Job Osazuwa
Tuberculosis, commonly called TB, is an infectious disease that is caused by a germ or micro bacterium called Mycobacterium tuberculosis. Primarily affecting the lungs, it is a single infectious agent that has continued to
constitute a major public health problem globally.
According to experts, this micro bacterium can affect different parts of the body. The most worrisome, however,
is the one that infects the lungs. When the germ affects the lungs, it causes a disease called pulmonary tuberculosis.
If it affects any other part of the body, it causes disease called extra pulmonary tuberculosis.
A researcher with over 40 years of experience on infectious diseases, especially in the management of tuberculosis and Human Immune Virus and Acquired Immune Deficiency Syndrome (HIV/AIDS) and former Director General of the Nigerian Institute of Medical Research (NIMR), Prof. Oni Idigbe, took the reporter through mode of transmission, diagnosis, treatment, epidemiology, government’s efforts, warning, drug resistance and others. As deadly as the
disease could be, he said it was 100 per cent curable through a comprehensive treatment.
Mode of transmission
On how TB is spread, Prof Oni explained that when the organism multi- plies in the lungs it could easily be transmitted. According to him, when a person that is infected coughs, he throws this germ into the air, and if another person inhales that germ, it settles in lungs, then he gets infected.
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He said: “While extra pulmonary TB can be gotten from contact or from consuming raw milk or water that are infected, the one being circulated through the air is more common and that is why it is of public health importance.
“But note, if a person whose defence mechanism is strong inhales the germ, the organism can get into the lung and can be there without any harm for years, which is called latent infection. But if anything happens to the body defence
mechanism and immune is weakened, the organism that was just hidden will suddenly wake up and begin to multiply, and advance to active infection. So, one can have a latent infection, reactivation of latent infection to active infection if the body mechanism is tampered with.
It can be tampered with by a number of other factors. It could be HIV infection, malnutrition, starvation and others.”
On minimising mode of transmission, he said there were certain precautions that could be taken to curtail the spread of TB. One of the ways is cough etiquette, meaning to merely cover one’s mouth while coughing or sneezing, with either a handkerchief or the hand.
He added that since the disease is an airborne infection, therefore, any place of inhabitation must be well ventilated
to avoid contamination. He warned that the disease is not a respecter of anybody – children, adults, aged, rich and
the poor can be infected. With ventilation, the room must not be allowed to be drought of air.
“Also, apart from covering the mouth, the patient must not throw sputum indiscriminately because it is a very funny organism. When it is throw on the floor for example, it may dry up in the sun but a wind or vehicle can blow it up
to the atmosphere even after days. Once one inhales it, it is still very effective to infect the person. In the house where people are living, there must be free flow of air.
Prof. Idigbe, a medical microbiologist by training, who recorded many major feats in the area of tuberculosis and HIV research, said underfunding has remained a clog in the wheel of progress in tackling the disease.
Symptoms and signs
In active pulmonary TB, whether moderate or severe disease, the patient may have no symptoms except “not
feeling well” or may have more specific symptoms. Cough is most common. At first, it may be minimally productive of yellow or green sputum, usually on rising, but cough may become more productive as the disease progresses.
Drenching night sweats are classic symptom but are neither common nor specific for TB. Dyspnea may result from lung parechymal involvement and spontaneous pneumothorax.
TB diagnosis
The expert said TB could be diagnosed and treated but informed that the important thing was for people to know
the signs and symptoms of the sickness, so that when this is observed, either by the carrier or people around, an immediate action could be taken for diagnosis.
He said: “If somebody is coughing consistently for two weeks upwards, and the person has seen a doctor and exhausted all the normal cough medicine but to no avail, the person is advised to visit the hospital for TB diagnosis.
Also when a person is coughing and losing weight, losing appetite, having fever, sweating at night and at the worst stage, the person coughs out sputum that is mixed with blood, TB is infection has occurred.
“The diagnosis is done by proper examination through the use of microscope. We do take the sample the person coughs out to the laboratory for scientific processing and the result is duly delivered.”
