Ending TB is no pipedream
The fight and prevention of TB should be the responsibility of all SA citizens. All hands should be on deck, Nazir Ismail writes
TUBERCULOSIS is the leading infectious fatal disease in South Africa, outstripping HIV for the number one spot Over the past decade, more than 3 million people have suffered from the disease, and every year new cases to occur. Addressing this epidemic requires bold initiatives aimed at treating the underlying cause rather than the symptoms.
Tuberculosis disease develops either from reactivation of latent TB in patients with immunosuppression or from direct transmission of an active and infective TB patient to close contacts. In South Africa, human immunodeficiency virus (HIV) has been a main driver for the former, while delays in diagnosis and treatment is the principal underlying issue for the latter.
In 2015, 57% of all cases treated for TB were HIV co-infected, and thus the importance of effective population-level interventions aimed at controlling HIV on TB cannot be underestimated.
The bold decision to rapidly expand the availability and use of antiretroviral treatment (ART) was bound to have a positive impact on the TB epidemic in South Africa. A national analysis of laboratory-confirmed pulmonary TB demonstrated a decline in the rate of new cases of TB annually began in 2008.
The upscaling of ART was an important contributor and showed a four-year lag in the impact on TB rates.
Encouraging declines have also been observed globally, resulting in radical transformation of the strategy from one of “control” towards that of “ending” TB. This new strategy, launched by the World Health Organisation (WHO), aims to reduce the number of new infections to less than 10 per 100 000 population by 2035. South Africa has the highest incidence rate globally, at 834 per 100 000, which makes the challenge even harder.
In order to reach the target, a 10% per year reduction in the rate of TB is required, and will be the cornerstone of the new strategic plan for TB in South Africa.
A recent update of the laboratory-based data at the National Institute for Communicable Diseases has provided important findings that will now need to be carefully considered.
The impact of ART has been massively important, but despite these great achievements, it addresses only half the problem. Current reductions are in the order of 5%, which is half of the required rate but much better than the 2% global average.
Further analysis has shown that the successes in reducing TB rates have been driven primarily by females aged between 25 and 44, the population primarily targeted by the HIV programme.
However, there are more males who suffer from TB than females, and it is in the former that declines have been slow to minimal in many provinces.
Accelerating reductions to reach the 10% a year required will undoubtedly need a greater focus on this population. Health-seeking behaviour is generally poorer for men than women, and exploring and addressing the underlying reasons are paramount.
Male role-models are hardly used, and this needs to be improved. History teaches us that legends like Nelson Mandela and Desmond Tutu also suffered from TB, but overcame the disease and have become icons of success. But we need more cases like these to be promoted.
Strategies to generate male interest in coming forward for health services through wellness and fitness campaigns also need to be considered.
A review of male medical circumcision programmes and their successes in targeting this population will also be useful and important, and provides an entry point for TB services for males.
Unfortunately, even these will not be enough to achieve elimination of TB in the time frame required.
It should also be appreciated that just under half of the TB patients in South Africa don’t have HIV co-infection. Early diagnosis and treatment of active TB is the core of cutting transmission.
The use of effective and appropriate treatment reduces infectivity by almost 90% within 48 hours. Unfortunately and despite the great advances in diagnostics for TB in South Africa, almost one in five patients with laboratory-confirmed TB do not start treatment. Such patients are a high community risk, primarily to their social contacts.
Efforts aimed at tracing cases who have not returned for care need to be an important priority. Major challenges with tracing efforts is the lack of reliable information to find patients and the community stigma around TB. Major efforts at community education are required.
A poorly appreciated fact is that although more than 3 million people were diagnosed with TB in the past decade, the vast majority have had a successful outcome – TB is curable and doesn’t need lifelong therapy.
The need for counselling TB patients, much like the programmes used in HIV that have shown success, is important and is lacking, while alternative strategies aimed at incentivising patients, like the use of conditional cash transfers, have shown success in other settings, and programmes and need be investigated.
Another important group requiring attention is close contacts of active cases of TB. These individuals are at the highest risk of progressing to active TB within the first six months to a year.
Current once-off screening of contacts is not sufficient, as disease may develop over time, and ensuring regular follow-up and use of invitation slips or other methods to trigger a reminder needs to be considered. These would increase the speed and yield in finding undiagnosed cases that pose a risk to others and impact on the ability to reduce new infections.
The last area requiring concerted effort is the management and use of data for informing decision-making and targeting interventions. The successful launch of the online TB Surveillance dashboard by the National Institute for Communicable Disease has demonstrated the power of data.
It highlighted the need not only to target specific populations but also geographic areas. The epidemic is widely heterogeneous, and targeting areas where the need is greatest will yield the greatest success using the least resources; an important consideration with current challenges with the fiscus.
The end of TB is not a pipe-dream and can be achieved if we have all hands on board working wisely targeting the root causes and focusing on relevant populations and hotspots. TB is curable, and millions have been cured! We all need to share our common humanity – the spirit of ubuntu – and not see TB as another person’s problem.
All of us share in the duty to help those with TB and thus protect our communities. We cannot allow fellow South Africans to die of a curable disease.