By Kemo Cham
Tuberculosis (TB) is one of the oldest human diseases, which continue to defy the supremacy of medicine. A combination of factors has connived to ensure this, despite decades or perhaps centuries of efforts supported by billions of US Dollars in research and treatment.
Nine million new cases are registered yearly, according to the World Health Organization (WHO), of which 1.8 million die within the same period. Africa is said to account for about 30 per cent of the global disease burden.
Sierra Leone, luckily, is not among the 22 most affected countries, nine of which are in Africa. But despite efforts by government, the TB disease burden on the country still remains a concern.
Due to the lack of an up-to-date data from the office of Leprosy and TB Control Program (LTCP), I will refer to global sources. According to the UN World Health Organisation (WHO), TB cases in Sierra Leone almost doubled between 2004 and 2007, that's despite a relatively high case detection rate - 52 per cent at the time. The WHO's target for case detection rate was 75 per cent.
TB/HIV co-infection was also of major concern, with prevalence rate thought to be about 11.6 per cent. HIV positive patients are said to be up to 30 times more likely to develop active TB than HIV negative people, the reason being that the two comprise a deadly combination, as each fuels the progress of the other. Besides susceptibility to death, active TB accounts for mass distribution of the bacteria. One patient with active TB can infect up to 15 others.
But of even greater concern to public health officials is Multi Drug Resistance TB (MDR-TB). This is wherein the pathogen becomes resistant to two of the most effective first-line drugs used in treating the disease: rifampicin and isoniazid.
TB is also called the disease of poverty, because it affects mostly people in the largely poor, developing world, where the vast majority of deaths - over 95 per cent - occur. It is second only to AIDS as leading cause of death by an infectious disease.
Basically, TB exists in two major forms: Pulmonary and Extra-pulmonary. The former affects the lungs, and essentially transmits the bacteria to the general population when victims cough, sneeze, or even talk in a way the pathogens are spread in the air.
Pulmonary cases account for between 80 and 85 per cent of global TB cases. General symptoms include feelings of weakness, weight loss, fever, and night sweats.
The symptoms of TB of the lungs notably include coughing, chest pain, and coughing up blood.
Extra-pulmonary cases occur outside the lungs, when the disease goes largely unattended to. The manifestations include TB of the spine, brain, and kidneys.
Prevalence levels
In Sierra Leone, the two cases are almost at a 50-50 level of prevalence. The problem though is we can't ordinarily tell who has the bacteria. And considering the realities of life in the developing world-overcrowded commercial vehicles and living quarters, etc, - we are perpetually at risk of contracting this airborne disease.
How, therefore, we are supposed to protect ourselves remains the million-dollar question even some experts don't fancy confronting.
The Global Fund is a leading sponsor of the fight against TB, providing almost 90 percent of funding. It works in collaboration with WHO, which recommends a focus on pulmonary cases.
Of the 9 million estimated annual infections, one third (three million) aren't on treatment. The 2014 commemoration of World TB Day was therefore dedicated to 'Reach the three million'.
Mining communities, migrant groups, drug users, prisoners, and commercial sex workers are among communities most vulnerable to TB, therefore, good places for the LTCP to look at.
Sierra Leone adopted the WHO recommended Directly Observed Treatment-Short Course (DOTS) strategy in 1993. Since then, the number of DOTS centres has multiplied to 170 nationwide, providing free treatments. The country is still short of 20 centres.
The DOTS model comprises a two-phased treatment. The first line of treatment, or the intensive phase, involves a combination of four drugs which patients swallow everyday for two months. Within the next four months (second phase), tablets intake is reduced to two. However, inconsistency in treatment among patients has been blamed for high defaulter rates, which leads to the dreaded phenomenon of MDR.
MDR is of concern because it is more difficult and costly to cure. It can only be treated with second-line drugs, which are less effective yet more expensive and associated with more serious side effects to patients.
Six years ago, the country piloted a project to determine the level of MDR in the country. And based on the result of test samples sent to Germany, the LTCP drew a guideline for the management of MDR.
Curiously though, officials at the New England headquartered office refuse to disclose the exact figures.
