Gaps persist as world plans to end TB by 2030

As Nigeria today joins the rest of the world to mark the World Tuberculosis (TB) Day, experts have identified gaps and challenges that are capable of aborting the Sustainable Development Goals (SDGs) of Ending TB by 2030 and the goal of the World Health Organisation (WHO), End TB Strategy. CHUKWUMA MUANYA, Assistant Editor (Head Insight Team, Science and Technology) reports.

The theme of the 2016 World TB Day commemoration in Nigeria is ‘’Find TB, Treat TB and Working together to Eliminate TB’’ while the global slogan is “Unite to End TB.”

Health authorities including the WHO and the National Agency for the Control of AIDS (NACA) said despite the progress made to end TB, formidable challenges remain.

The gaps and challenges identified by NACA and WHO include fragile health systems, human resource and financial constraints, and the serious co-epidemics with Human Immuno-deficiency Virus (HIV) that causes Acquired Immune Deficiency Syndrome (AIDS), diabetes, tobacco use, and Multi-Drug Resistant TB (MDR-TB).

They said urgent and effective action to address antimicrobial resistance is key to ending TB by 2030; and so are increased investments, as the global tuberculosis response remains underfunded for both implementation and research.

The WHO’s End TB Strategy, adopted by the World Health Assembly in May 2014, is a blueprint for countries to end the TB epidemic by driving down TB deaths, incidence and eliminating catastrophic costs. It outlines global impact targets to reduce TB deaths by 90 per cent and to cut new cases by 80 percent between 2015 and 2030 and to ensure that no family is burdened with catastrophic costs due to TB.

Ending the TB epidemic by 2030 is among the health targets of the newly adopted Sustainable Development Goals. WHO has gone one step further and set a 2035 target of 95 per cent reduction in deaths and a 90 percent decline in TB incidence – similar to current levels in low TB incidence countries today.

The strategy outlines three pillars that need to be put in place to effectively end the epidemic: integrated patient-centered care and prevention; bold policies and supportive systems; and intensified research and innovation.
According to the WHO, the success of the strategy will depend on countries respecting the following four key principles as they implement the interventions outlined in each pillar: government stewardship and accountability, with monitoring and evaluation; strong coalition with civil society organizations and communities; protection and promotion of human rights, ethics and equity; and adaptation of the strategy and targets at country level, with global collaboration.

The WHO in a statement ahead of the World TB Day noted that there has been significant progress in the fight against TB, with 43 million lives saved since 2000, but the battle is only half-won since over 4 000 lives are still lost to each day to tuberculosis. It noted that many of the communities that are most burdened by tuberculosis are “those that are poor, vulnerable and marginalized.”

TB is caused by the bacterium, Mycobacterium tuberculosis, that most often affects the lungs. But it is a curable and preventable disease.

TB is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air. A person needs to inhale only a few of these germs to become infected.

About one-third of the world’s population has latent TB, which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease.

People infected with TB bacteria have a 10 percent lifetime risk of falling ill with TB. However, persons with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a much higher risk of falling ill.

When a person develops active TB disease, the symptoms (cough, fever, night sweats, weight loss and so on) may be mild for many months. This can lead to delays in seeking care, and results in the transmission of the bacteria to others. People with active TB can infect 10 to 15 other people through close contact over the course of a year. Without proper treatment, 45 percent of HIV-negative people with TB on average and nearly all HIV-positive people with TB will die.

Tuberculosis mostly affects adults in their most productive years. However, all age groups are at risk. Over 95 per cent of cases and deaths are in developing countries.

People who are infected with HIV are 20 to 30 times more likely to develop active TB. The risk of active TB is also greater in persons suffering from other conditions that impair the immune system.

According to the WHO, TB occurs in every part of the world. In 2014, the largest number of new TB cases occurred in the South-East Asia and Western Pacific Regions, accounting for 58 percent of new cases globally. However, Africa carried the most severe burden, with 281 cases per 100 000 population in 2014, compared with a global average of 133.

The WHO noted that in 2014, about 80 percent of reported TB cases occurred in 22 countries. The six countries that stand out as having the largest number of incident cases in 2014 were India, Indonesia, Nigeria, Pakistan, People’s Republic of China and South Africa. Some countries are experiencing a major decline in cases while in others the numbers are dropping very slowly. Brazil and China, for example, are among the 22 countries with a sustained decline in TB cases over the past 20 years.

