WORLD TB DAY: STUBBORN TUBERCULOSIS GERM STILL KILLS MORE PEOPLE GLOBALLY ANNUALLY, ARGUABLY MORE THAN ALL WARS AND TERRORISM RELATED DEATHS COMBINED
Tuberculosis (TB) is one of the oldest known bacterial infections. For hundreds of years the disease has been responsible for a lot of human illness and sometimes death. It also affects modern human beings worldwide. The bacteria/germ that causes Tuberculosis infection is an airborne germ called Mycobacterium Tuberculosis; typically a slow-growing aerobic bacterium, which mainly affects the respiratory system.
Its cells are rich in oxygen content, although it is not limited to the respiratory system. The bacterium can infect any body cells outside of the lungs, for example, the vertebral spine, brain and its coverings, kidneys, the reproductive organs, skin, lymph nodes, bones, and many other body parts.
The TB germ is spread from one person to another through the air infected droplets, for example when the TB infected and sick person coughs, laughs, sneezes, sings, or even talks. When another person breathes in that TB germ-infected air droplet, that recipient person will become infected with the TB germ, and may or may not proceed to full-blown Active TB illness. It is not easy to be infected with the TB germ.
One must have prolonged close contact to be infected by it, for example at home or work, as opposed to brief contact with an infected and sick person. It is also important to share the fact that there are other forms of the TB germ that mainly affect animals, which may infect human beings who have close contact with TB-infected animals, for example, Mycobacterium Bovis (Cattle TB infection) or Mycobacterium Avis (Birds TB infection).
With the general improvement in the social quality of lives of human beings globally, especially in the so-called developed countries, coupled with improvement in the availability, quality, and efficacy of anti-TB medications; this pandemic, was largely restricted to being a public health problem of the so-called developing world or third world. The emergence of HIV and AIDS pandemic in the 1980s, seriously brought back the TB public-health challenge to the fore once again, even in the developed countries such as Europe and the Northern Americas.
Almost 2,5 billion or a third of the world population is infected with the TB germ. However, in most people who are infected with the TB germ, the strength of their immune systems has kept the TB germ in check, meaning it is not able to cause any harm or sickness and is therefore called Latent TB. In about 9.6 million of people, in serious minority of the TB-infected people worldwide, the TB germ causes sickness, or ill-health.
This is referred to as Active TB disease, and this is the form of TB infection that is responsible for the TB pandemic worldwide, especially in the developing world; especially in Africa, Asia, and the South Americas. WHO estimates that worldwide, 1.8million people in 2015 died from TB and 480 000 were diagnosed with Multi-Drug Resistant TB.
South Africa, the most developed economy in the African continent is one of the countries with the highest burden of TB, including Latent TB and Active TB cases. It is estimated that 80% of South Africans have Latent TB, and 1% of the South African population develop Active TB annually. WHO estimated that SA had 450 000 Active TB cases in 2013, and 270 000 (60%) of those TB cases were also infected with HIV germ simultaneously. The National Department Of Health, revised the figure of concomitant TB and HIV to 73% based on actual figures as opposed to the lower estimates by WHO.
In terms of the natural death statistics that were released by the Stats SA recently (28th February 2017), it was revealed that TB is the number one cause of natural deaths in South Africa, far ahead of HIV and AIDS. 7.2% of the natural deaths in 2015 were due to TB, more than Diabetes Mellitus which came in at number 2. TB being the number 1 cause of natural deaths has been the case for more than a decade, something that led our former President Dr Thabo Mbeki to ask “Why was a Number 9 cause of natural deaths which was HIV and AIDS in 2005, being elevated to higher prominence than the number 1 cause which was TB”.
In terms of the 2006 TB prevalence statistics in SA, they vary from province to province, with KwaZulu-Natal found to be in poll position at Number 1 (with most cases 104 000), and Northern Cape at Number 9 (least cases at 8 000). The TB prevalence provincial picture was found to be as follows:
|SA Province||2006 – Number Of Actual TB Cases|
|1. KwaZulu-Natal||104 705|
|2. Western Cape||49 093|
|3. Eastern Cape||48 512|
|4. Gauteng||46 093|
|5. North West||28 421|
|6. Free State||23 374|
|7. Limpopo||17 301|
|8. Mpumalanga||15 035|
|9. Northern Cape||8631|
Looking at the above TB provincial prevalence, as much as the relationship with HIV and AIDS is an established fact, it does not completely explain the above picture, because whilst it can be strongly argued that KwaZulu-Natal being the province with the most HIV and AIDS cases, it is expected that prevalence of Active TB should be highest there. Western Cape province, is amongst the least affected by HIV and AIDS in SA, yet when it comes to the provincial TB prevalence, it was the second highest in the country.
Based on serial annual provincial HIV and AIDS prevalence from the National Department Of Health, one would have expected Mpumalanga and Gauteng to feature in the top 3 in TB provincial prevalence statistics as well. There are obviously other factors at play in the TB provincial picture that we are seeing above.
