Why renewed effort is needed to fight against tuberculosis

By Dr Robert K Majwala

Today, March 24, 2017, Uganda has once again joined the rest of the World in commemorating the World Tuberculosis (TB) Day; an annual event that honors the day that Dr. Robert Koch announced his discovery of mycobacterium tuberculosis, the germ that causes TB, in Berlin Germany in 1882.

This day is designed to build public awareness that tuberculosis remains an epidemic, as it was 135 years ago in much of the world, causing the deaths of nearly one-and-a-half million people each year, mostly in developing countries. Globally the number of new TB cases is equal to the number of new HIV cases per year and TB kills more people than Malaria and HIV. This year's World TB Day theme is, 'Unite to end TB'; and the slogan is, 'Find the Missing TB Patients'. We actively need to find the missing TB patients if we are to deal with the TB disease in Uganda.

According to the 2015 Uganda National Tuberculosis Prevalence Survey, Uganda has an annual prevalence of 253 TB patients per 100,000 population, translating into about 90,000 TB patients per year. However, according to the 2016 Global Tuberculosis report, Uganda notified only 43,736 TB case patients in 2015, which was only 49% of the expected TB patients in that year.

Furthermore, this is complicated by emergency of drug resistant TB, a complicated strain of tuberculosis, whose treatment is very costly. Treating resistant TB requires about sh18,000,000 (about $5,000) for up to 20 months; with severe side effects.

According to the Uganda National TB and Leprosy Program records, in 2016, only 420 drug resistant TB patients were notified out of the expected 2600; suggesting that up to 84% of all the drug resistant TB patients were not notified. These patients continue to be a danger to the public and continue to spread drug resistant TB in the communities where they reside.

The current state of affairs calls for renewed efforts to address the TB epidemic. Given that the available public health actions are missing more than half the expected number of TB patients as well as up to 85% of drug resistant TB patients, there is an urgent need for innovative strategies to improve TB prevention, TB case finding; TB treatment to completion and management of drug resistant tuberculosis.

In order to find the missing TB patients, there is a need for concerted efforts engaging multiple stakeholders - government, development partners, implementing partners, civil society organizations and the community need to improve TB case notification. Funding for TB programs needs to be prioritized by the government. Currently, government funds only 4% of all the resources needed for TB prevention, treatment and care including drug resistant TB; with development partners contributing the greatest proportion (76%).

The remaining 20% of the resources needed to tackle TB is left unfunded. This situation calls for renewed advocacy for TB, just like it was for HIV in the early 1990's. There is a need to teach the general public about the signs and symptoms of TB in order to create demand for TB diagnosis and treatment across the board. This will help to reduce stigma associated with TB diagnosis.

All partners need to support efforts geared towards systematic TB case finding, focusing on the most-at-risk groups for TB including; prisoners, people living with HIV/AIDS, people with diabetes, children below 15 years, men, refugees and internally displaced persons, pastoralists and nomadic communities; people in hard to reach areas including urban slum residents and urban poor, and contacts of persons confirmed to have multi-drug resistant TB, among others.

There is need for massive investments in better and newer diagnostics for TB screening and diagnosis, while ensuring their continued functionality. Results from the 2015 Uganda TB prevalence survey suggest that when a chest X-ray was added to smear microscopy, this helped to identify 33 more TB patients compared to the 30 patients that were identified with symptom screening alone.

Thus, the addition of a chest x-ray for TB screening has the potential to increase more TB case patients and should be considered. Other newer technologies including the geneXpert technology, if deployed optimally and supported with consumables and demand creation for TB, have the potential to increase the number of TB patients diagnosed.

There is an urgent need for TB capacity building among health workers at all levels. Nationally, the number of smear negative and extra pulmonary TB case patients has been declining over the years and this is attributable to lack of enough clinical acumen to diagnose TB by health workers. A training curriculum needs to be developed and implemented in a phased manner until all health workers have been trained.

In conclusion, finding missed cases requires concerted efforts at all levels and by everyone. Renewed efforts are needed by all stakeholders at every level. Just like this year's World TB Day theme and slogan, let us all unite to find missed TB case patients.     

The writer is a Public Health Fellowship Programme attached to the National TB and Leprosy Programme, Ministry of Health