Fighting TB: Rural challenges, hopes and dreams
Every time I diagnose a child with TB, I wonder how far we are from winning this fight against the disease. Considering that the effort put into preventing mother-to-child transmission of HIV has produced outcomes that point to the potential elimination of paediatric HIV by 2015, what would it take to achieve similar successes with TB, at least for children? Is it a matter of resources or the way we approach the disease?
Children usually get TB from adult contacts and most of their parents will report that someone at home is or has been on TB treatment in the past year. Sadly, infection control measures perceived to be simple, such as having the children sleep in a separate room away from the infected adult, are not always possible for poor, overcrowded households. From a health services point of view, home visits, contact screening and identifying those who need to be on TB prophylaxis can be done by community health workers, however when this service is poorly resourced or absent, a crucial aspect of dealing with TB outside health facilities is undermined. Whether it is a weakened immune system or ineffective infection control, TB slips through the cracks and causes death and destruction.
According to recently published mortality statistics based on death notifications, the absolute number of TBrelated deaths is declining but it is still the leading cause of mortality among South Africans. Besides death, the disease leaves many individuals permanently impaired as pulmonary infection destroys lung tissue, and bone and brain tissue, among other organs, are eroded in extra-pulmonary infection.
The treatment for extra-pulmonary TB is longer, more arduous and carries the increased risk of adverse drugrelated side effects. Specialist treatment and rehabilitation services are often unavailable in rural areas and sometimes inaccessible due to the incredibly long waiting times at referral centres. This results in a large number of people surviving on disability grants for the duration of their treatment, or the rest of their lives in the case of permanent impairment. For those who have lost their income as a result of TB, or are poor and without support to begin with, the grant allows them to cover the costs of food (it’s almost impossible to tolerate TB treatment on an empty stomach), and transport to health facilities for follow-up visits and collecting medication.
From the number of treatment interrupters reported anecdotally, we must ask ourselves if the grants represent sufficient support. In 2011, the estimated incidence of TB suggested that 1% of the population of about 50 million South Africans would develop active TB each year. Bearing in mind how the disease affects individuals, one can assume that the external unaccounted costs to families and communities, and essentially the country as a whole, goes beyond the state’s financial burden of paying social grants.
Although the rollout of GeneXpert has transformed the diagnosis of TB and DR-TB, we still face a national crisis when it comes to treatment and support for TB patients. As an example, TB hospitals in KwaZulu-Natal are currently overwhelmed with the number of DR-TB patients that are being referred for treatment on a daily basis. Despite the availability of national guidelines on the management of DR-TB since 2011, the actual implementation of decentralised care is far behind. This is due to a variety of factors ranging from a general shortage of resources, such as vehicles for hospital TB teams, the unavailability of drugs for treating MDR-TB at district hospitals, the lack of training for nurses and doctors on managing MDR-TB, and an overall failure of district and provincial health departments to proactively prioritise and champion the fight against TB.
There are promising new drugs on the horizon for MDR-TB but if access to existing treatment is limited or confined to hospitals with waiting lists, how likely is it that these novel treatments will reach eligible patients in peripheral areas? Aside from GeneXpert, it’s now possible to diagnose TB using urine specimens to detect mycobacterium tuberculosis antigens, also known as urine LAM and has proven to be highly sensitive for HIV-infected patients with very low CD4 counts. Because urine specimens are much easier and safer to obtain than sputum, the difficulty we experience on a daily basis of making a laboratory diagnosis of TB in severely immune compromised patients may be a thing of the past if this technology were made available nationally.
With R500 million from the Global Fund to treat TB in South Africa, Dr Aaron Motsoaledi the Minister of Health, announced in March this year the intention to screen all inmates in correctional facilities and follow their families, as well as screen all mining communities across South Africa. This is an ambitious goal but one that is achievable given the technology (GeneXpert), additional resources and political will from the national Minister.
It would be extremely encouraging to hear a similar plan of action for rural communities ravaged by TB, and to go further in detailing a plan to treat and support the patients diagnosed with MDR-TB after such a campaign. It’s also worth noting that for all the research, information and technology generated to address infection control at health facilities, many rural hospitals and clinics are in desperate need of infrastructure upgrades to improve ventilation and waiting areas. This represents not only a crucial step to prevent crossinfection between patients, but also between patients and healthcare workers. Political will, especially at management level, and dedicated financial resources would go a long way in fixing these problems.
Professor Nulda Beyers, director of the Desmond Tutu TB Centre, recently spoke out quite strongly about the need for greater political will and collective responsibility towards managing this ‘public health crisis, which is out of control’. Her message is clear: We need to make a stronger effort in raising awareness about the disease, supporting the right to be tested, following up on patients who are diagnosed with TB and ensuring that they are put on treatment.
Given that health services are already stretched beyond their capacity to deal with the burden of TB, I would add that we need to invest more resources in community-based strategies to support individuals and communities battling TB. Through community engagement, concrete plans can be developed to ensure that patients have access to food, children and other vulnerable household contacts are protected, and more responsive assistance is provided to those at risk of interrupting their treatment. It will probably mean addressing difficult issues, such as poverty and malnutrition which fuel the spread of the disease. I would like to believe that stigma and the fear of isolation or destitution can be overcome by a communal goal to eradicate TB. In the same way that we took on the fight against HIV, it’s evident that we’re not going to beat TB from the clinics, we have to reach out and win the fight in the community.
Govender is a RuDASA National Committee Member.