A Synopsis Of TB Control In Ghana Towards Commemoration Of World Tuberculosis Day 2016

All over the world, 24th March is commemorated as World TB Day after the discovery of the germ that causes tuberculosis (Mycobacterium tuberculosis) in1882 by Dr. Robert Koch.Since this discovery, the world has made tremendous strides in the fight against Tuberculosis. However, the disease still remains a major public health concern globally and current efforts to reach treat and cure everyone who gets ill with the disease has not been sufficient though the disease is curable.

The day will also be commemorated in Ghana in 2016 with the theme “Unite to End TB” and calls upon all partners and stakeholders to unite towards achieving the goal of TB elimination by 2035.

Objectives

Objectives for World TB day 2016 commemoration are:

  • To place TB high on the political agenda of the country through the Ministry of Health and to increase commitment of all stakeholders to END TB in Ghana by 2035
  • To attract more partners into TB control in Ghana
  • To empower affected communities towards ending the TB epidemic in Ghana
  • To increase public awareness on the threat TB poses
  • Combat stigma and discrimination against TB patients
  • Mobilize resources to fight the disease.
  • To reduce catastrophic cost on TB affected families

 

TB Disease

Tuberculosis is a contagious bacterial disease caused by Mycobacterium tuberculosis. TB mostly attacks the lungs (pulmonary TB) but it can affect any organ in the body (extra Pulmonary TB). TB that affectsother parts of the body is not as infectious as TB of the lungs.

Pulmonary TB is transmitted from a sick TB patient as a droplet infection through coughing, singing and sneezing. Inhalation of these droplets by an uninfected person may cause infection.  The risk of contracting TB increases with the frequency and duration of contact with people who have the disease.

The cardinal symptom of pulmonary TB is a cough lasting 2weeks or more and for people living with HIV (PLHIV) a cough of 24hours is significant along with other constitutional symptoms. Other symptoms are weight loss, tiredness, night sweats, chest pain and cough with blood stained sputum

 

Who Is at Risk

It must be emphasized that adultsin most parts of the developing world including Ghana havebeen exposed to TB bacteria without knowing resulting in TB Infection. Those at higher risk of progressing to disease are: smokers, alcoholics, people living in overcrowded and poorly ventilated rooms, mine workers, and personswith loweredimmunity due to medical conditions such as HIV, Diabetes, cancers, kidney failure and malnutrition.

However, TB is a preventable and curable disease. Diagnosis and treatment is available free of charge in all public and accredited private health facilities. It is also not a curse nor a hereditary condition and traditional medicine has not been proven to cure TB.

 

Diagnosis

A person who visits a hospital or clinic withsymptoms of the disease is sent to the laboratory to do a sputum test. Two sputum samples are examined, one on the spot and the other in the morning of the next day or where inappropriate a second sample is produced at least 1 hour after the first spot sample.

If the patient is positive, he is counselled and commences treatment as soon as possible. In order to prevent lossto follow up during treatment, home visits are done and family members are counselled to serve as treatment supporters. Household members including children under 5 years of age living in the household of a smear positive patient are screened for TB. If they are positive they are put on treatment, if they are negative, they are put on Isoniazid preventive therapy (IPT).

Treatment

TB is cured with effective drugs usingthe Directly Observed Treatment (DOT)approach. The treatment regimen is for six months and divided into two phases: a 2-month intensive phase and a 4-monthcontinuation phase of treatment. Patients take their medications in theircommunity under the supervision of a treatment supporter who couldbe a community health officer, a relative of the patient or a volunteer. This strategy is known as Community TB Care. If the patient does not get cured after 6 months of treatment, they are enrolled on an 8-month Retreatmentregimen.

Note: A TB patient on effective treatment is less infectious after 2-4 weeks and does not spread the disease when theycoughbut still needs to cover theirmouth. They must complete their treatment (6 or 8 months) to be completely cured.

Surveillance

TB ranks alongside HIV/AIDS as the leading cause of death worldwide. In 2014, 9.6 million people fell ill with TB. Of this number, 1.2 million of them also had HIV; 1 million of them were children; 1.5 million people died from the disease; 6 million (63%) were diagnosed by NTPs and 480,000 people developed multi drug resistant TB.

In Ghana, following the NationalPrevalence Survey (2013), we now have a better view of the state of the epidemic. Theestimates are:

  • Estimated Prevalence Rate: 282 per 100,000 population = 76,095 existing cases
  • Estimated Incidence Rate: 165 per 100,000 population = 44,524 new cases
  • Estimated Mortality Rate: 36 per 100,000 population = 9,714 deaths due to TB
  • Estimated Drug Resistant TB: = 640 new cases per year

Impact on the nation at the end of 2015, among the population of26,984,328 Ghanaians is:

  • Endof 2015:                76,095 people have TB disease

44,524 people get TB disease

9,714 people die from TB

  • Every day:                  122 new TB cases develop
  • people die from TB
  • Every hour: 5 people get TB

1 persondies from TB

In 2015, the NTP achieved the following:

  • Cases diagnosed & put on treatment: 14,999
  • Cases confirmed by Lab: 8,222 (54.8%)  
  • New TB cases identified: 14,460 (96.4%)   
  • Number of Children diagnosed: 730 (5%) 
  • Number of Women diagnosed: 5,073 (33.8%)
  • Tested for HIV: 12,016 (80%)
  • HIV Positive: 2,662 (22%)
  • Successfully Treated (2014): 85%

 

The current surveillance system is detecting about 55.7 per 100,000. Case Detection Rate (CDR) is 33% and Male:Female ratio of diagnosed cases is 2:1. The TB/HIV Co-infection Rate is 22%.

