Tuberculosis: Modern challenges in diagnostics and treatment
By: Sandy Tat
Dying tragically young from tuberculosis (TB) has been a feature of many plays and films taking place in times long past: ranging from the sorrowful character of Fantine in Les Miserables to the star-crossed lover Satine in the Moulin Rouge. Such deaths in works of fiction draw on the olden Victorian belief that the Great White Plague, an antiquated nickname for TB, was a disease of a poetic and romantic nature. These captivating performances may evoke in us the vague assumption of TB being a historic disease — one that has been long cured and eradicated from public concern. In reality, this is far from the case.
Mycobacterium tuberculosis is the bacterium responsible for TB. When inhaled, the bacterium travels to the lungs where it is met with defense responses from the immune system. If the bacterium isn’t destroyed, it can remain inactive which is most often the case as 25% of the world’s population have latent TB (with the possibility of becoming active) or immediately develops as an infection. From there, Mycobacterium tuberculosis forms hard nodules that can break down lung tissue and cause bleeding.
TB can also cause persistent coughing, fever, extreme tiredness, and weight loss. If left unattended, TB prevents the lungs from taking in enough oxygen, ultimately resulting in death.
In 2016, TB was responsible for more than 1.7 million deaths, effectively making it the world’s deadliest infectious disease and eclipsing the total number of lives lost from HIV and malaria combined. According to the 2017 Global Tuberculosis Report, more than 95% of TB mortalities occur in developing countries. In the same year for the second time in a row, India has had the highest number of deaths from TB, accounting for almost a third of total TB mortalities. India isn’t alone in facing the burden of TB — its ranking in TB deaths is followed closely by Indonesia, China, the Philippines, and Pakistan. The World Health Organization (WHO) reports that most of these deaths can be prevented with early diagnosis and appropriate treatment, but that’s more easily said than done.
Challenges Diagnosing Tuberculosis
Diagnosing TB in resource-poor settings can often be difficult because of a lack of effective diagnostic tools and protocols. The gold standard for diagnosing TB involves collecting sputum (i.e. phlegm) from a patient and examining it under a microscope for evidence of TB. However, conventional practices urge patients to undergo numerous trips to the health centre for additional sputum collection, and to confirm diagnosis and start treatment. Unfortunately, in many developing countries, up to half of all patients never return to the health center after the first visit, often because they live too far away and can’t afford to make the trip back. There is a need to ensure these communities have access to diagnostics equipment that can provide fast, same-day results, but the lack of funding and training keeps these available technologies away from the countries that need it most.
Challenges Treating Tuberculosis
Even if patients are able to receive a timely diagnosis from their healthcare practitioner, accessing and staying on treatment can be additional hurdles.
Treatment can be incredibly arduous, potentially lasting 6 to 24 months. Treatment necessitates taking medication daily that amount to more than 800 pills for the shortest of regimens. For those with multidrug-resistant tuberculosis (MDR-TB), a form of the infection that’s immune to at least the two most powerful TB drugs, the side effects, which include severe nausea, permanent hearing loss, and psychosis, are difficult to endure.
Though some financial burdens can be alleviated for patients by offering treatment without cost, those living in poverty still face barriers that can prevent them from successfully finishing. Food insecurity, loss of income due to time-off for recovery, and costs of transportation can make the continuation of treatment nearly impossible.
There is also a lot of stigma associated with having TB, and the real fear of social isolation and shame can delay or hinder many from seeking treatment. Social prejudices for having TB are particularly severe for women, as the disease can be perceived as a marker of sexual promiscuity and deviancy.
Looking at these limitations can make it seem that addressing TB in developing countries is a hopeless cause. At one point in time, the WHO held a similar sentiment and suggested that MDR-TB was virtually incurable in these places. In spite of this, there have been and continue to be great successes in treating TB.
Photo by William Castro Rodríguez from Partners In Health.
Tuberculosis in Peru
In the mid-1990s, Partners in Health, known as Socios en Salud in Peru, began a MDR-TB treatment program that would prove that tackling TB in developing countries is possible. Since the 1980s, TB had been one of the leading causes of death for Peruvians. During that time, up to 47% of TB patients in Peru were not able to see their treatment to completion, mostly due to the many barriers to treatment that were discussed above. It was Partners in Health’s “community-based model” that ensured TB patients, particularly those who faced the most taxing of treatments, had the greatest chance of recovering. The community-based model empowered community members to administer daily medications and helped patients access the clinical, socioeconomic (e.g. food baskets, subsidized housing, microfinance loans), and social supports needed to stay in treatment. The recognition that curing TB can only be possible by addressing the social and financial challenges of patients were key to Peru’s achievement of one of the highest cure rates for TB in the world.
Moving Forward
There is much to be learned from the successes in Peru. Beyond reaffirming that patients in developing nations deserve and need quality healthcare, the progress against TB in Peru emphasized the importance of considering the social factors that influence the spread of and susceptibility to disease. There exists an intimate relationship between the prevalence of TB and socioeconomic factors like cyclical poverty, poor housing conditions, and overcrowding; a relationship that is evident in the countries and communities struggling with TB. Addressing these social concerns and implementing community-based clinical programs may be what is needed to place the goal of eradicating TB in closer reach. Then, hopefully, one day, dying from TB will be confined to the television screen or the stage rather than the current reality for millions of people around the world.
