On March 24th the global community marks World TB day to commemorate the day in 1882 when Dr. Robert Koch discovered the cause of tuberculosis. At the time, the tuberculosis (TB) epidemic was raging out of control in Europe and the Americas, and this discovery paved the way for millions to be successfully treated. Today, TB remains a major public health threat with 4,000 lives lost daily to this highly curable disease. But this TB day stands out from previous ones.
The global community has now mobilized to End TB by 2030, bringing an end to this crippling disease that hits predominantly working age adults. But children have not been spared. The Louder than TB global alliance aims to focus attention on the plight of children, showing how TB continues to steal laughs and rob children of their childhood.
Globally, 9.6 million people fell ill with TB, of which 1 million children, and 1.5 million succumbed to the disease (2014). TB is now the leading cause of death from an infectious disease. The Africa region has roughly 28% of the world’s cases but the most severe burden relative to the population (281 cases for 100,000 people, more than double the global average of 133).
This World TB day I am in Tanzania, one of the high TB burden countries in Africa. Tanzania has made important strides in TB control but like other countries grappling with the disease increased efforts are needed. Virtually all high TB burden countries in Africa need to improve case detection, strengthen diagnosis and ensure prompt treatment, and follow up defaulters as adherence can be problematic.
When I mention the End TB goal to the head of the TB ward at the Ndanda Hospital, Barbara’s eyes light up and she smiles widely. I see in her face both a healthy sense of cynicism and a glimmer of hope. At the faith-based Ndanda Hospital in the Mtwara region of Tanzania, Barbara assists TB patients to complete their six-month drug regimen. Patients are accompanied by family members who assist in collecting medications, as this requires frequent visits in the first two months and some patients are too frail to travel long distances.
Salma sits quietly in a wheelchair eager to share her story which sounds strikingly familiar. The 47-year old recounts how she was initially diagnosed with hypertension. The coughing persisted and within a month she was diagnosed with TB and became physically inactive and economically unproductive. More bad news followed when she tested HIV positive. Rates of TB/HIV co-infection in Tanzania are over 40% and require facilities to provide holistic care so that patients can receive treatment at the same location. Salma is among the fortunate patients in Africa, as the Ndanda Hospital receives free anti-TB drugs from government and was able to place her on treatment promptly following diagnosis. As soon as she completes TB treatment, Salma will receive antiretroviral drugs which are readily available at the hospital. She is also fortunate to have a supportive family by her side. “Stigma is no longer a problem,” Salma says proudly, underscoring progress in some settings to tackle the social aspects of the disease.
“Access to quality diagnostic services is pivotal to TB control efforts in Tanzania,” notes Dr. Fausta Moshe, Director of the National Quality Assurance Laboratory and Training Center. Under the Bank-funded East Africa Public Health Laboratory Networking Project (EAPHLNP) the Ndanda Hospital is among the facilities that benefitted from the roll out of the GeneXpert machine, which is able to accurately diagnose drug resistant TB in hours rather than waiting months for culture results, saving time and money. The new technology has allowed the laboratory to conduct over 900 tests over the past 18 months with a four-fold increase in monthly tests, demonstrating enhanced capacity.
Compliance with treatment remains an important challenge, particularly for multi-drug resistant TB patients who face lengthy treatment and high risk of side effects. Operational research supported under the EAPHLNP is providing information to better understand factors that hinder the referral process and treatment completion rates. At the Bank-supported Musoma Regional Referral Hospital, a study conducted on people with presumptive TB revealed difficulties in paying for transport and problems with long distances. Another study found significant gaps between specimens for MDR-TB received at the national TB laboratory and cases arriving at Kibong’oto Hospital which served the country for decades as a sanatorium for TB patients, and now functions as the center of excellence for treatment of MDR-TB. Tracing of patients will provide critical information to understand factors associated with pre-treatment loss of MDR-TB patients. “It is critical to support facility personnel to conduct on site research to understand the causes of poor adherence, impediments to a well-functioning referral system, and socio-cultural dimensions of effective TB control,” notes Dr. Esther Ngadaya, Principal Research Scientist at the National Institute of Medical Research.
Looking back at my visit to Ndanda Hospital I recall a tiny, frail two-year old girl named Gladness who was recently placed on TB treatment, sitting in the pediatric ward, connected to an oxygen machine unable to join her playmates. Let’s join forces to make the dream of a world free of TB a reality.
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