The big question that should be rightly asked when reflecting on the above global and national TB statistics is whether the global fight against TB is being lost worldwide? Focusing more specifically on South Africa, the same question should be asked of whether as a nation we are making progress in the fight against TB. To attempt to answer that question, it is important to look at the table below, which looks at several progress variables in the national fight against TB.
|TB Fight Progress Variable||Year 2001||Year 2009|
|1. TB Cure Rate (%)||49.7||71.1|
|2. TB Success Rate (%)||60.5||77.1|
|3. TB Mortality Rate (%)||6.7||7.2|
|4. TB Defaulter Rate (%)||11.1||7.1|
Source: National Strategy On HIV, STI and TB 2012-2016
The above table that tracks South African progress picture, zooming in at the various progress variables that share objective evidence on progress, it is evident that as a nation already by 2009 we were making progress in the fight against TB.
TB Cure Rate: This is the percentage of TB-infected people, who had completed their TB treatment, and there was objective evidence that the TB germ has been cleared from their bodies. In this variable, there was a substantial increase in the cure rates by 2009, and surely this will have improved significantly, ever since the intensified implementation of HIV and AIDS programmes, and more specifically the Anti-Retroviral Therapy and TB massive roll-out, under the President Jacob Zuma presidency.
TB Success Rate: This is like the TB Cure Rate. The difference is that in this variable the TB infected persons have completed their TB treatment, they are clinically cured, but there is no objective evidence that the TB bacteria has been eradicated from their bodies. Just like the previous variable, there should be further progress on this variable with the intensified HIV and AIDS ARV and anti-TB roll-out programme under the President Jacob Zuma Presidency.
TB Mortality Rate: In this variable, we are looking at the percentage of deaths as a direct result of the TB infection. In the above table, it shows that there was a marginal increase in the number of deaths related to TB infection. The main reason behind this picture was the silo approach to TB management, wherein it was not mandatory for TB infected people to be tested for HIV infection and be put on ARV treatment.
These individuals tested positive. Since then our National Department of Health made it mandatory for any TB case to be tested for HIV and vice versa, and for dual therapy against TB and HIV to be commenced to ensure pharmaco-therapeutic management for both conditions. I, therefore, believe that this policy change with respect dual therapy will have reduced the TB-related mortality.
TB Defaulter Rate: This is the percentage of TB patients who for whatever reason stopped taking treatment prescribed by their treating doctors. This poses a problem, because the TB germ becomes resistant to the same drugs when they are re-introduced. This is referred to as Multi-Drug Resistant TB (MDR-TB), or even worse, Extreme Multi-Drug Resistant TB (E-MDR TB), both of which are very difficult to treat. The two conditions are a big public health problem, hence the prolonged isolation of these cases, to mitigate spread of these multi-drug resistant TB germs in the communities in which those people live.
Looking at the variable above, there was a significant 4% percentage drop in the dropout rate. I believe that with the more comprehensive approach to HIV and AIDS and TB management, as well as the massive awareness campaigns that are focusing on adherence to prescribed drug therapy by all those who are HIV and TB infected, the two conditions will be crippled.
The TB epidemic in South Africa is still a major public health challenge. I sincerely believe that the tide is slowly turning though. With more awareness programmes focusing on prevention and treatment, the aggressive comprehensive approach on dual investigation and treatment of both TB and HIV infections, and the massive investment by our government on expensive more efficient technologies to early detect TB infection, like the GeneXpert technologies; the fight against TB will be surely won.
Human genetics researchers from the University of Stellenbosch recently announced that they have started a specialised Genetic Mapping Technique called ADMIXTURE. This technique will help to better understand if there are genetic predispositions to some exposed individuals being infected with TB germs, whilst others do not. It will also help to explain why some TB infected people progress to Active TB, whilst others do not.
Further, on the 24th March 2017, as part of the World TB Day, Minister Of Health Dr Aaron Motsoaledi, publicly announced that the National Health Department has partnered with a Japanese Drug Manufacturing Company, Otsuka Holding Company Limited, to launch a Two Year Pilot Treatment Programme with a New Drug called DELAMANID. This is a specialist drug used for treatment of Multi-Drug Resistant TB, a condition that has increasingly been a big treatment challenge in South Africa.
This specialist drug is already in use in Japan, the European Union, and South Korea. South Africa is the first country in the African continent to roll it out. It is reported that this new drug has minimal side effects, and is therefore better tolerated by patients than current drugs that are being used to treat Multi Drug Resistant TB. It was also found that there is minimal resistance to it by the MRD-TB germs.
In conclusion, victory against this very complex and clever TB bacteria is certain. However, we must all play our part in the prevention, symptom recognition, early diagnosis, early treatment, compliance, completion of treatment and support of loved ones who are TB-infected.
Aluta Continua!!! The Struggle Continues!!! Forward Ever!!! Backward Never!!!