Resistance to TB drugs worries experts

By Vision Reporter

AS the world commemorates World Tuberculosis Day (tomorrow), Uganda is busy strategising on how to combat the effects of the looming multi-drug resistant TB, which could reverse strides made in the fight against the disease.

By Irene Nabusoba

AS the world commemorates World Tuberculosis Day (tomorrow), Uganda is busy strategising on how to combat the effects of the looming multi-drug resistant TB, which could reverse strides made in the fight against the disease.

The day coincides with reports of severe TB drug shortages, which experts warn, will undermine efforts towards the World Health Organisation’s goals of detecting and treating TB by 70% and 85%, respectively come 2010.

Dr. Henry Luwaga from the National Tuberculosis and Leprosy Programme says: “We shall not only continue falling short of the global targets, but also risk doubling cases of multi-drug resistant TB which can be very tragic given that the other alternative second line treatment is expensive.”

“The first line treatment for ordinary tuberculosis costs about $30 (sh60,000) per patient for eight months. The second line treatment is estimated at $1,500 (sh3m) for each patient over a two-year period,” Luwaga says.

What causes TB?
TB is a viral disease caused by germs that are spread through the air. They usually affect the lungs, but can also affect other body parts.

These germs can float in the air for several hours, so people who breathe in the germs may become infected, depending on their immunity and no symptoms may show.

Luwaga says the disease is treatable, but patients can die if they do not get proper treatment. “And it can also fail to respond to treatment if the patient does not follow the drug schedule and instructions,” Luwaga says.

He says multi-drug resistant TB is one whose strains are resistant to at least two of the best anti-TB drugs, isoniazid and rifampicin, which are considered first-line drugs for TB.

Apparently, not all the four common anti-TB drugs — Isoniazid, Rifampin, Pyrazinamide and Ethambutol are out of stock, but still the damage can be enormous.

“The patient is started on all the four drugs but ends up with only the two that are available. This affects treatment. The reason they are administered in clusters is because they interact,” he explains.

The Government requires about $1.5m (about sh3b) per year to buy TB drugs, but often relies on the Global Fund for malaria, TB and HIV/AIDS.

The mishap has pointed at poor management as the delay found no fall-back and this can be a lesson learnt as we celebrate the global holiday.

TB and HIV/AIDS, a double jeopardy:
According to the WHO, about 16% of new TB patients are HIV-positive. TB is one of the leading causes of death in people with HIV, with about 13% of AIDS-deaths worldwide. Joseph Imoko, the WHO national professional officer for TB, says in many countries with a high prevalence of HIV/Aids, TB cases have gone up.

“TB infections increased by almost 12% between 2001 and 2005 and we estimate that 70% of Ugandans living with it also have HIV,” he adds.

Nsambya Hospital’s Dr Maria Musoke says living with both HIV/AIDS and TB often leads to early deaths, drug adherence problems and resistance.

“Both conditions increase pill count as either drugs come in clusters. Sometimes we are forced to stop ARVs for a while (particularly the first two months) for one to effectively adhere to TB drugs,” she reveals.

But experts also warn of increasing resistance against ARVs. “Patients also tend to abandon treatment courses once they improve, which increases resistance,” she adds.

Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged for instance when patients do not complete their full course of treatment; when health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs; when the supply of drugs is not always available; or when the drugs are of poor quality.

Research shows that people who are more susceptible to resistance usually do not take their medicine as prescribed, have recurrent active TB even after full course medication, come from areas where drug-resistant TB is common or have spent time with someone with drug-resistant TB.

Musoke says if one suspects they have been exposed to someone with TB, they should contact a doctor or local health department about getting a TB skin test or special TB blood test. It costs at least sh25,000.

She says there are low detection rates because of poor access to healthcare services, a limited number of skilled staff and diagnostic facilities.

Besides, certain drug combinations, especially for children are hard to import. Up to 3% of deaths in children globally and 6% of children below five years in sub-Saharan Africa are a result of TB.

Burden of TB and multi-drug resistant TB
Globally, 9.2 million new tuberculosis cases and 1.6 million deaths occur annually. Dr. Francis Adatu-Engwau, the programme, says in 2007, the country reported 41,579 cases, of which 20,364 were infectious.

About 80,000 new cases occur annually, and studies put the infection prevalence at 600 per 100,000 people, with the 20 — 45 age group mostly affected.

“Unfortunately, only about half the cases are tracked, yet people infected with TB do not necessarily become ill but can infect between 10 and 15 people a year, if left untreated,” he says.

However, Uganda has no local comprehensive survey to ascertain the problem. Adatu says the process, which is a prerequisite to qualify for the Green Light Committee funds that help governments procure second line drugs for the disease, is underway.

Dr. Maria Musoke, the coordinator of Nsambya Hospital Homecare Department where HIV and TB patients are treated, says they are handling 11 cases of multi-drug resistant TB.

“Since we have no drug alternatives, we give them drugs that are showing resistance. We deliver the drugs to the patients’ homes so they do not infect others with the resistant strains,” she explains.

Prevention of tuberculosis
The health ministry recommends that every child at birth be given a TB vaccine commonly known as BCG to reduce the spread of the disease. However, Luwaga says the vaccine does not provide 100% protection.

It only protects a child from severe forms of TB, but it is highly recommended.

Dr. Joseph Kawuma, a consultant with the German Leprosy and Tuberculosis Relief Association, says the only way of containing TB spread is early detection and treatment. He recommends a check-up when one gets cough for three weeks.

“Health workers should look out for multi-drug resistant TB to minimise its spread. Healthcare providers can help prevent multi-drug resistant TB by diagnosing cases, following the recommended treatment, monitoring patients’ response to treatment and making sure therapy is completed.”
An internet site,, advises people to avoid exposure to multi-drug resistant TB patients. TB symptoms include body weakness, weight loss, fever and night sweats.

Uganda has embarked on a plan to increase the TB case detection rate from 49.6% in 2006 to 75% by 2011. It also plans to increase the treatment success rate from 73.2% in 2006 to 80% by 2010.

This year’s theme, I am stopping TB and controlling HIV, aims to encourage people living with HIV/AIDS to often consider TB tests.

Resistance to TB drugs worries experts