Overview
TUBERCULOSIS
Tuberculosis (TB) caused by Mycobacterium tuberculosis, spreads through the air by coughing. Only people who are sick with TB in the lungs (pulmonary TB) are infectious. Left untreated, each person with active pulmonary TB will infect approximately 15 people each year. But many of these newly infected people will not become sick. The immune system "walls off" the TB bacilli that may remain dormant for years. When the person's immune system is weakened, the chances of becoming sick increases.
Prevalence: Overall, one third of the world's population is currently infected with the TB bacillus.
5-10% of these people become sick at some time during their lives (co-infection with HIV markedly increases this percentage through weakening the immune system).
TB is most highly prevalent in Africa and South-East Asia.
TB and HIV: TB is a leading cause of death among people who are HIV positive, accounting for 13% of AIDS deaths world wide.
Although the drugs used to treat TB are relatively new, TB resistance to our best drugs is developing. Drug-resistance is caused by inconsistent or partial treatment of TB, which occurs when health workers dispense drugs inappropriately, or supplies of drugs fail, or when patients fail to take drugs correctly. The incidence of multi-drug resistant TB is increasing, especially in the former Soviet Union.
From a public health perspective, poorly supervised or incomplete treatment of TB is worse than no treatment at all. Failed TB treatment promotes drug-resistance. Drug-resistant TB is difficult and expensive to treat. (see DOTS-plus on WHO web-site)
TB spreads best in conditions of overcrowding and poor health and nutrition. Occupants of refugee camps are at high risk of contracting TB.
Control of TB: TB can be effectively controlled using the DOTS strategy (Directly Observed Therapy, Short-course).
The five key elements of DOTS are:
* Government commitment
* Detection of TB by sputum smear microscopy among people with symptoms
* Good drug supply
* 6-8 months of regularly supervised multi-drug TB treatment (combinations of rifampicin, isoniazid, pyrazinamide and ethambutol)
* Reporting systems for monitoring and improving the quality of programmes.
The DOTS strategy can produce cure rates of 95%, even in poor countries. It prevents new infections by curing infectious patients. It guards against the development of drug-resistant TB.
LEPROSY
Leprosy is also caused by a Mycobacterium, M. leprae. It is not as infectious as TB, but usually spreads in the same way - by coughing.
M. leprae multiplies very slowly in the body so that symptoms may not appear for 20 years after infection. It effects mainly the skin and nerves. When untreated, leprosy causes permanent damage to the skin, nerves, limbs and eyes.
Classification of the disease - into pausibacillary leprosy (PB) and multibacillary leprosy (MB) is performed on the basis of skin smear results.
Leprosy is curable with multi-drug therapy (MDT) (dapsone, rifampicin and clofazimine) which is available free of charge through the WHO. Cure of leprosy is achieved through using 6 or 12 months of regular treatment depending on disease classification. The patient becomes non infectious from their first dose of drugs.
Although there has been excellent progress made in reducing the prevalence and incidence of leprosy, it is still regarded as a public health problem in Africa (Angola, Central African Republic, Democratic Republic of Congo, Madagascar, Mozambique and the United Republic of Tanzania) South-East Asia (India and Nepal) and Latin America (Brazil).
Similar elements as for the control of TB using DOTS (see above) are appropriate for the continuing fight against leprosy.
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Excerpt from setting up community Health programmes by Ted Lankester
Ted's book devotes one chapter to practical details about setting up and sustaining TB services. The following excerpt caught my eye:
We will need to understand local beliefs and customs, the difficulties faced by the poor BOTH IN GETTING DIAGNOSED AND IN completing treatment [for TB]. WE ALSO NEED TO UNDERSTAND THE ROLE OF PRIVATE PRACTITIONERS.
Local beliefs and customs:
These vary from place to place but common FEARS INCLUDE:
* TB can’t be cured (this may well be true in their experience).
* Only the poor, low caste or those under a curse get TB.
* TB patients are unclean and should be distanced from their families or communities.
* A belief that TB is inherited (quite common in many African countries).
* If you have TB it means you also have AIDS (often true where HIV/AIDS is common).
In practice, patients may be excluded by their community, barred from marriage and face serious discrimination. THIS STIGMA MAY INCREASE IN AREAS WHERE PEOPLE ASSUME THAT IF YOU HAVE TB YOU ALSO HAVE AIDS.
Difficulties faced by the poor:
Imagine a poor villager or slum-dweller who starts to cough up blood. A frightening sequence of problems will have to be faced:
• ’Now I’ve caught the disease which has killed my close friends.’
• ‘I don’t have the energy to chase after a cure.’
• ‘Can I trust the doctor or will I be cheated?’
• ‘I’ve only enough money for four weeks of medicine: how can I afford six months?’
• ‘I don’t know who will take me to the clinic or pay for the journey.’
• ‘I’m worried I will get AIDS if I have to have injections: perhaps I’ve caught it already.’
• ‘If I can’t go to work my family will starve and my children may die.’
In the case of a woman with TB these problems are multiplied. Often her family may be unwilling or unable to spend money on her treatment. They may prevent her from attending doctors and hospitals because she should be busy at home, collecting ?rewood, or earning income.
RECENT RESEARCH FROM THE GAMBIA HAS SHOWN JUST HOW ESSENTIAL IT IS FOR HEALTH WORKERS TO UNDERSTAND THE VARIED REASONS WHY PATIENTS WITH TB DO NOT SEEK TREATMENT OR WHO DISCONTINUE TREATMENT EARLY. WHEN WE DISCOVER WHAT THE REASONS ARE IN OUR COMMUNITY, WE CAN HELP PEOPLE MAKE PLANS TO OVERCOME THESE OBSTACLES.
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Practices members have applied in their own situations
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This topic is convened by: |
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Dr Nick Henwood
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