Unemployed, a single mother of two small children, aged 6 and 10 years, and not feeling well – coughing for some time with chest pain – forced Ms P.M. to seek help at the nearest public clinic in Tshwane. Despite telling symptoms and another visit to the clinic with an additional tell-tale complaint – significant weight loss (4kg) since the first visit – it was not until 6 weeks later, and a hospital admission when eventually sputum was collected to initiate investigation for Tuberculosis (TB). Finally, Ms P.M. was diagnosed with and put on TB treatment. In the meantime, she was coughing her heart out at home and spreading the TB bacilli in the air of their small dwelling thereby exposing her two children to this million-year-old bacillus that is spread by airborne route.
TB, a fully treatable disease, is still the top cause of mortality in South Africa. It ranks amongst the top ten TB burden countries – after India, Indonesia, China, Nigeria and Pakistan. South Africa notified a total of 244 053 TB cases in 2016, but WHO Global TB Report 2017 estimates are calculated at 438 000 cases. Taking these estimates into account, there should be at least another 90 000 (range approx.60 000-190 000) undiagnosed TB patients “out there” not being identified, incorrectly diagnosed as a pneumonia, flu, etc., not being investigated despite tell-tale symptoms or stigma-related factors influencing both health care worker as well as patient behaviour, patients not accessing health care services because of time constraints and/or poor services, transport problems or other factors. TB has been named by some as one of the “scarlet pimpernel” diseases, (together with malaria, because of it being here, there, everywhere and its difficulty in diagnosis). Clinicians need to have a high index of suspicion and tenacity to point them in the direction of TB. Symptoms can be misleading, vague and general for a long time, but with a history of cough and weight loss, the diagnosis becomes easier. Testing sputum for TB, is not the end of the journey. Once treatment is started, it is very important to complete the six-month course of daily pill taking to prevent relapse and drug resistance from developing.
World TB Day is celebrated yearly on the 24th March as it was the day that the scientist, Dr Robert Koch, who diagnosed the tuberculosis bacillus, presented his findings to the Berlin Physiological Society on 24th March 1882 – up to today, it is often referred to as the Koch-bacillus. World TB Day is there to raise awareness for, and create space and eliminate stigma for people with TB. Communities are still unfairly discriminating against people with TB as it was historically linked to poor social circumstances, poverty, overcrowding and emotional or physical stress. With the discovery of powerful antimicrobials in the early fifties and sixties, it seemed that the demise of tuberculosis was inevitable. Until the HIV virus changed the face of TB, together they became the terrible twin, causing havoc in people with a compromised immune system. It is only after the introduction of Anti-retroviral treatment, that TB numbers started to decline again. The theme for this year’s World TB Day is: Wanted: Leaders for a TB-free world. You can make history. End TB.
For the first time in history, assisting the international drive to find the missing cases and end TB, the general Assembly of the United Nations will have a dedicated session in September focussing on TB3. All high burden countries will have to make presentations. The hope is that South Africa will be able to identify at least 60 000 additional TB cases by then. As always, the challenge is making sure that all presumptive (with symptoms) TB patients are diagnosed and put on treatment at the first contact session with the health care provider.
In Buffalo City in the Eastern Cape, in a small study in 20 randomly selected clinics during March – December 2015, it was estimated that the health system missed 62.9-78.5% of TB patients attending primary health clinics for TB related symptoms, as in the case of Miss P.M. above.
Apart from missing and not diagnosing TB patients, the other dilemma is that private general practitioners, as a rule, do not treat TB. There is little if any communication and collaboration between the private sector and the public sector as far as TB is concerned. Often male patients, as breadwinners, cannot access health services at public clinics, due to ungainly long queues and poor services. They show up at private practitioners for their health related problems and are then referred back to public clinics for further management of TB, should the doctor suspect that the patient might have TB.
Mr J M. a 36-year-old man, presented to a public clinic with a letter from his GP stating that he should be investigated for TB due to his symptoms. This request was flatly ignored. He left the clinic with a course of broad-spectrum antibiotics for a presumed pneumonia/bronchitis. A week later, and still not better, he returned to the clinic, was then referred to Mamelodi Hospital where an X-ray and sputum investigation confirmed that he had TB. He was promptly started on treatment.
Unless we can address this seemingly lax attitude of health care workers, the fight to end TB is far from being won.
These are but a few of many similar stories and the reason why, South Africa is amongst the highest burden countries in the world in terms of the number of tuberculosis cases (prevalence and incidence). Although South Africa has made notable progress in combating TB (Roll-out of rapid diagnostics(GeneXpert), reducing TB-linked complications and deaths and improved treatment outcomes for new smear positive TB cases), the burden of TB remains enormous. TB is the leading cause of death in people living with HIV and is the leading natural cause of death in South Africa according to StatsSA.2 According to the WHO Global TB report 2017, 124 000 deaths (including those with HIV co-infection) were attributable to TB in South Africa in the year 2016.