Treatment
If somebody has any of the symptoms, it is advisable to go test for TB. When tested positive, Idigbe said the person should not be left to carry the burden himself, as he is referred to Directly Observed Therapy Short course (DOTS) centres or clinics across every state in Nigeria, to get treated.
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Said he: “But one thing that people still don’t know that they must know is that TB is treatable. There are drugs one can take in various combinations according to prescription that are capable of curing the disease, unlike HIV, which is still not curable for now.
“Treatment for TB can be between six and eight months depending on the combination of drugs prescribed. The treatment can be got in the DOTS centres.
One good news is that testing for TB is free everywhere at the DOTS centres located both at the primary, secondary and tertiary health institutions in Nigeria. Not just a free testing, all the drugs and treatment are also free.
“People should know that drugs are free in all the DOTS centres. The government has also started public private partnership. However, the drugs and treatment are also free in some of the private hospitals approved as DOTS centres. Unfortunately, some patients are dying of TB out of ignorance.
“The drugs most private hospitals prescribe, which they don’t often have are expensive and are purchased at the open market by the patient. These patients may end up buying either expired or fake drugs.
Most importantly, TB drugs are always prescribed for continuous dosage but the patient along the line may become financially handicapped, which will have a negative effect on the treatment procedure.
We know the private sector is doing much to support the government in health care delivery but on the issues of TB, Nigerians should get the best treatment for free. As you may be aware, the drugs are received from various global drug aids.
These drugs are got directly from international donors, then distributed to all DOTS centres. In essence, the originality is guaranteed.”
On the complexity of treatment, he said: “It is getting more crucial because we now have a new wave of the epidermis of TB organism that are resistant to the drugs used for the treatment. We call it drug resistant TB.
There are two major drugs for treating TB infections and they are Isoniazid and Refampicil. If a patient inhales TB organism that is resistant to these first line drugs, we say that the patient has multi drug resistant TB.
Though this kind of condition has been long, it is becoming more common and reversing all the gains that various countries had made in fighting the disease. This set of people can only be treated with second line drugs.
“Remember, treatment with first line drugs can take between six and eight months for both the intensive and continuation stages but for MDRTB, it is a different ball game, a dangerous one. The reasons are, firstly, the patient has to be treated with second line drugs, and these drugs are 10 times more expensive than the first line drugs.
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The second line drugs have more serious side effects than the first line drugs. Somebody with multi drug resistant TB has to be treated in a specialised ward.
Also treatment with second line drugs last for nothing less than 18 months. Just imagine a patient taking drugs
for eighteen months.
“If a patient fails second line drugs, the patient has developed Extensively Drug Resistant (XDR TB). To be honest, at this point, more prayers are needed for the person’s survival. This is even emerging in Nigeria and spreading like wild fire. You can imagine when a person that has XRTB sneezes and what would happen to the people around.
Whoever is infected with this cannot be treated with first line drugs. Most often, Nigeria does not have adequate capacity to test for this new case called XDR TB. It is just a few laboratories that have the capacity to carry out the test. This is not a situation of walking into any laboratory centre to diagnose it. It is beyond using microscope to assess the organism.
Epidemiology
About 1.3 billion people are said to be globally infected with the disease, with a high prevalence in Nigeria, where about 400,000 are infected annually. Globally, there are 22 countries that have high prevalence of the disease, harbouring about 75 per cent of all TB cases. Nigeria used to occupy fourth position some years back, but has
tremendously improved over the years.
According to Idigbe, “in the late 80s and 90s, we thought the world was winning the war against the disease, but suddenly, new cases began to emerge that the World Health Organisation (WHO) declared TB as a global emergency.
The emergency puts scientists on their toes to unravel the major causes of the increase. One of the findings of the resurgence was the emergence of HIV.
“TB, as discovered, is an opportunist infection, which thrives among HIV patients. Most of HIV/AIDS patients don’t die because they are having HIV but die from opportunist infection, and TB is a leading cause of death among HIV patient. This still brings us to the importance of body defence mechanism.