According to NACA, Nigeria has the third highest TB burden in the world with 574,600 cases that is 338 per 100,000 of the country’s 170 million population; and 22 percent of the patients also have HIV/AIDS.

NACA in a statement ahead of the 2016 World TB Day noted that 3.5 million persons are HIV positive while close to one million of these persons are on treatment for HIV.
Also, the country incidence rate of TB is estimated to be about 338 per 100,000 population.   “Nigeria is the second amongst the highest HIV-burdened countries in the world and the third among the highest TB-burdened countries globally,” the report stated.

Common symptoms of active lung TB are cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats. Many countries still rely on a long-used method called sputum smear microscopy to diagnose TB. Trained laboratory technicians look at sputum samples under a microscope to see if TB bacteria are present. With three such tests, diagnosis can be made within a day, but this test does not detect numerous cases of less infectious forms of TB.

Diagnosing MDR-TB and HIV-associated TB can be more complex. A new two-hour test that has proven highly effective in diagnosing TB and the presence of drug resistance is now being rolled-out in many countries. Tuberculosis is particularly difficult to diagnose in children.

NACA noted that efforts have been made in the past to improve TB diagnosis among People Living with HIV (PLHIV), especially as TB is the number one cause of deaths among people living with HIV. “In 2014, it was reported that globally, 1.5 million people lost their lives to the TB infection, and of this number, 400,000 people were also infected with HIV.”

To reduce the risk of TB among HIV-positive clients, the WHO in 2010 endorsed the use of GeneXpert MTB/RIF assay to diagnose TB among PLHIV sub-group and other sub-groups. This technology is a cartridge based, automated nucleic acid amplification test, which can identify the Deoxy ribo-Nucleic Acid (DNA)/genetic material of Mycobacterium tuberculosis, the main causative organism, which causes TB, as well as identifies Rifampicin resistance.

TB is a treatable and curable disease. Active, drug-susceptible TB disease is treated with a standard six-month course of four antimicrobial drugs that are provided with information, supervision and support to the patient by a health worker or trained volunteer. Without such support, treatment adherence can be difficult and the disease can spread. The vast majority of TB cases can be cured when medicines are provided and taken properly.

Between 2000 and 2014, an estimated 43 million lives were saved through TB diagnosis and treatment.
Standard anti-TB drugs have been used for decades, and resistance to the medicines is widespread. Disease strains that are resistant to a single anti-TB drug have been documented in every country surveyed.

MDR-TB is a form of TB caused by bacteria that do not respond to, at least, isoniazid and rifampicin, the two most powerful, first-line (or standard) anti-TB drugs.

In some cases, more severe drug resistance can develop. Extensively drug-resistant TB, Extremely Drug Resistant TB (XDR-TB), is a form of multi-drug resistant tuberculosis that responds to even fewer available medicines, including the most effective second-line anti-TB drugs.

As part of the commemoration of the 2016 World Tuberculosis Day, the National Tuberculosis and Leprosy Control Program NTLCP, is collaborating with the Association of General and Private Medical Practitioners of Nigeria (AGPMPN) to inform and educate the public about the disease.

A host of medics known as the “big guns”, Dr. Lovett Lawson, Chairman, Stop TB partnership in Nigeria, Dr. Gabriel Akang, Dr. Josephine Okechukwu, and Dr. Emmanuel Meribole, all of NTLCP are billed to attend the 38th Annual General Meeting and Scientific Conference of the AGPMPN in April to enlighten the public and healthcare practitioners on TB.

Disclosing this in Abuja, spokesperson for AGPMPN, Dr. Biodun Ogungbo, said the multi-sectoral collaboration would enhance the number of diagnostic, treatment and research centres in the country.

Ogungbo said diagnosis and treatment of TB are provided free of charge by the NTLCP with support from partners including the Global Fund to Fight AIDS, Tuberculosis and Malaria, United States Agency for International Development (USAID), WHO, Clinton Health Access Initiative and private sector organisations like the Agbami-Co-Ventures.