lifetime risk of falling ill with TB. Persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a higher risk of falling ill.
Explaining the global health issue, the WHO Country Representative in Nigeria, Dr Wondimagegnehu Alemu, said the burden of the disease in Nigeria is further fuelled by huge number of undetected TB cases, which serves as a pool of reservoir for the continuous transmission of the disease, as each undetected case has the potential of infecting 10 to 15 persons in a year.
Alemu said Nigeria is among the 10 countries that accounted for 64 per cent of the global gap in missing TB cases, adding that even though the federal and state governments were working to bring TB under control, Nigeria should strengthen its efforts to address the challenges by finding the remaining 300,000 cases, which are still missed by the health sector; expand quality TB diagnostic coverage nationwide; optimisation of the existing gene Xpert diagnostic machines (390) and adding more; and increase awareness of general public about TB so that they report to health facilities of suspecting signs.
Causes
According to an expert, Dr. Michael Iseman of National Jewish Health, tuberculosis is caused by a bacterium known as mycobacterium tuberculosis. (The related bacteria Mycobacterium bovis and Mycobacterium africanum can also cause tuberculosis).
According to him, “the body’s response to active TB infection produces inflammation that can damage the lungs. Areas affected by active TB gradually fill with scar tissue. TB is a contagious or infectious disease. It is spread from person-to-person. A person is often infected by inhaling the germs. These germs have been sprayed into the air by someone with the active disease who coughs.
“However, inhaling the germ does not mean you will develop active disease. A person’s natural body defences are often able to control the infection so that it does not cause disease. In this case, the person would be infected, but does not have active disease. Only about 10 per cent of those infected will develop TB in their lifetimes.
“Active disease can occur in an infected person when the body’s resistance is low or if there is a large or prolonged exposure to the germs that overcome the body’s natural defenses. The body’s response to active TB infection produces inflammation that can damage the lungs. The amount of damage may be quite extensive even though the symptoms may be minimal.
“TB is contagious, but it is not easy to catch. The chances of catching TB from someone you live or work with are much higher than from a stranger. Most people with active TB who have received appropriate treatment for at least two weeks are no longer contagious. Since antibiotics began to be used to fight TB, some strains have become resistant to drugs. Multidrug-resistant TB (MDR-TB) arises when an antibiotic fails to kill all of the bacteria, with the surviving bacteria developing resistance to that antibiotic and often others at the same time.”
Symptoms and diagnosis
According to Center for Disease Control and Prevention (CDC), the symptoms of TB disease include, feeling sick or weak, loss of appetite and weight loss, chills, fever, and night sweats, a severe cough that lasts for three weeks or more and chest pain.
TB can also affect other parts of the body. Symptoms will depend on the part it affects.
Common symptoms of active lung TB are cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats. Many countries still rely on a long-used method called sputum smear microscopy to diagnose TB.
Trained laboratory technicians look at sputum samples under a microscope to see if TB bacteria are present. Microscopy detects only half the number of TB cases and cannot detect drug-resistance.
According to an expert, the use of the rap- id test Xpert MTB/RIF has expanded sub- stantially since 2010, when WHO first recommended its use. The test simultaneously detects TB and resistance to rifampicin, the most important TB medicine.
Diagnosis can be made within 2 hours and the test is now recommended by WHO as the initial diagnos- tic test in all persons with signs and symptoms of TB.
Diagnosing multi-drug resistant and extensively drug-resistant TB as well as HIV-associated TB can be complex and expensive. In 2016, four new diagnostic tests were recommended by WHO, a rapid molecular test to detect TB at peripheral health centres, where Xpert MTB/RIF cannot be used, and three tests to detect resistance to first- and second-line TB medicines.
“Tuberculosis is particularly difficult to diagnose in children and as yet only the Xpert MTB/RIF assay is generally available to assist with the diagnosis of paediatric TB,” says an expert.
Treatment
TB is a treatable and curable disease. Active, drug- susceptible TB disease is treated with a standard six month course of four antimicrobial drugs that are provided with information, supervision and support to the patient by a health worker or trained volunteer. Without such support, treatment adherence can be difficult and the disease can spread. The vast majority of TB cases can be cured when medicines are provided and taken properly.
Between 2000 and 2017, an estimated 54 million lives were saved through TB diagnosis and treatment.
A study reveals that the major historical landmarks of tuberculosis therapy include: the discovery of effective medications (streptomycin and para-aminosalicylic acid) in 1944; the revelation of (triple therapy) (streptomycin, para-aminosalicylic acid and isoniazid) in 1952, which assured cure; recognition in the 1970s that isoniazid.
Prevention and management
A few general measures can be taken to prevent the spread of active TB, according to experts. Avoiding other people, by not going to school or work, or sleep- ing in the same room as someone, will help to minimise the risk of germs from reaching anyone else.
Wearing a mask, covering the mouth, and ventilating rooms can also limit the spread of bacteria.
According to an expert, Samuel Olufunsho, improving the quality of TB and HIV services in the non-public sector through the use of the internationally accredited SafeCare standards and International Standards for Tuberculosis Care (ISTC) is essential for the management of TB.
“While, increasing case finding through integration in the quality improvement approach and increase ac- cess to services and strengthening the role of the non- public/private sector to complement the public sector in improving TB and HIV prevention and care for TB.
Who is most at risk?
Tuberculosis mostly affects adults in their most productive years. However, all age groups are at risk. Over 95 per cent of cases and deaths are in developing countries.
People who are infected with HIV are 20 times more likely to develop active TB (see TB and HIV section below). The risk of active TB is also greater in persons suffering from other conditions that impair the immune system. People with under-nutrition are 3 times more at risk.
There were globally 2.3 million new TB cases in 2018 that were attributable to under-nutrition. 1.1 million children (0-14 years of age) fell ill with TB, and 230 000 children (including children with HIV associated TB) died from the disease in 2018.
Alcohol abuse and tobacco smoking increase the risk of TB disease by a factor of 3.3 and 1.6, respectively. In 2018, 0.83 million new TB cases were attributable worldwide to alcohol abuse and 0.86 million were attributable to smoking.
Global impact of TB
TB occurs in every part of the world. In 2018, the largest number of new TB cases occurred in the South-East Asia region, with 44 per cent of new cases, followed by the African region, with 24 per cent of new cases and the Western Pacific with 18 per cent.
In 2018, 87 per cent of new TB cases occurred in the 30 high TB burden countries. Eight countries accounted for two-thirds of the new TB cases: India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.