This shortfall in case detection may be due largely to the low sensitivity of screening and diagnostic tools, poor access to TB services by patients, stigma and low health infrastructure coverage of diagnostic and health care services. To address this, the NTP has evolved new approaches to case finding which are currently implemented successfully in 90 selected districts across the country with plans for scale up in 2016.

New diagnostics for TB

The country has made strides in diagnosing TB cases in both adults and children. New diagnostic tools have been continually introduced to improve diagnostic capacity apart from the use of the standard light microscopes for sputum examination.

In 2007, the NTP introduced liquid culture MGIT (Mycobacterium Growth Indicator Tube) machines for the diagnosis of drug resistant TB. There are currently 6 sites in Teaching and Regional Hospitals providing service with these equipment including the National TB Reference Laboratory network of Korle Bu Teaching Hospital and Koforidua Regional Hospital.

In early 2013, Light Emitting Diode (LED) microscopes were introduced to 175 high burden sites to reduce workload and improve speed of diagnosis. In addition, GeneXperttechnology was introduced into selected sites to improve TB diagnosis among difficult cases such as PLHIV and children and for the early detection of drug resistant TB. This has been very successful and more machines have been deployed in all Regional Hospitals and Teaching Hospitals round the country. More Gene Xpert machines are being procured for 90 district hospitals round the country to improve TB among PLHIV and early detection of drug resistant TB cases.

The country is also gearing up to receive through the Dutch and Ghana Government co-financed ORIO Grant mechanism, 49 digital x-ray machines to be deployed round the country in support of the Programme’s new strategy of active TB case finding using x-ray screening approach.

The Programme also now has capacity to conduct outreach services using a mobile laboratorydonated by the International Organisation of Migration (IOM) and mobile x-ray machines procured through The Global Fund financing mechanism.

 

Improving Early TB Case Detection

The NTP has put in place interventions throughout the country to improve on case detection. These interventions include:

  1. Improving hospital-based TB case detection
  2. Improving TB case detection among persons living with HIV (PLHIV)
  • Improving TB case detection among other high risk groups (diabetics, children etc)
  1. Improving contact tracing &investigations in households of index pulmonary TB cases
  2. Involving pharmacies and chemical sellers to improve TB case detection
  1. Improving hospital-based TB case detection

Before the implementation of this intervention, TB case finding inhealth facilities was passive. Several patients were missed since there was no systematic approach to screening all the potential TB cases who may be presenting with significant and non-significant respiratory symptoms.

All patients attending OPDs are now screened for TB during vitals taking regardless of the symptoms they present with the aid of a symptom-screeningquestionnaire. Patients who meet the criteria of presumed TB (suspects) are fast tracked to the laboratory for sputum examination. Two (2) sputum samples taken within a day and those diagnosed with TB are put on treatment.

  1. Improving TB case detection among persons living with HIV (PLHIV)

PLHIV enrolled into clinical care are prepared for anti-retroviral therapy by screening for opportunistic infections. Using a symptom-screeningquestionnaire, PLHIVs are systematically screened for TB at every visit if feasible and a minimum of two times a year. A history of 24-hour cough with or without other constitutional symptoms such as fever, drenching night sweats and weight loss are significant indicators for possible TB disease. Patients who meet the criteria of presumed TB (suspects) are fast tracked to the laboratory for sputum examination. Two (2) sputum samples taken within a day and those diagnosed with TB are put on treatment either in the HIV/ART Clinic or referred to the DOTS Corner within the facility.

  • Improving TB case detection among other high risk groups (diabetics, children etc)

As part of routine care, diabetics accessing care at diabetic clinics are systematically screened for TB at every clinic visit using a symptom-screening questionnaire. A history of 24-hour cough with or without other constitutional symptoms such as fever, drenching night sweats and weight loss are significant indicators for possible TB disease. Patients who meet the criteria of presumed TB (suspects) are fast tracked to the laboratory for sputum examination. Two (2) sputum samples taken within a day and those diagnosed with TB are referred to the DOTS Corner within the facility for treatment.