Cultural practice
"I can assure you that the level of MDR in this country so far is low," insists Abu George, head of laboratories, when repeatedly confronted over the figures.
Another cause of MDR is wrong prescription, which happens because patients fail to report for timely and proper diagnosis. But that is also attributable to lack of faith in the system and, for many patients, they simply don't know where to go when symptoms appear.
Mohamed Bangali was infected with the bacteria at age two. His mother, he says, told him he began experiencing fever and then his legs got weakened. He soon developed a hump on his spine, and then paralysis set in.
The story of Bangali, now in 40s, represents the many who, for lack of awareness, resort to superstitious redress. When they wanted to go to hospital, his parents were told the witches would follow them. Their only option was therefore traditional healers.
But his experience there, too, reveals how widespread ignorance helps exacerbate so many a curable illnesses in this country. At first, they heat up a bunch of leaves and tied them to his back, apparently to cure his hump.
In some other places, Bangali explains, they use hot clay, mixed with concoction. For his paralysis, he goes on, he was tied to a pillar of a farmhouse, supposedly to straighten his legs.
Other treatment measures include exposure to the heat of boiling water'. The patient is covered with a thick blanket, over a steaming pot full of herbs.
"These things are still happening and it's because of this ignorance that I founded KITE," Bangali says.
KITE comprises mainly survivors of various forms of extra-pulmonary cases of TB, and was originally aimed at raising awareness, although they have provided financial aid through the support of a US-based charity, African Surgery Incorporation. A number of young Sierra Leoneans have benefitted from life-saving operations through this.
With global effort to eradicating TB focusing on pulmonary cases, patients of extra-pulmonary TB feel neglected. Diagnosis alone is a costly business, they say.
At the Connaught Hospital, they are charged Le 200, 000 (around US$ 50). Even after
diagnosis, most patients require complicated surgeries, which cost, on average, $11,000 per individual. Bangali says this huge cost has also forced many to explore the traditional 'remedy' which he calls the 'torture chamber.'
Since the year 2000, KITE has sponsored over 200 surgeries. They flew in medics and, in some other cases, airlifted patients to Ghana.
Awareness raising is needed, but government also needs to equip health centres with medicines and machines, says the activist. He also contends that a properly crafted health education system could prevent many children from TB infection.
He cites a common societal practice that allows young ones to be held by anyone, and in some cases get kissed.
"This kind of thing exposes children to infected people," he says.
Drug shortage
Meanwhile, figures at treatment centres suggest higher prevalence rates than the LTCP officials would admit. TB drugs are so expensive that government spends a minimum of $500,000 annually. But still, patients claim they are often told there are no drugs available, which they blame for interrupting their treatment regimen.
The LTCP denies this
Any delay could be attributed to centres requesting for drugs late, says Dr Alie Wurie, Manager, LTCP. He adds that this rarely happens.
According to the LTCP, 13, 000 patients were registered countrywide in 2013. At the Connaught Hospital Chest Clinic, which is one of 10 centres in Freetown alone, over 1,000 patients are registered.
Lab Assistant, Emmanuel Bobson Momoh told me that on average, eight patients are placed on treatment there, daily. And while admitting low awareness levels, the young medical student intern laments the attitude of patients whom he says fail to turn up for treatment only to give all sorts of excuses.
He says the fear of stigma forces many to sidestep their nearest centre and register at Connaught where they wouldn't like meet people who know them.
"We have more than expected cases here, but there is no day patients come without getting tablets," Momoh insists.
In any case, the numbers at Connaught suggest a worrying trend of infections, although the centre accounts for over half of the national figures, and that as such it precludes suggestion of a worrying trend.
"We know for sure that TB is still a public health concern in Sierra Leone, but we are registering over 90 percent of treatment success. So there is no cause for alarm," adds his boss, Dr Wurie.
But Wurie also admits that because there aren't as many global partners for TB as there are for HIV/AIDS, financial constraint remains a major obstacle to eradicating the disease. And this, he agrees, points to the need for increment in the national health budgetary allocation.
(C) Politico 08/05/14
