The World Tuberculosis Day is being observed on March 24
Tuberculosis has been known to man for the last 6000 years. Though its origin is unknown, the disease today kills about two million every year. And, by 2020, nearly a billion people will be infected by the disease; 200 million will get sick and 70 million will die.
In Pakistan, over two million cases of tuberculosis are reported every year. The WHO has identified 22 high burden countries TB countries; Pakistan is sixth after China, India, Indonesia, Bangladesh and Nigeria.
Tuberculosis is a contagious disease, that spreads through the air like the common cold. When a TB patient coughs, sneezes, talks or spits, the germs are expelled into the air. Any person who inhales these germs is likely to catch the disease. This way the disease is more infectious than Aids, Hepatitis B and C, as the latter three don’t spread by air.
Tuberculosis is a disease that strikes even the young. Every year, more women are killed by this disease than all combined causes of maternal mortality. The spread of TB among women affects child survival, economic productivity and family welfare. And this in a country where medical facilities for women are basic.
The main reasons for the rise in TB epidemics are:
NEGLIGENCE: In many developing countries, including Pakistan, the public health authorities have failed to recognize the seriousness of the situation. In Pakistan, the TB control programme was started over 15 years ago, but an attempt to tackle the problem seriously has only been made in the past four to five years.
INFLUX OF AFGHAN REFUGEES: The prevalence of TB is very high amongst the Afghans who came to Pakistan as refugees. These refugees are responsible for the spread of TB in major cities like Peshawar, Quetta and Karachi.
AIDS: HIV and TB form a lethal combination; in the past five years, over a third of the TB cases have been attributed to HIV. In fact, TB is the most common cause of death in patients suffering from Aids.
MULTIPLE DRUG RESISTANCE (MDR): MDR-TB is caused by inconsistent or partial treatment; when patients do not take their medicines regularly for the required period of six to eight months; when a doctor prescribes wrong drugs or improper combinations of drugs or when substandard drugs are used.
In a study conducted at the Aga Khan University, one-third of the TB germs were found to be resistant to at least one of the anti-TB drugs. Multi-Drug Resistant TB is almost impossible to cure in countries like Pakistan, where resources are scarce.
POVERTY: It is indeed sad that the gap between the rich and the poor has widened in the past decade or so. Poverty aggravates the TB epidemics. The disease thrives in people who are exposed to malnutrition, over-crowding, improper ventilation and poor sanitation — all factors associated with poverty. Most patients who have TB cannot afford the treatment and stop taking medicines prematurely. The developed world must give debt relief to the poor countries if they are really serious about stemming the growth of TB and eventually destroying it for good.
SYMPTOMS: TB can involve any organ in the body, but most commonly it affects the lungs. The usual symptoms of lung-TB are cough, fever, weight loss, chest pain and night sweats. The patient may also produce blood-tinged sputum. Any cough which lasts for more than three weeks should be investigated in order to rule out TB.
Brain-TB may manifest itself as headaches or fits.
Skin-TB is usually indicated by non-healing ulcer, while bone or joint-TB may have symptoms of pain and restriction in the affected joint. Every untreated patient spread the disease to others. The risk is greatest to those who live with the patient in the same house. It has been estimated that each untreated case of TB will spread the disease to 15-20 individuals in one year’s time.
TREATMENT: TB germs do not die with just one antibiotic. Initially, one has to take at least four different antibiotics in proper dosage for about two months. Then, the sputum is tested again and if it is negative then two anti-TB drugs are given for another four to six months. With proper treatment, over 95 per cent of the TB patients can be completely cured.
CONTROLLING IT IN PAKISTAN:
POLITICAL COMMITMENT: Unfortunately, we have not yet been able to tackle the problem of tuberculosis properly. The present government has taken several important steps in the right direction but until and unless, Pakistan’s large private sector is involved in the TB control programme, we cannot expect a major change in the present scenario. We need to learn from Bangladesh where the efforts to control TB have been so successful that the WHO has described it as a “model for the entire world”.
PUBLIC EDUCATION: The electronic media runs advertisements on Aids, polio and hepatitis, but there is almost complete silence on this important public health problem. The general public needs to be educated about this disease. They must be informed why it is important to complete the whole course of anti-TB treatment, and what will be the consequences of stopping the treatment prematurely.
MEDICAL EDUCATION: Majority of the doctors coming out of medical schools are inadequately trained to deal with tuberculosis. Our medical schools’ curriculum needs to be changed and TB should be given its due importance as a subject. Most textbooks in medicine currently available in the country do not teach students about TB control. A recent survey done to assess the knowledge of fresh medical graduates on TB, conducted by the Pakistan Chest Society, showed major deficiencies in our doctors’ basic knowledge of this disease. The practising physicians in Pakistan, including specialists, need to be educated about current concepts in TB diagnosis and management. In a recent survey by Aga Khan University, it was found that only one in 10 general practitioners in Karachi know how to prescribe correct anti-TB treatment.
DOTS EXPANSION: Directly Observed Treatment Short course (DOTS) is recommended by WHO as the best way to detect and cure TB patients. DOTS does not simply mean direct observation of treatment, where trained healthcare workers observe the patient swallow each dose of anti-TB medication. It is actually a comprehensive package, which requires political commitment, microscopy services, reliable drug supply and a good monitoring and recording system. The World Bank has ranked the DOTS strategy as the most cost-effective of all health interventions. DOTS coverage of government run health sectors is increasing. In Sindh, the DOTS coverage is almost 100 per cent but as the majority of patients are still going to private practitioners there has been no decline in the prevalence of this disease in this area.
SUPPLY OF QUALITY ANTI-TB DRUGS: In Pakistan, many essential and lifesaving drugs disappear from the market from time to time. This holds true for anti-TB medicines also. The quality control of some of these medicines is also lacking. Various combined pills containing three to four anti-TB drugs are present in the market, which have not undergone ‘bioavailability testing’. The use of these poor quality medicines is one of the reasons for the rising TB drug resistance in this country. It is the responsibility of the government to make sure that TB drugs of proven value are available in the market throughout the year. Attempts should be made to provide free TB drugs to each patient in accordance with the DOTS strategy.
SPUTM MICROSCOPY LABORATORY SERVICE: Sputum test for TB germs is relatively a simple test. The government must make sure that this test is available free of cost to all TB patients as well as ensure the quality control of the laboratories while doing this test. At present, even in a major city like Karachi, there are very few laboratories that can provide good quality sputum microscopy service. There is also a need for creating a central reference laboratory where sputum of patients with suspected MDR-TB could be analyzed.
Apart from the government, the private sector, especially the medical societies should ensure that its members are fully informed about TB control measures as well as about National TB guidelines. It is unfortunate that the disease, which resulted in the death of our Father of the Nation, Quaid-i-Azam Mohammad Ali Jinnah, is still as active as it was at the time of independence. We have done very little in the past for the control of this disease in Pakistan. In 1947 no anti-TB drug was available, but today in the presence of effective chemotherapy nobody should die from this disease.
Regular audits should be carried out in order to make sure that our doctors are writing correct prescriptions for TB patients as recommended in our national guidelines. It is the responsibility of each one of us to make sure that every TB patient in this country is cured of this infectious disease. This is the only way we can protect ourselves as well as our children from becoming victims of this disease.
The World Tuberculosis Day is being observed on March 24 
