Tuberculosis is a contagious but curable disease yet in Uganda, it continues to kill silently and in huge numbers. This is in part because of a high default rate and the advent of HIV/Aids. The country is also detecting only 57 per cent of all cases. These factors have all combined to hinder successful treatment, writes Sunday Monitor’s Evelyn Lirri;
She spoke with great difficulty. Her breathing was slow. But in Ms Evelyn Abur’s eyes, it was easy to see the determination and hope of living despite being diagnosed with Tuberculosis, a disease that globally kills an estimated two million people annually or 4,700 every day.
Sadly, most of these deaths occur in developing countries like Uganda.
Ms Abur had first survived the deadly disease in 2006. At the time, she was living in an internally displaced people’s camp in northern Uganda where a 20-year-old civil war had forced people out of their homes. The camps were cramped; families lived in squalid conditions which made them vulnerable to infectious diseases including TB.
Many like Ms Abur would eventually get infected this way.
“We were living in very terrible conditions at the time that if your neighbour had TB, your chances of getting infected were almost one 100 per cent. That’s how I think I got infected.”
“It started with general body weakness, prolonged cough and chest pain. The cough couldn’t go away and so I went to Anaka Hospital where I was diagnosed with TB. I started treatment but it was difficult,”Ms Abur recounted.
Because she stayed far away from the hospital, it became increasingly impossible for her to adhere to the treatment and so she missed some dozes of her drugs. All the same, and months later, she was declared TB free.
This, however, was short lived. In January this year, after a persistent cough, she visited St. Mary’s Lacor Hospital. Here she was for a second time diagnosed with TB.
Doctors said she was a case of TB relapse and has now been re-admitted to the hospital.
The 43-year-old mother of four is frail and weak. And for her age, she weighs just 46kgs. She has now been put on a full doze treatment of a daily injection for 60 days and a number of antibiotics. Abur’s case is a demonstration of just how hard it is to tackle tuberculosis in a developing country like Uganda.
Although there is already a strategy for treatment and prevention, Uganda still faces an uphill struggle to control the disease with about 102,000 new cases occurring every year and contributing a large proportion of the country’s already high disease burden.
Health Minister Stephen Mallinga acknowledges that not enough has been done to combat the disease which can be easily prevented and cured with effective and yet simple treatment.
“The drugs for effectively treating and curing TB have been known for over 60 years but the number of TB cases continues to rise. The increasing numbers show that indeed we have not done enough to combat TB,”said Dr Mallinga.
The only TB vaccine currently available, the Bacille Calmette Guerin (BCG) gives limited and unreliable protection and does not protect against pulmonary TB which affects 75 per cent of those infected.
Ms Emmy Laker, a nurse at Lacor Hospitals’ TB ward explained that the biggest challenge in treating TB among patients is adherence. “After completing the injections, she will be discharged but she will have to continue with the drugs. We usually give TB patients drugs that last up to two weeks and then they have to come back for another doze,”Ms Laker said of Ms Abur.
“When patients come back after every two weeks, we are able to monitor them properly and see if they are responding well and are taking their drugs as has been prescribed,”she added. Even without the medical worker’s precaution, which many patients do not adhere to after feeling better, Ms Abur is determined to complete her medication.
“I will make sure I follow the advice of my doctors and take all my drugs. I don’t want to suffer from TB a third time,”she said. Patients like Ms Abur are well aware that missing their doze of drugs only complicates treatment; subsequently leading to early death, yet many more others need to be educated on the danger of defaulting on treatment.
And this is one of the biggest challenges health experts are aggressively trying to deal with.
According to Dr Ignatius Magombe, a public health specialist at St Mary’s Hospital Lacor, some patients opt not to take their medication after showing signs of recovery.
“It is difficult for some patients to appreciate the length and duration of treatment. When some of them feel better, they stop taking their drugs and this affects the whole treatment process,” said Dr Magombe.
For some patients though, Dr Magombe says the long distance to the health facility makes it hard for them to adhere to treatment. “Many cannot afford the regular trips from remote rural areas to health centres for diagnosis and treatment.”
In fact a low TB cure rate, an equally low detection rate of new smear-positive cases and a high number of patients who fail to complete their treatment, have all combined to keep Uganda at 15th position among the 22 high-burden countries affected by the TB epidemic.
These countries collectively contribute up to 80 per cent of the global TB burden.
According to the Uganda National TB and Leprosy Porgramme, of all the TB patients who started treatment in 2008, only 75 per cent were successfully treated and cured.
“As a country, we are not performing well enough. These performance levels are below the global and national targets of detecting 70 per cent of infectious cases and successfully treating 85 per cent of them,” said Dr Mallinga.
Targets for global TB control have been outlined within the framework of the Millennium Development Goal 5 to halt and reverse the incidence and rates of TB by 2015 compared to their 1990 levels and detect at least 70 per cent of new smear positive cases and treat at least 85 per cent of detected cases.
Equally more disturbing is the fact that the country is detecting only 57 per cent of all new cases. The World Health Organisation (WHO) global Tuberculosis Control report of 2008 noted that between 2004 and 2005, Uganda registered the lowest TB cure rate in the world-at just 32 per cent.
In both years, Uganda also had the highest default rate of any high-burden country, despite the use of the WHO recommended Directly Observed Therapy (DOTS). Under the DOTS programme, patients must swallow their drugs under the direct supervision of a caretaker.
But this prolonged and painstaking treatment plan is very demanding and many patients stop taking their drugs as soon as they feel better only for them to relapse or in severe cases, develop a drug-resistant strain of the disease which is more difficult to treat.
Another challenge, health experts say is TB’s deadly synergy with HIV/Aids which is threatening gains in treatment and control of the disease. At least 60 per cent of TB patients in the country are co-infected with HIV yet by 2006 only one quarter of TB patients were tested for HIV.
Dr Magombe explained that many of the patients who have been tested positive for TB have also been found to be co-infected with HIV/Aids. “These two diseases move hand-in-hand and so it is difficult to disassociate,” said Dr Magombe.
“We must implement TB/HIV collaborative activities countrywide. The policy guidelines are in place and should be operationalised fast,” Dr Mallinga said. The Ministry of Health is already working on a plan to see that all TB patients can access treatment as easily as possible.
The hope is that eventually all patients who are tested positive for TB can get cured after completing a full course of treatment. But to turn the tide on the TB epidemic, health experts agree that increased financial commitments for TB and a faster and better TB drug regimen will be crucial and could save millions of lives.