  1. Improving contact tracing & investigations in households of index pulmonary TB cases

TB patients who are diagnosed with TB are accompanied by a health worker to their homesfor verification of their residential address as part of the process of enrolment into care. This is called Home Verification. The health worker during this and subsequent visits to the home identifies and screensall contacts (all persons within the household of the index case i.e. all who eat from the same pot with the index TB case) using a symptom-screening questionnaire. The health worker will arrange for all TB suspects to have their samples taken for TB diagnosis either by sending them to the laboratory or transporting their samples to the laboratory. Diagnosed patients are referred for treatment as soon as possible at the nearest facility. Where index cases are children less than 5 years, there is a likelihood of an adult index case in the home of the child. In this case adult contacts are screened for TB.

  1. Involving pharmacies and chemical sellers to improve TB case detection

All clients visiting a pharmacy or chemical shop to buy cough medicines for their own use are asked few probing questions about their cough to identify possible TB suspects. These suspects are given information about the benefit of having a TB test done. They are given a sputum request form and directed to the nearest diagnostic centre specifically to see the facility Focal Person. Where available a Volunteer may be available to escort this TB suspect to the health facility. At the facility, the suspect produces two sputum samples. On receipt of results, smear positive patients are sent to the nearest DOTs Corner for treatment.

Addressing Drug Resistant TB

Drug resistant TB occurs whenever a TB patient’s sample is observed to have resistance to any of the first line TB medicines. Various types of drug resistance occurs such as mono and poly resistant TB. Most significant to the Programme is the occurrence of Rifampicin Resistance (resistance to Rifampicin alone or in combination with other medicines) and Multidrug Resistance (resistance to Isoniazid and Rifampicin together and in combination with other medicines).

Treatment of drug resistant TB is very difficult and expensive. Treatment lasts for 2 years including minimum 8 months of injections; side effects of medicines are very severe including hearing loss; medicines cost up to 100 times more than first line medicines ($25 compared with $2,500) and treatment outcomes are much poorer with the possibility of evolving Extensively Drug Resistant TB (XDR-TB) where resistance occurs to the second line medicines.

The NTP began enrolling multidrug resistant TB (MDR-TB) cases onto treatment in 2012 and at the last count about 105 patients have been enrolled onto treatment (2012 = 4; 2013 = 25; 2014 =14; 2015 = 60). Of these numbers, 15 have been declared cured, 12 have died; 6 have defaulted from treatment, 51 are still on treatment.

TB/HIV Co-Infection

TB is the leading cause of death in people living with HIV. TB causes severe illness and increases progression to AIDS however this TB is also curable. PLHIV are screened for TB as part of routine care and TB patients are also offered HIV testing as part of routine care.

TB/HIV co-infection rate is 22% and treatment outcomes are poorer.

Effects of TB on Society

TB poses a serious threat to society both socially and economically.

  1. Stigmatization

TB patients tend to suffer severe stigma and are ostracized because of the cultural stigma attached to the disease. For example, tenants are evicted from their homes, marriage couples are divorced and some employees are sacked from their jobs.

According to the Ghana Demographic Health Survey, (2014), 83% females and 89% males had heard of TB. Of these respondents, about 80% of both sexes knew about its spread through coughing; 85% believed it could be cured but a third of females and a quarter of males wanted the information kept secret if a relative was diagnosed with TB. This still does not help us de-stigmatize the disease.

Fear of discrimination can delay people with TB symptoms from seeking help hence many arrive very late and gravely ill worsening myths that TB treatment leads todeath. Delayed reporting creates the opportunity also for active spread of disease. Stigma around the disease also makespatients reluctant to stick with their treatment resulting in drug resistance.
Economic Impact of TB on the Patient, Society and Country

The effects of TB economically, on both the individual and the state are significant. The sick patients may stop working due to the magnitude of the infection to seek treatment. TB treatment is free because the government of Ghana has taken over to purchase the drugs that cost about $25 to cure one patient as well as other logistics.  The intensity of the issue has resulted in government sourcing for external funding from bodies like World Health Organisation (WHO) and Global Fund who give financial and technical assistance to purchase sophisticated equipment to fight the disease.

Programme Challenges

The TB programme faces varied challenges that affects the Programme’s ability to attain its set goals and objectives.

The Programme is experiencing a low TB case detection rate. Results from the recent TB Prevalence Survey conducted in2013, show Ghana is detecting only one third (1/3) of presumed cases in the population. Furthermore, less than one third of the estimated Drug Resistance TB cases are detected and enrolled in treatment. The proportion of childhood TB cases notified has also been lower (5%) than the Programme’s acceptable target of 8-10%.

There is insufficient laboratory capacity to bacteriologically confirm TB cases in Ghanaas well as insufficient state of the art equipment with high sensitivity for diagnosis across the country.

The Programmealso needs funds to embark on intensified Advocacy Communication and Social Mobilisation activities to keep sensitizing the general public about the disease.

Conclusion

The risk of TB in Ghana is high. TB anywhere is TB everywhere. We are all at risk. The good news is that TB is curable if we seek early treatment. Any person coughing for two weeks or more should report to the nearest health facility. We should try to avoid overcrowded rooms and ensure proper ventilation. TB patients should be encouraged to complete treatment rather than being ostracized

It is therefore prudent to come together as a nation to “Unite to End TB”.images

 

 

 

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