Recently in Beijing, health experts described the deadly drug-resistant strain of tuberculosis (TB) spreading fast in the developing world as a time bomb.And one of Kenya’s leading chest specialist and researcher with the Kenya Medical Research Institute, Dr. Jeremiah Chakaya, says incidences of Multi-Drug Resistant TB (MDRTD) and Extreme Drug Resistant TB (XDRTB) may become a nagging health challenge in the developing world, especially Africa with its weak implementation systems.
“Africa has the highest per capita incidence of TB in the World. Swaziland leads with the highest incidence of TB per population,” he says.
While tuberculosis is largely under control in developed countries, it still haunts the poor in the developing world. Chakaya attributes this, among others, to overcrowded housing, undernourishment, increased number of people abusing drugs and poor access to quality health care.
HIV/AIDS Compounding the Problem
The HIV/AIDS scourge is compounding the problem. A research study titled “TB Prevalence Survey and Evaluation of Access to TB Care in HIV-Infected and Uninfected TB Patients in Asembo and Gem, Western Kenya,” says that HIV/AIDS is fueling large increases in TB incidence in Africa, and a large proportion of cases are not diagnosed.
Chakaya argues that, although XDRTB is not yet common in Africa, it is bad news. “XDRTB is very difficult to treat and some people consider it untreatable. If we generate a lot of this form of TB we will have pushed ourselves back to the pre-antibitiotic days of the last century,” says Chakaya.
Africa, according to him, will end up with a disease that is killing people and cannot be treated, just like it was at the beginning of the last century.
Other than for Southern Africa States such as South Africa, Lesotho and Swaziland, most other African states have low rates of Multi-Drug Resistance TB (MDRTB) and an unknown rate of the more lethal XDR.
MDRTB is TB resistant to Rifampicin and Isoniazid, the two most powerful anti-TB drugs while XDRTB is MDRTB that is also resistant to second line drugs in particular resistance to an injectable and a fluoroquinolone.
In Kenya the most recent figures gathered in 2005 indicate that about 1 percent of new, not previously treated patients have MDRTB. The country may have one or two cases of XDRTB. “This is the situation in most other countries of Africa,” pointed out Chakaya. “But in Southern Africa, the rate of MDRTB in new patients may be more than 3 percent,” said Chakaya.
Whereas most countries have elaborate plans to deal with the problem, the implementation of those plans is something else. Countries in Africa are constrained by inadequate resources, poor laboratory infrastructure and weak surveillance systems which make it difficult for these countries to mount robust responses to the MDRTB menace.
According to a World Bank document, “Tackling Tuberculosis in Africa,” over the past two decades, sub-Saharan Africa has seen a resurgence of this airborne disease, which disproportionately affects the poor. In Africa, TB is the leading killer of people living with HIV/AIDS.
For instance, the bank says that weak control systems coupled with spiraling HIV epidemics is one of the causes of MDR TB in South Africa. This makes treatment expansive and over along periods of time with minimal chances of success.
Those suffering from both HIV and TB in Africa are faced with multiple challenges like covering long distances for TB medications at health clinics and access to antiretroviral which is only at district hospitals.
“While services and drugs are generally free or highly subsidized, patients complain about the cost of lab exams, hospitalization, and transportation,” WB says.
Chakaya explained that the side effects and the hassle of taking fifteen to twenty pills a day for six months means that many patients might stop taking medicines as soon as they feel better. This is specially true in Africa where keeping patients on therapy for such along time is extremely difficult.
Problem is Not Drugs but Linkages
When it comes to treatment standards, Chakaya says Africa follows keenly World Health Organisation (WHO) norms and standards. “There is no single African country that does not follow the recommended processes for the diagnosis and treatment of TB,” he says. The drugs used in Africa are mostly from the Global Drug Facility which is an instrument set up by the Stop TB Partnership to help poor countries such as those in Africa to provide high quality anti-TB drugs to their patients.
“The problem is not drug treatment of new patients by the programs in the African region: It is linkages with the private providers who may not follow national guidelines, it is supporting and educating patients to adhere to treatment and it is ability to rapidly identify patients who may have TB germs that may not respond optimally to treatment (such as patients with resistance to a single drug).”
Some of the most current and effective drugs for the MDRTB include Amikacin, capreomycin or Kanamycin, ethionamide or prothionamide, cycloserin, paraaminosalicylic acid, and the fuloroquinolones (ofloxacin, moxifloxacin or gatifloxacin.)
The rise in drug resistant strains complicates the fight against the contagious lung disease, since the drugs needed to fight the tougher strains are far more expensive and unpleasant, according to Chakaya
“The treatment of usual TB costs US$56.25 at the maximum (drug costs only). Treating drug resistant TB (MDRTB) cost not less than US$15,000.
This is a time bomb but this time bomb can be stopped, if only we all played our roles,” concluded Chakaya.
Stigma persists across Africa forcing some to seek care from traditional healers in vain. This makes the disease reach advanced stages which increases the risk of infecting others and making treatment more complicated, long and costy.
Dr. David Okelo, WHO Representative, Kenya Country Office, says stigma is an awful thing in the fight against TB. “People consider it terrible to be seen coughing for months. Most of them keep away from treatment. It is one of reasons for the MDRTB in Africa,” he says.
The wealthy and the elites of the society also get affected. They prefer private hospitals, some of which do not have standard treatment procedures for TB. They even stop treatment halfway once they feel a little fine.
“TB is completely treatable but there is no shortcut. You must go treatment full distance and at the end of it tests must be done for several months,” Okelo points out.
TB Can be Overcome
In 2007, 8,600 MDRTB cases were reported in Africa with Southern Africa countries accounting for 85.4 percent of these, says Dr. Joel Kangangi, also of WHO.
But the scourge can be overcome, according to Kangangi, and what is needed is sensitization of the masses so that people go for early diagnosis when it’s still only ordinary TB. If people also comply with treatment regimen and are on good diet, TB is curable.
“The issue is not the drugs, which are free, or standards. TB is treatable if you get the right diagnosis and get treatment at designated places,” says Kangangi. “Any person with a cough of unknown cause running for more than two weeks should for diagnosis. Thirty percent of us are predisposed with TB but the disease has not shown,” added Kangangi.
Okelo also points out that any person on ARV’s or diagnosed with TB should go for regular TB testing because even with HIV/AIDS TB is treatable.
Research Paper: TB Prevalence Survey and Evaluation of Access to TB Care in HIV-Infected and Uninfected TB Patients in Asembo and Gem, Western Kenya
“Tackling Tuberculosis in Africa.” Worldbank.org. March 21, 2008. Accessed May 17, 2009.