Doris Obinna
Wife of President Mohammadu Buhari recently declared that tuberculosis (TB), an infectious disease usually caused by Mycobacterium tuberculosis (MTB) bacteria, must be eradicated in Nigeria.
As the world marked World Tuberculosis (TB) Day on March 24, she said all hands must be on deck to tackle the dis- ease and totally eradicate it.
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.
People infected with TB bacteria have a 5–15 per cent lifetime risk of falling ill with TB. However, persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes or people who use tobacco, have a much higher risk of falling ill.
When a person develops active TB dis- ease, the symptoms (such as cough, fever, night sweats, or weight loss) may be mild for many months. This can lead to delays in seeking care, and results in transmission of the bacteria to others. People with active TB can infect 10–15 other people through close contact over the course of a year. Without proper treatment, 45 per cent of HIV-negative people with TB on average and nearly all HIV-positive people with TB will die.
According to World Health Organisation (WHO), TB remains the world’s deadliest infectious killer. 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 com- bat TB have saved an estimated 54 million lives since the year 2, 000 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.
Every March 24, each year the world commemorate World Tuberculosis (TB) to raise public awareness about the devastating health, social and economic consequences of TB, and to step up efforts to end the global TB epidemic.
The date marks the day, in 1882, when Dr. Robert Koch announced that he had discovered the bacterium that causes TB, which opened the way towards diagnosing and curing this disease. The theme for this year’s World TB Day, “It’s time,” puts the accent on the urgency to act on the commitments made by global leaders to: scale up access to prevention and treatment; build accountability; ensure sufficient and sustainable financing, including for research; promote an end to stigma and discrimination, and promote an equitable, rights-based and people-centered TB response.
WHO launched a joint initiative “Find. Treat. All. #EndTB,” with the Global Fund and stop TB partnership, with the aim of accelerating the TB response and ensuring access to care, in line with WHO’s overall drive towards Universal Health Coverage.
According to the Country Director (Challenge TB program) of KNCV, Dr. Bassey Nsa, which partners the Federal Ministry of Health in TB control, treatment and prevention, a lot more political commitment and funding were required from the government at all levels to fight TB in Nigeria.
He said: “Nigeria is among the 14 high burden countries for TB, TB/HIV and Multi Drug Resistant TB. The country is ranked seventh among the 30 high TB burden countries and second in Africa. The problem of TB in Nigeria has been made worse by the issues of drug resistant TB and the HIV/AIDS epidemic.
“It is estimated that 407, 000 people in Nigeria have TB each year. This is the estimated number of HIV negative people. In addition, there are an estimated 63,000 HIV positive people that get TB each year. An estimated 115, 000 HIV negative people die from TB in Nigeria each year and an estimated 39, 000 HIV positive people also die. It is difficult to appreciate what it means for 154, 000 people to be dying each year from TB.
“It has been said that ‘achieving the reduction in TB incidence rate for attainment of the 90-90-90 target of the End TB strategy will be a mirage, if something drastic is not done.’ The incidence rate is the number of new cases of TB in a population in a given time period, which is usually a year.”
Causes
According to an expert, Dr. Michael Iseman of National Jewish Health, tuber- culosis 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 Centers 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 (see Multidrug-resistant TB section below) 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.
TB burden in Nigeria
“Global tuberculosis report by WHO (2018), states that Nigeria, with population of 191 million in 2017, is one of 10 countries with highest TB, TB/HIV and MDR-TB burden.
“Also, in 2017, the country accounted for nine per cent of 3.6 million missing TB patients globally and Lagos, 18 million, greater than 50 per cent live in crowded/slum areas while greater than 60 per cent of ‘Lagosians’ patronise the private sector (clinics and the informal private sector) as first point of health contact,” Olufunsho added.
While speaking about the disease, Dr. Bolaji Adebiyi said, “There are many challenges we face in managing tuberculosis cases. Nigerians do not come to hospital on time for general check up until they are at the point of death.
“Again some people who have tuberculosis infection don’t comply to finish drugs prescribed for them. People who have tuberculosis are always been stigmatised in their family because they feel that tuberculosis can affect other members of the family, which is consistently true but that doesn’t mean that they should be stigmatised.
“We always have large number of patients who come down here for tuberculosis treatment. Every day we run the clinic, volume of patients with tuberculosis become higher. We have seen cases of younger
children, old adult, men and women, some time one would be wondering if he would not contract the disease
“When you talk about management of tuberculosis you start with diagnosis. When a patient is diagnosed with tuberculosis, there are procedures we go through during treatment. Luckily it is curable and if a patient is based on a medication and the patient continue taking this combination therapy on regular basis, time would come when the infection would totally clear in the system.
“We do mantel test and chest x-ray to go through the lumps and once the diagnosis is made, the treatments would start. We also tell patients the kind of food they would eat, the kind of diet they would take. The kind of exercise they would engage into, the kind of environment to live, how to relate with people among others.
“In managing the cough, you need to be with handkerchief all the time and of course, keeping appointment is very important in managing tuberculosis. Patient who has been diagnosed or who is on medication should keep appointment.”
He explained that the disease is not hereditary but is transmittable. “It can be transferred from an infected mother to a child but it is not in the gene of the mother. It can- not be transferred through gene but through droplets. If a person that is affected coughs and a person who is tuberculosis free get this cough through droplet he or she can be infected.”
A doctor at Igando General Hospital de- bunked the assumption that after taking TB medication for three weeks, the patient may no longer infect others.
He said: “Why do we insist that all patients must cover their mouth and nose with white handkerchief, including those who have been on treatment for long, if it’s true. Such assumptions are based on hearsay or unreliable materials not authored by medical authorities.
“Authentic medical Information can only be gotten from qualified medical practitioners or written textbooks. The worst is relying on internet materials which can be posted by anybody.”
Risk factors
People with compromised immune sys- tems are most at risk of developing active tuberculosis. For instance, HIV suppresses the immune system, making it harder for the body to control TB bacteria. People who are infected with both HIV and TB are around 20-30 per cent more likely to develop active TB than those who do not have HIV Tobacco use has also been found to in- crease the risk of developing active TB. About eight per cent of TB cases worldwide are related to smoking.
People with the following conditions have an increased risk; diabetes, certain cancers, malnutrition and also kidney disease. Also, people who are undergoing cancer therapy, anyone who is very young or old, and people who abuse drugs are more at risk.
Travel to certain countries where TB is more common increases the level of risk, too.
• With additional report from Romanus Okoye.