HIV weakens or breaks down the patient’s immune system, thereby making all the latent infection in the body to become active.
“In the other way round, a person who is already infected with HIV, then contract TB, the immune is already weakened initially, the organism goes straight into the lung and immediately becomes active. But still, for a person who has both HIV and TB, the latter can be treated and cured but in long period of drug combination, though could also recur if the person is exposed to the infection again.
HIV triggers all kind of infections in the body system,” he said. Government’s effort in tackling TB The microbiologist said most of the HIV and TB drugs Nigerians consume were donated by foreigners, revealing that the government contributes little into it.
He expressed worry over dependence on foreign donors, saying the country has since ran into donors’ fatigue, while projecting that if by tomorrow the donors withdraw, Nigeria would be at a dilemma.
“The drugs are either from American government or Global Fund for TB, malaria and HIV. Nigerian government should start looking forward to sustainability. The government should set a target for itself through policy and determination.
The federal, state and local government should be involved in this fight against TB. For example, government should define the percentage it wants to cater for in the coming year.
We have the resources to achieve this, and we don’t expect other countries to keep on donating money to take care of our citizens. They are helping us, fine, but we must look at the long run, how to help ourselves,” Idigbe advised.
Caution, warning
The expert stated: “If somebody says he has never had TB, the tendency for doc- tor to place the patient on first line drug is very high, but unknowingly, the patient is infected with MDR TB.
If such a patient is being treated with first line drug, he would not respond. This may take up to three or four months for the doctor to realise that the patient is not responding. All through this period, the patient might have spread the disease to as many people as possible.”
Many, including health workers, have expressed concern on the scarcity of second line drugs for both HIV and TB treatment across the country.
They are, however, arguing that dearth of second line treatment is a threat to attaining total eradication of the disease from Nigeria in the nearest future.
Prof Idigbe said: “Yes, the drugs are avail- able in Nigeria but very expensive. Again, they are brought to us by donors. They are also free at the DOTS centres. It is not also financially convenient for the donors to buy these drugs.
Consequently, shortage may arise at any point for so many reasons, mainly depending on the rule of demand and
supply.”
How multi drug resistant TB occurs
He said one gets multi-drug resistant TB when there is mismanagement of susceptible or what we may call first stage TB. He explained that resistant to first line drugs could be developed when doctor prescribes inadequate combination.
He said: “That brings us back to patronage of private clinics where most of the doctors don’t even know the right combination. On the other hand, the doctor may prescribe the right combination but the patient may take
it for some time, with relative improvement and suddenly abandons the continuation.
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For 100 per cent cure of TB, there must be absolute compliance to drug routine. “Note, even with these free drugs from the international donors, there could be problems because the drugs might have been sent to the government (Nigeria) but to clear them from the wharf may take another one or two months. In the main time, the patient cannot
maintain consistency in drug routine, which is detrimental to the healing process.
There are many players that are responsible for why TB cases transcend into MDR TB. A different factor, most of the second line drugs are in form of injection.
“You can imagine hammering somebody’s buttock with syringe continuously for three months, sometimes, the patient may run away. This is why we continue to emphasize that TB should be treated properly with first line drugs.
If not treated well, it would develop to MSR TB; if this is not also treated well, it will transcend to XDR TB.”
The way out Idigbe advised: “Nigerian should know the signs and symptoms of TB. Such knowledge is very crucial for the public, both those at rural and urban areas. The mode of transmission is by air. Therefore, we must teach ourselves and the children to always cover their mouths when sneezing or coughing, so that others would not be infected.
“People should not throw the sputum (cough) on the street because the germ can be active for days. Once signs are noticed, testing should be done immediately. Most importantly, TB is curable. There is nothing one should compromise his health with, not only in TB cases but also for general wellbeing.
Finally, the government needs to invest more in health care institutions so that it can be strengthened for better performance.”