The tuberculosis burden in Uganda

Harriet Katusiime, 34, a resident of Lugube-Kawempe, was diagnosed with tuberculosis (TB) while pregnant with her fourth child in September 2014. At the time of diagnosis, she was 24 weeks pregnant and had been coughing for more than two months. She had sought treatment for the cough in several clinics, and was given antibiotics but registered no improvement.

However, it was at Kiganda Maternity Clinic located in Kawempe Division, Kampala where a sputum examination was ordered and it turned out positive for TB. She then started on an eight-month course of treatment.

“I am in the fifth month of my medication and I no longer feel any signs and symptoms of the disease and in December, I was blessed with a healthy baby boy,” says Katusiime as she attends a post-natal care at Kiganda Maternity Clinic.

The private clinic integrates maternal care and TB treatment. It is one of the free TB private urban clinics supported by the International Union against Tuberculosis and Lung Disease, a non-profit organisation headquartered in Paris.

Katusiime is one of the estimated 60,000 patients living with tuberculosis in the country, according to Dr Frank Mugabe, the programme manager of the National TB and Leprosy Programme (NTLP).

He says about 44,000 TB patients were detected last year while 16,000 patients remain undetected due to lack of awareness, poor health seeking behaviour, inadequate diagnosis such as non-functional x-ray machines, limited capacity of health workers and lack of a patient-tracking mechanism.

“Uganda is among the 22 high burden countries of the world. These are countries with the highest number of TB cases,” says Dr Mugabe.
Furthermore, Uganda has a high number of TB/HIV co-infected persons with about 50 per cent of the patients co-infected with HIV/Aids.
Dr Mugabe explains that if you are a TB patient, you are seven times more likely to have HIV/Aids than when not a TB patient.

“If you have both diseases and one of them is not treated, you’re likely to die of it,” adds Dr Mugabe.

HIGH MORTALITY
Currently, TB mortality remains high in Uganda, with about 4,000 people dying of the disease every year, according to Dr Mugabe, an equivalent of the population in a parish setting.

The high death rates have been attributed to the challenge of poor health-seeking behaviour, poor drug adherence and inadequate funding.
“People die because they do not adhere to the treatment. But in presence of a disease, some people may die,” says Dr Mugabe.

Although, he says the country has attained capacity to manage both TB and HIV together in an integrated manner, the progress has been crippled by inadequate funds released by government towards diagnosis, treatment and cure of the disease.

When asked about funding, Dr Mugabe was hesitant to mention the exact amount of money government disbursed towards TB treatment in the current financial year, only saying it is no good at all.

“There is a lot of dependency on donors, who are making a big contribution but with high challenges of commitment. They can choose where and when to release the money yet we want funds according to national TB control priorities,” he says.

He, however, acknowledges the contribution of Global Fund whose funding bridges the gaps on availability of medication, the role played by the International Union against Tuberculosis and Lung Disease, which has helped in case identification and treatment in Kampala and Mukono districts, and other development partners.

THE COST OF TREATING Tuberculosis
A programme review report conducted in 2013 indicates that less than $30,000 (about Shs85m) was allocated by the government to NTLP and about $2m (Shs5b) to the National Medical Stores (NMS) for TB drugs.

However, Dr Mugabe notes that the allocations excluded funds for TB reagents and a laboratory supply which resonates with limited funding at a time when the country has about 400 multi-drug resistant Tuberculosis (MDR) patients.

According to Dr Mugabe, it costs about $4,000 (about Shs12m) to treat one patient of multi-drug resistant TB for a period of 24 months and $80 (Shs236,000) per patient with drug susceptible TB whose treatment duration is six months.

The programme manager argues that for TB to be controlled, it has to be looked at as a national epidemic which is in line with the Maputo Declaration of 2005 where African countries were advised to do so.

“Every year, we need medicines and laboratory supplies of not less than Shs9b for TB patients and operational funds of not less than Shs2b at a national level if we are to do what we need to do as a programme,” Dr Mugabe notes. He also adds that each district needs about Shs6m dedicated to TB control.

Dr Jane Aceng, the director general of health services at the Ministry of Health, also admitted to the lack of funds.

“We have challenges with laboratory reagents but it’s due to budgetary issues which we are addressing with the Finance ministry,” she says.

LITTLE DATA COLLECTED
Besides under-funding, controlling TB in Uganda has been difficult due to the lack of accurate and reliable TB data or information to inform policy, support effective planning and control plus coming up with strategy.

However, Makerere University School of Public Health, on behalf of the Ministry of Health is currently conducting the first nationwide population based TB prevalence survey with financial funding from Global Fund.

The project that started in September last year is targeting a sample size of 40,180 respondents from 57 districts in Uganda. The survey is expected to be complete by July this year.

The World Health Organisation country representative, Dr Wondimagegnehu Alemu, says the information from the survey will be valuable to inform where the country is and design TB control strategies.

“This will place us in a position to use our own data to assess our performance as opposed to estimates,” says Dr Alemu.

History of Tuberculosis

The story of the airborne disease dates back to the ancient days of Egyptian mummies from 2400 BCE. During these days, the disease existed in the population. Information obtained from the website of the Global Tuberculosis Institute indicates that exact pathological and anatomical descriptions of the TB began to appear in the17th century.

