Linked with HIV, TB still a crisis despite cure

Friday January 24 2014

Resurgence of tuberculosis in Africa blamed on its link with HIV infection. TEA Graphic

Resurgence of tuberculosis in Africa blamed on its link with HIV infection. TEA Graphic 

By PAUL REDFERN Special Correspondent

More than half a decade since a cure was found, TB remains a public menace across the East African region as health officials grapple with its links with HIV and the need to tackle increasing numbers of people suffering from the drug-resistant strains of the disease.

Uganda, Kenya, Tanzania and Ethiopia all remain among the 22 “high burden” countries listed by the World Health Organisation — countries where new TB cases per year are above 100 cases per 100,000.

In Ethiopia and Kenya the rates are particularly high at around 210 and 130 respectively. TB kills up to 21,000 people a year in Ethiopia, 15,000 in Kenya, 12,000 in Uganda and 10,000 in Tanzania.

Rates are falling, albeit slowly and it is only recently — particularly in Kenya — that efforts have been made to really tackle the disease. Before 2007 few countries had implemented nationwide prevalence surveys to try and find out the extent of the problem.

This was because up until the beginning of the new millennium the problem of TB in Africa attracted little attention.

Part of the reason was that TB incidence was relatively low and appeared to be falling in most parts of the continent. Since that time the burden of TB in sub-Saharan Africa has grown.

Continuing poverty and political instability in parts of the continent have inhibited progress in implementing effective TB control measures. But the principal reason for the resurgence of TB in Africa is not the deterioration of control programmes. Rather, it is the link between TB and the human immunodeficiency virus (HIV).

The reason so many people with HIV are so vulnerable is because people whose immune systems are compromised are more likely to succumb to TB.

The result of this realisation is a series of prevalence surveys in sub-Saharan Africa over the past 18 months including in Tanzania and Rwanda to ascertain the extent of the problem.

TB is a disease of poverty, mainly affecting young adults in their most productive years.

The statistics are alarming. In 2012, 8.6 million people fell ill with TB and 1.3 million died from TB worldwide. Over 95 per cent of TB deaths occur in low- and middle-income countries, and it is among the top three causes of death for women aged 15 to 44.

East Africa is beset with co-infection of TB and HIV. Around 45,000 people are HIV positive and living with TB in Kenya, 35,000 in Uganda, 32,000 in Tanzania and 23,000 in Ethiopia.

Overall Africa accounts for 75 per cent of TB cases among people living with HIV world-wide. The region also suffers from increasing numbers of what is termed (multi-drug resistant) MDR-TB.

People mainly succumb to MDR TB when they do not complete their prescribed period of drug treatment for TB, either because they feel better after a period of time or because of inadequate monitoring. Both MDR-TB and regular TB in Aids patients need specialised laboratories for diagnosis and treatment which is not available in many parts of the region.

As a result, in May 2010, the World Bank-supported the East Africa Public Health Laboratory Networking Project which provides a network of high-quality public health laboratories to improve access to TB diagnostic services among vulnerable populations living in the cross-border areas of Kenya, Tanzania, Uganda, and Rwanda.

In 2012, Burundi was added to the project, funded by an additional $15 million from the IDA wing of the World Bank.

The high prevalence of TB cases in Kenya has prompted the government and donors to turn to a new social model in an effort to tackle the disease. It has deployed 6,000 volunteers to scout for possible tuberculosis patients across the country offering them free drugs therapy.

The programme has one volunteer monitoring 20 households. To aid the volunteers, Nairobi has invested in Gene Xpert Machines to establish diagnosis centres in as many parts of the country as possible.

“When volunteers suspect a TB case, they approach the person and offer education on the next steps to be made, which is testing,” Dr Joseph Sitienei, the head of the Division of Leprosy, Tuberculosis and Lung Diseases at the Ministry of Health in Kenya, told The EastAfrican recently.

After diagnosis, the patient is assigned to a community health worker or a volunteer to monitor the taking of drugs and response in a model known as DOTS, the WHO-recommended “Directly Observed Treatment Strategy.”

The aim of the project is to ensure that TB patients get the best social support available, which will help them tackle the stigma that is associated with TB. The model will be replicated in other TB high-burden countries like Tanzania and Uganda.

The programme has proved a success as new cases of TB in Kenya dropped from 116,000 in 2007 to 99,152 in 2012, in the wake of improved access to free testing services.

Kenya has also started an innovative electronic system to support its surveillance and management of TB Called “Tibu,” which means “treat” in Swahili.

This system makes use of Kenya’s extensive mobile communications network to make payments to MDR-TB patients through M-pesa. The system is also used to manage drug supplies and laboratory data and store details about individual patients.

Dr Sitienei said the model adopted by Kenya had enabled the country to move from position 13 to 15 of the league of 22 high-burden TB countries that account for 89 per cent of all TB cases in the world.

In Uganda, a slightly different model of community volunteers is being used by the Kampala-based International Medical Foundation.

It uses Village Health Teams (VHTs) as the first point of contact with the community. They are key to the success of projects such as the TB Lira project, being implemented by IMF through the funding of the UK-based NGO Target Tuberculosis by UK aid.

The aim of the project is to provide outreach prevention, testing and TB treatment services to low-income, slum dwelling communities of Lira District, Northern Uganda.

A total of 32,515 people were beneficiaries in 2012: 1,821 benefitted directly and 30,694 indirectly through health education activities.

IMF says the Village Health Teams have contributed to strengthening of the whole Ugandan health system.

So why is TB such a menace?

TB is mainly a disease of poverty – around one-third of people worldwide have the bacteria in their systems – but only develop the symptoms when their immune systems become weakened. It is spread through the air from person to person and is usually fatal if not treated.

Most TB is pulmonary TB, found in the lungs and diagnosed with a sputum test but TB is also found in other parts of the body such as the kidneys, bones and joints (skeletal TB), the digestive system (gastrointestinal TB), the bladder and reproductive system (genitourinary TB) and the nervous system (central nervous system TB). These types of TB are harder to detect.

TB is the second biggest infectious disease killer worldwide behind only HIV/Aids. It also causes many of the current HIV/Aids related deaths. The fact that the rates remain so high when there is a cure and treatment remains an international scandal that few hear about.

Target TB chief executive Wendy Darby said: “While TB rates have seen a slight decline globally over the past few years nearly 1.5 million people still die each year and an estimated 3 million go undetected. This is an unacceptable situation in the 21st century.”

People with weakened immune systems, with HIV/Aids, fighting malaria or in children under five, are at a greater risk because when they breathe in TB bacteria, it settles in their lungs and starts growing and they cannot fight it off.

These are the people Target TB concentrates on through its partner organisations in Uganda, Zambia, Malawi and South Africa. The organisation is hoping to expand its activities into Kenya in the near future.

In over 90 per cent of patients, tuberculosis can be cured with appropriate treatment, which consists of taking several different antibiotic drugs for 6 to 12 months.

However, a tuberculosis cure relies on close cooperation between the patient and doctor in order to make sure that the right amount of medicine is taken for the right amount of time. This support is not always available.