Leave No One Behind – A Call To End TB

A tuberculosis patient in a mask

“It started as malaria so I went to the Ga South Clinic and I was treated for malaria. But I was coughing so they prescribed medication for cough for me and asked that I do an x-ray which I did,” says 49-year-old Richard Musa Alhassan, an electrician.

The test conducted on Richard showed he had pneumonia and was treated as per the findings of the test.

“But the cough still persisted,” Richard says. And the doctor after several medications advised that Richard try alternative medicine.

Richard, however, indicated that after months of moving from one product to the other, his health rather deteriorated.

“I grew lean and could not sleep at night. I was also coughing severely, sometimes blood was in my sputum,” he adds. After more than a year in that condition, a Good Samaritan saw him one day and decided to encourage him to run another test, which, this time around, showed it was TB.

The Good Samaritan stood as the treatment support for Richard during his TB treatment and his sleepless nights were soon over as he was responding to the treatment.

TB Facts
Tuberculosis (TB) is caused by mycobacterium tuberculosis which mostly affects the lungs.

About one third of the world's population is infected with tuberculosis (TB) bacteria. Only a small proportion of those infected will become sick with TB, but people with weakened immune systems have a much greater risk of falling ill from TB.

A person living with HIV is about 26 to 31 times more likely to develop active TB which they can spread to 10 to 15 close contacts per year.

The bacteria are spread from person to person by air through coughing, sneezing and spitting. In Ghana, prevalence of TB is 286 per 100,000 populations.

TB is the world's top infectious disease killer, claiming 5,000 lives each day.

The heaviest burden is carried by communities which already face socio-economic challenges: migrants, refugees, prisoners, ethnic minorities, miners and others working and living in risk-prone settings, and marginalised women, children and older people.

Multi Drug Resistant TB
Richard faced some family challenges during the time of his treatment and the love and support he expected from his family was not forthcoming.

This period of treatment, Richard says, was so difficult he missed some of his medications which resulted in him developing multi-drug resistance TB after he had early been treated for TB.

“I was treated and told I was cured but it came back again, I was given injection for three months and an additional six months, but still no improvement.

So my sputum was taken for further tests and it showed I had multi drug resistant TB so I was referred to Korle-Bu TB Unit for treatment for two years,” he explains.

“I was so frustrated that I contemplated suicide because there was no one to help me and I was left all alone,” he adds. He says but for the love and support he was shown by a faith-based organisation, he would have ended his life.

“A nurse at the hospital called Sister Francisca really helped me with feeding and transport to and from the hospital. She encouraged me and I went through the treatment successfully,” he states.

Dr Linda Van-Otoo, Greater Accra Regional Health Director of the Ghana Health Service (GHS), says patients develop MDR TB because they either do not complete their TB medication or miss some days for their medication due to various factors.

Poverty, malnutrition, poor housing and sanitation, compounded by other risk factors such as HIV, tobacco, alcohol use and diabetes, can put people at heightened risk of TB and make it harder for them to access care.

“TB has a set of drugs used to treat it and normally the person must survive, sometimes they do not get cured and they go on to become resistant to these medications and sometimes its multi drugs,” she explains.

More than a third (4.3 million) of people with TB go undiagnosed or unreported, some receive no care at all and others access care of questionable quality.

The Greater Accra Region has recorded some multi drug resistant TB over the years. In 2013, the region recorded 12 MDR TB, then 2 MDR TB in 2014, 15 MDR TB in 2015, and 17 MDR TB in 2016.

Lost TB Patients
TB cases that go undiagnosed and, therefore, untreated in the country are more than the diagnosed TB cases.

In the Greater Accra Region, according to new statistics by the Ghana Health Service (GHS) regional health directorate, only 49 TB cases out of the expected 268 per 100,000 population are found, translating into more undiagnosed cases of TB.

“Within the 286 TB cases per 100000, there are more undiagnosed cases within the population and this is rather unfortunate because TB treatment is free and we must find and treat them,” Dr Van-Otoo says.

Explaining further, Dr Van-Otoo adds that in 2014, the region of about four million inhabitants recorded a total of 2073 cases, the number of TB cases detected increased to 2,391 in 2015 and then decreased to 2,248 in 2016.

“In Greater Accra with a population of over four million people, we are supposed to have over 11,000 reported cases but we have less than 3000,” she says.

Dr Van-Otoo indicates that the trend poses a dangerous threat to TB control in the country, as an undiagnosed person with active TB can infect close contacts unknowingly or die without receiving treatment.

From Guidance to Action
One of the targets of the Sustainable Development Goals (SDG) for 2030 is to end the global TB epidemic.

But new data from the World Health Organisation (WHO) reveal that the global TB burden is higher than previously estimated.

The WHO 'End TB Strategy' approved by the World Health Assembly in 2014 calls for a 90 percent reduction in TB deaths and an 80 percent reduction in the TB incidence rate by 2030, compared with 2015.

“Countries need to move much faster to prevent, detect and treat TB if the 'End TB Strategy' targets are to be achieved in the next 15 years,” the global health body states.

Dr Van-Otoo stresses that the Greater Accra Region has recorded impressive treatment results among those diagnosed with TB.

She indicated that the cure and success rate of TB determined by an examination of the sputum had shown 91 percent cure and 96 percent success rates respectively.

The Greater Accra regional health director appeals to stakeholders, particularly the media, to help improve the case detection by consciously creating awareness about TB and the importance of diagnosis and treatment.

But it is not easy to apply the principles of ethics on the ground, as patients, communities, health workers, policy makers and other stakeholders frequently face conflicts and ethical dilemmas.

The current multi drug-resistant TB (MDR-TB) crisis and the health security threat it poses accentuate the situation even further.

“Only when evidence-based, effective interventions are informed by a sound ethical framework, and respect for human rights, will we be successful in reaching our ambitious goals of ending the TB epidemic and achieving universal health coverage. The SDG aspiration of leaving no one behind is centred on this,” says Dr Mario Raviglione, Director, WHO Global TB Programme.

New Tuberculosis (TB) Ethics Guidance
The WHO in commemoration of the World TB Day yesterday launched a new guideline which aims to protect the human rights of TB patients.

It also aims to help ensure that countries implementing the 'End TB Strategy' adhere to sound ethical standards to protect the rights of all those affected.

The new WHO ethics guidance addresses contentious issues such as the isolation of contagious patients, the rights of TB patients in prison, discriminatory policies against migrants affected by TB, among others.

It emphasizes five key ethical obligations for governments, health workers, care providers, non-governmental organisations, researchers and other stakeholders to provide patients with the social support they need to fulfill their responsibilities.

Other ethical obligations include refraining from isolating TB patients before exhausting all options to enable treatment adherence and only under very specific conditions, enable 'key populations' to access same standard of care offered to other citizens, ensure all health workers operate in a safe environment, rapidly share evidence from research to inform national and global TB policy updates.

“The guidance we have released today aims to identify the ethical predicaments faced in TB care delivery, and highlights key actions that can be taken to address them,” he adds.

“TB strikes some of the world's poorest people hardest. WHO is determined to overcome the stigma, discrimination, and other barriers that prevent so many of these people from obtaining the services they so badly need,” says Dr Margaret Chan, WHO Director-General.

Richard who has now become a TB advocate says family support from health workers' care and adherence to medication was what helped him go through the treatment successfully.

“If our families will stand with us and health professionals will encourage us so we keep to our medication, no one will die of TB,” he says.

By Jamila Akweley Okertchiri