In his Opera Medica of 1679, Sylvius was the first to identify actual tubercles as a consistent and characteristic change in the lungs and other areas of consumptive patients.
He also described their progression to abscesses and cavities. The earliest references to the infectious nature of the disease appear in seventeenth century Italian medical literature

It was in the colonial times, around 1882, when a German scientist known as Robert Koch isolated the germ that causes TB known as (mycobacterium tuberculosis). He discovered a staining technique that enabled him to see the bacteria.
The use of drugs came later in 1940 when one drug was used before there was resistance that led to use of combined chemotherapy.

According to Dr Frank Mugabe, the programme manager of the National TB and Leprosy Programme (NTLP), it is reported that in the 1960s, all diseases were managed by a robust Ministry of Health which collapsed around the 1970s. The NTLP was established in 1989 and slowly, the programme has extended to reach all districts. Dr Mugabe says more than 1,300 facilities, mainly hospitals, health centres IVs and IIIs diagnose and treat TB.

The programme has since expanded taking on new challenges, including TB and HIV integrated services, which began in 2006.

In 2008/2009, capacity to diagnose multi-drug resistance TB was attained and treatment in 2012 with the programme boasting of about 15 multi-drug resistant treatment sites all over the country.

THE NUMBERS

• Uganda is one of the 22 high TB burden countries in the world
• 60,000 TB patients are expected in the country out of which 44,000 were detected in 2014.
• A total of 16,000 patients remain undetected due to absence of a National Population based Tuberculosis Prevalence Survey.
• 50 per cent of TB patients are HIV positive
• TB affects any part of the body but the most common is Lung TB which accounts for 80 per cent of the TB patients in the country. Others include TB of the intestines and the bones.
• Currently, the National TB and Leprosy Programme is treating about 400 multi-drug resistant TB patients.
• $4,000 (Shs12m) is the cost of treating on MDR patient while $80 is required for treating one drug susceptible TB patient.
• In 2013, according to the TB programme review report, government allocated $30,000 (about Shs75milion) to TB control and about $2millon (Shs5billion) to NMS for medicines. The programme manager estimates that about Shs9billion is required for both medicines and laboratory reagents. While about Shs2b should be set aside as operational funds.

FACTS ABOUT TUBERCULOSIS

Today, Uganda joins the rest of the world to celebrate the International TB Day under the theme: “Reach the 60,000 patients in Uganda.” Gulu District is hosting this year’s celebrations under the slogan: “Find, test, treat and cure all.”

Tuberculosis is caused by a bacterium known as mycobacterium tuberculosis. It can affect any body part but 80 per cent occurs in the lungs. Lung TB is a chronic debilitating illness characterised by a long-standing cough, normally for two weeks or more.

Some of the signs and symptoms include: coughing up blood, body wasting, chest pain, excessive night sweats, evening fevers, weight loss depending on the disease toll, loss of appetite and swellings around the neck and in the armpits.

Lung TB is transmitted when a susceptible person breathes in contaminated air from an infected person when he or she sneezes, laughs or sings.

Risk factors
Dr Frank Mugabe identifies the risk factors as:
Immune suppression: Any diseases that reduce body immunity such as HIV/Aids and other factors such as malnutrition can lead one to acquire TB.

Exposure: TB is not a congenital disease but you can acquire the disease once exposed to an infected person (airborne disease). It can be transmitted in places such as health centres, schools, churches, slums, factories, markets and prisons.

Age: Usually the very young and the very old are at a higher risk.

Congestion and poor ventilation: People living in houses with no windows are at risk, for example; prisons, factories and informal housing units in slums.

Preventive Measures
At birth, every child is given BCG vaccine. This protects severe forms of TB and offers protection for about 15 years.

Dr Mugabe says there is also secondly prevention, using isoniazid, a preventive treatment given to persons who are exposed to TB and are at risk.

Other preventive measures include: prompt identification of persons with infectious TB and quickly treating them.

“We need to achieve high cure rates, and sustain them in order to stop transmission and human suffering. By doing this, everyone needs to be involved by ensuring that diagnosis patients get support,” Dr Mugabe emphasises.

By doing this, he adds that the country will minimise the lost number of follow up of patients from the current 10 per cent to about five per cent.

There is need to identify the 16,000 missed TB patients who are living in the communities who are either hard to reach or hard to diagnose. These include: Children under five, HIV positive patients, people in slums, fishing communities and factory workers.

Recommendations
Dr Mugabe says there is need to allocate resources at all levels together with personnel, and revamp the infrastructure and equipment. “This requires serious equipment, multi-drug resistant TB isolation wards, X-ray machines, gene-xpert machines and other crucial laboratory supplies,” says Dr Mugabe.

In addition, the public should avoid self-medication and develop the behaviour of always consulting a physician. He also says that the general public should not stigmatise TB patients because it a curable disease but should advise them to adhere and complete their treatmen.

“If you are TB patient do not be intimidated. Always contact a health worker. Families also need to support their members,” he adds.

To health workers, Dr Mugabi cautions that the disease is dangerous when unknown. In a scenario, where there is persistent cough, fevers, HIV positive, weight loss, diabetes and other immune depressing conditions, doctors should think about diagnosing TB.

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