By Dorothy Namutamba
Tuberculosis (TB) remains a major global health problem. It causes ill-health among millions of people each year and ranks as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV).
The latest estimates published in the World Health Organization Global Tuberculosis Report 2012 indicate that there were almost nine million new TB cases in 2011 and 1.4 million TB deaths (990 000 among HIV negative people and 430 000 HIV-associated TB deaths.)
According to the Global Report, Uganda is ranked 18 among the 22 high burden countries that account for approximately 80% of new TB cases arising each year globally. According to Ministry of Health and the National TB and Leprosy Programme, there were approximately 49,000 new TB cases in Uganda in 2011. The high burden of the TB disease is mainly in the urban and peri-urban centres, with Kampala accounting for 7,800 cases, Wakiso, 1,300 cases and other regional towns account for between 1,300 – 1,600 cases each. TB affects mostly adults in the economically productive age groups 24- 45 years. Without treatment, mortality rates are high.
TB is not being given the priority it deserves in terms of resource allocation, both human and financial support, community education, research and advocacy. The country has not yet come up with a sustainable mechanism for addressing TB disease.
TB is an infectious disease caused by the bacillus Mycobacterium tuberculosis. It typically affects the lungs (pulmonary TB) but can affect other sites as well (extrapulmonary TB). The disease is spread in the air when people who are sick with pulmonary TB expel bacteria, for example by coughing. In general, about 10% of people infected with Mycobacterium tuberculosis will develop TB disease in their lifetime; however, the probability of developing TB is much higher among people infected with the human immunodeficiency virus (HIV).
One of the major reasons for why TB is still a big problem in Uganda is the limited information in the community about the disease. Unlike the HIV, which has gained ground through community sensitisations and literacy programmes implemented by the Government (MOH) and the civil society efforts, TB has been left to the laboratories and the health care providers. The International Community of Women Living with HIV Eastern Africa (ICWEA), a regional advocacy network run by and for positive women that promotes their voices and advocates for changes that improve their lives carried out an assessment on the availability and accessibility of TB, TB/HIV services in Kampala, Wakiso, Mityana and Mubende Districts in 2010 and in 2012 and interviewed community members who included people living with HIV and TB, persons who have suffered from TB before and other community members who accessed the services at the different health facilities in the districts and the results showed low information about TB in the community on the TB including the signs and symptoms, infection control, prevention and treatment and the results revealed high level of TB-related stigma and discrimination in the community. “There is low uptake of the services besides the community cannot advocate for better services,” lamented a TB Advocate in Mubende. “When you request someone with some signs and symptoms of TB to go for screening and testing, they fear to go that they might be also be having HIV, and suffer the double stigma associated with it”
One of the major obstacles to TB control is the long duration of treatment required—at least six months— for drug-susceptible pulmonary disease. Although TB treatment is free in Uganda, the treatment duration for drug-susceptible TB is still eight months despite WHO recommendation of the six months regimen; and, the major resulting problem faced by the health system is treatment defaulting. In Mityana Hospital, a health care worker reported that “after the first two months, TB patients feel better and then they do not come back for the rest of the treatment; besides, we do not have any mechanism to trace them” Meanwhile, in Mubende, the health care staff mentioned that “the majority of patients do not utilise the facilities nearer to them due to stigma associated with TB and they end up not coming back to because they cannot make it due to financial problems and besides they feel better and think they are cured.”
Inability to comply with the lengthy and unpleasant TB treatment has finally brought the bigger critical TB strain – multidrug- resistant TB (MDR-TB), which has finally exploded here in Uganda. This has further been escalated by the continuous drug stock out of first line anti TB drugs in the country.
MDR-TB is a form of TB that does not respond to the standard six month treatment using first line-drugs (i.e. resistant to isoniazid and rifampicin). It can take two years to treat with drugs that are 100 times more expensive than first-line treatment. The bacteria responsible for TB becomes resistant when people who are ill with TB are not provided with or do not complete a full course of medication. Drug-resistant TB, like drug-sensitive TB, can also be transmitted through the air from an infected person to a non-infected person.
The National TB and Leprosy Programme reported a cumulative total of 237 MDR patients by end of 2011 and in addition, that the country has secured adequate funding from the Government of Uganda and Global Fund to purchase enough quantities of second line drugs to start all drug resistant patients on treatment by January 2013.
There are only eight laboratories in the country with capacity to diagnose drug resistant TB, of which seven are privately owned. The only National TB Reference Laboratory (NTRL) based in Wandegeya Kampala relies on sample referral system to enable health facilities all over the county to send sputum samples of smear positive retreatment suspects and contacts of MDR-TB patients to the NTRL for culture and Drug Sensitivity Testing (DST)
But the reality at the community level is extremely different. When at the Mubende Hospital at the end of March 2013, five patients who had been confirmed with MDR TB had been sent back to the community, (inevitably spreading the resistant TB strain to the community). “We did not have anywhere to keep them here, we are also scared of them since we had tried to refer them to Mulago Hospital but they were tossed back! Some must have died, and even though we have been asked to trace them, we do not have some of their contacts.”
What we need are highly potent tuberculosis regimens of shorter duration, which would facilitate treatment completion and improve individual and public health.
Such efforts have been made through research initiatives like the TB Trial Consortium (TBTC). With funding from the U.S. Centre for Disease Control and Prevention (CDC), TBTC is conducting clinical, laboratory and epidemiologic research concerning the diagnosis, clinical management, and prevention of tuberculosis infection and disease with their major focus on making TB treatment shorter and easier.
TBTC has been conducting clinical trials to find new drug combinations that
• Can cure active TB in three to four months and
• Can prevent TB from ever re-activating, in three months.
With study sites in the United States and Canada, the consortium established international sites in Brazil, Spain and Sub-Saharan Africa, one of which is (Kampala Site 30) based in Mulago National Referral Hospital near the TB ward.
Studies conducted at site 30 and other TBTC sites have demonstrated new drugs with ability to shorten and/or simplify treatment for both active TB, and to prevent latent TB from turning into active disease. One Study aimed at substituting rifampicin with rifapentine when administered daily to TB-HIV co-infected patients, showed that rifapentine remains a promising drug with potential for TB treatment shortening, and is safe and tolerable
Other trials by the CDC- TBTC used rifapentine for treatment of latent TB infection, and have shown that a new combination regimen of isoniazid and rifapentine administered once-weekly for 12 weeks is as effective for preventing TB as other regimens, and is more likely to be completed than the standard regimen of nine months of INH daily
Commitment from our government for fight TB is needed to finance the implementation of such evidence based TB practices. TB is in the communities, we as communities, we have a critical role to play through community mobilisation, sensitisation and advocacy for scale up of investment in TB research, participation in research and ensuring that quality access to TB, TB/HIV services.
Let’s work together to defeat TB in our lifetime!
Dorothy Namutamba is a Program Officer – International Community of Women Living with HIV- Eastern Africa & Community Representative for the TBTC Community Advisory Group