Towards a Tuberculosis-free tomorrow

Dr. Buddhadasa Kaluarachchi (President - CNAPT)

Tuberculosis (TB) is a deadly disease known almost from the time of evolution. Over the years the disease has killed billions worldwide.

The germ has been found in excavated remains of Neolithic Man and in Egyptian mummies dated as early as 3,700 B.C. Mycobacterium tuberculosis of the human type is the bacterium that causes TB.

The bacterium avoided detection by researches for centuries until Dr. Robert Koch discovered it on March 24, 1882. At the time of Koch’s announcement, TB was raging throughout Europe and the Americas, causing the deaths of one in seven people. His breakthrough discovery opened the floodgates for the diagnosis and cure of this lethal disease.

Finding a successful treatment for the disease took another half century, when in 1943 Samuel Waksman discovered the powerful antibiotic Streptomycin.

In 1982, a century after Koch’s discovery, the International Union Against Tuberculosis and Lung Disease (IUATLD) proposed that annually, March 24 be proclaimed World TB Day to honour Koch’s ground breaking announcement in Berlin and to promote awareness of the seriousness the disease posed.

today’s world

However TB, assumed by many to be a bygone disease, has returned with a vengeance. Associated with turn-of-the-century romantic poets, TB is once again posing a serious health threat in the industrialised world and is spreading rampantly in the developing world.

The World Health Organisation (WHO) has warned of a global TB resurgence that could affect approximately 90 million people worldwide within the next decade, and TB is the only disease to be declared a ‘global emergency’.

According to WHO officials, more people died of lung disease in 1995 than any other year in history, claiming the lives of nearly 3 million people.

“Not only has TB returned, it has upstaged its own horrible legacy”, Dr. Hirkoshi Nikajima, Director General of the WHO in Geneva said.

Unbeknownst to many TB, remains the single most infectious cause of death among youth and adults today.

The annual number of adults who succumb to TB is more than the adult fatalities caused by Acquired Immune Deficiency Syndrome (AIDS), Malaria and various tropical diseases combined.

Despite new developments in the treatment and management of this condition, TB has claimed a record number of lives during the past five years.

Considered a dreaded disease in Sri Lanka during the past, TB has been receiving less public attention in recent times. This is perhaps due to the notion that the threat has dwindled over the years due to the availability of effective modern medicines.

However this misconception has led to a careless disregard of the disease, which has resulted in the increased number of reported cases.

TB has become a public health risk and virulent killer, even in the developed world, who for decades thought that they had rid themselves of it, where its spread has become increasingly out of control.

Over 95 percent of the infected succumb to the disease, making TB responsible for more than a quarter of avoidable adult deaths in the developing world. The number of TB cases is on the rise in Denmark, Norway, the Netherlands, Italy, Britain, the US and many other industrialized countries, say WHO officials, who warn the crisis will grow unless immediate action is taken.

Socio-economic destroyer

With the increase in urbanisation and the world being reduced to a global village, no part of the world can afford to remain complacent.

Today, a staggering one third of the world’s population is infected with the TB bacillus.

The disease occurs particularly in young adults and it has been observed that it affects more males than females. Every person infected in this age group will be kept out of productive work for several months.

As a result, the loss of income due to the illness deprives dependents of the valuable contribution each person makes towards the sustenance of their families. This is what makes TB a social disease that seeps into every facet of human life.

Since over 75 percent of the deaths also occur in the most productive age group of 15-45 years, it has a great impact on the economic growth of ceratin countries. This contributes to perpetuate poverty and under development around the world, with serious implications on the struggling economies of developing nations who are striving to overcome severe poverty.

Spread, symptoms and detection

Fortunately only 10 percent of the people infected with the bacillus will actually develop the disease at varying points in their lifetime.

A persistent cough often associated with fever, tiredness, loss of appetite, loss of weight and coughing out blood should alert everyone to the possibility of TB infection.

A positive Tuberculin (Mantaux) test is of little value to Sri Lankans, since a significant percentage of the population has had a BCG vaccination and some may have a harmless, non-progressive, primary infection. A negative test however rules out TB.

Examining sputum samples and finding the germ is the most effective way to diagnose the infection. If there are any questionable symptoms the person should seek proper medical advice and help, as these services are readily available in the country.

Both patients and their families should remember that in general TB is curable, with early detection making it much easier to treat.

Only people with an active disease can spread it to others. It can spread from inhaling TB bacilli that has been coughed up, sneezed or in droplets spread while talking. If left untreated, a person with active TB will typically infect around 10-15 people a year. Further, unsanitary living conditions, a poor state of general health and malnutrition will make a person much more vulnerable to the disease.

The stigma attached to the condition was caused mainly by the ignorance of the public. This was a major obstacle to the early detection and prevention of the disease. However the availability of effective drugs has, to a great extent, helped eradicate such prejudices.

Use of the Directly Observed Treatment Short Course, (DOTS), has proven to be the most successful and cost effective course of treatment used the world over. DOTS help make a patient non-infective within a period of two weeks, and completely cures within 6-8 months.

Unfortunately, the advantage achieved through education and improved outreach of health services has suffered a serious set back with the emergence of multi-drug resistant TB and AIDS.

While TB is the biggest killer of HIV positive patients worldwide, it is also appearing in forms resistant to multiple drugs (MDR-TB) and therefore cannot be cured by medicines that have previously proven to be successful.

Resistance strains - A global problem

It is estimated that there are more than 50 million people in the world infected with resistant stains of TB, making this a global problem. These drug resistance strains pose a threat of becoming an incurable condition. Further, people infected by a patient carrying the resistant strain of the bacilli will also become carriers of the multi-drug resistant strain.

Health officials warn that the emergence of drug resistant strains of TB threatens to make the disease incurable and can amount to a death sentence.

Multi-drug resistant strains are man-made, primarily due to poorly implemented treatment programs and incomplete antibiotic therapy.

The main reason for inept treatment, which has contributed to this alarming condition, is the lack of compliance with internationally recognized standards of care, improperly prescribed drugs, and the failure to ensure that patients take their medication accordingly.

Conquering Tuberculosis

In addition, the effective treatments available today give patients a false sense of security, lulling them into the misconception that they may discontinue taking the treatment over the prescribed period. This dangerous trend of thought adds to the burden of TB prevention.

A high-risk segment of the modern world are the people infected with AIDS which lowers the body’s defence mechanisms, making them more vulnerable to TB.

This leaves a person defenceless and most certainly makes such a person, a high-risk fatality. Very simply, it is due to the low priority given by health policy-makers. In many low to middle income countries, less than 1 percent of the annual health budget is allocated for TB. Inadequate funding and inefficient TB control programs has led to an increase in the world situation.

It has been recorded that in countries poorer than Sri Lanka, such as Nepal and Bangladesh, (with per capita GNP of around $ 200, compared to a per capita GNP of US $ 840 for Sri Lanka), more than 90 percent o f Tuberculosis patients can be cured with the emergence of multi-drug resistant Tuberculosis controlled treatment.

However, compared to other South Asian countries, Sri Lanka is far ahead in terms of life expectancy, literacy and maternal and infant mortality.

This is a consistent source of amazement to developed countries like Japan, who wonder how we maintain indices comparable to a developed country despite the ongoing civil war.

The answer lies in the solid infrastructure and the standard of literacy and education of our population.

It would be tragic if the TB situation in Sri Lanka were allowed to deteriorate, in spite of possessing such a proud record of healthcare.