As the world marked World Tubercuosis Day, setting new targets to combat the disease which claims millions of lives annually, Nigeria worried about emerging cases of multi-drug resistant tuberculosis which poses a threat to the global effort to stop TB. Kingsley Obom-Egbulem examines this development and Nigeria’s readiness to deal with it
Stigma and discrimination against people living with HIV/AIDS can be devastating. Coping with the clinical challenges of the human immunodeficiency virus itself is tough. Add that to a loss of job, loss of apartment, rejection by friends and family members, excommunication from church and even expulsion of children from school by intolerant and unenlightened proprietors, and you have someone under pressure. Ask anyone living openly with HIV/AIDS; its tough!
Abigail Obetan Atireni lived and coped with all of these for over ten years, often using the media and other available platforms, to address and educate the public, including her adversaries, to love and not leave people living with HIV; to accept and relate with them as kith and kin because that is who they are.
But there was something Abigail could not cope with. At some point in her sojourn with HIV, she developed Tuberculosis (TB), a highly infectious disease which is the bane of many people living with HIV. The battle against TB turned out to be one of Abigail’s fiercest. In fact, her fiercest. It cost her her life.
Tuberculosis is a common, and in many cases, lethal infectious disease caused by the bacteria Mycobacterium tuberculosis. It typically affects the lungs but can also spread to other parts of the body. It is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air, and all an uninfected person needs do to become infected is inhale a few of these germs from the droplets of the already infected person.
Tuberculosis was first declared a global emergency in 1993 by the World Health Organization (WHO). Between the 1950s and the late 1980s, the disease was practically eradicated in most parts of the world, particularly North America. In the early 1990s, however, the world became alarmed when incidence of the disease dramatically escalated. This resurgence was attributed to the increased susceptibility to tuberculosis of people infected with HIV. TB is one of the main opportunistic infections affecting people living with HIV. It typically becomes more severe in people with AIDS than in those with a healthy immune system.
According to WHO, someone becomes infected with the bacteria that cause TB every second. One-third of the world’s population is infected with the bacteria, and as many as one in ten of those infected will develop active symptoms of tuberculosis at some point in their lives with people living with HIV said to be at much greater risk than others.
“The reality is that many people harbour the bacteria but have no symptoms of disease because they still have a strong immune system that can withstand the disease”, says Dr. Dan Onwujekwe, an infectious diseases specialist and Senior Research Fellow at the Nigerian Institute of Medical Research (NIMR), Lagos.
“Because HIV weakens our immune system, these dormant bacteria becomes active, chronic and infectious and when symptoms develop, they include coughing, chest pain, shortness of breath, loss of appetite, weight loss, fever, chills, and fatigue. ”
“In 2007, I was pleasantly surprised to see her walk into our Abuja office. I noticed she was coughing intermittently-it was a deep throaty cough and I had to confront my fears about her health”, wrote Olayide Akanni, Executive Director, Journalists Against AIDS (JAAIDS) in her tribute to Abigail.
Abigail was apparently coming from the hospital where she had gone to undergo some TB tests, the results of which revealed that she had developed a multi-drug resistant strain of tuberculosis (MDR-TB).
MDR-TB refers to tuberculosis that is resistant to isoniazid (INH) and rifampicin (RMP), the two most powerful first-line anti-TB drugs.
Abigail’s situation was a frightening reality as help was not close by, given Nigeria’s capacity then with respect to TB intervention.
“As at that time, only two centres in the country had the required capacity to conduct tests for drug resistant TB. Besides, the World Health Organisation (WHO) had only approved for a pilot MDR-TB treatment programme in Nigeria.” said Olayide.
“We discussed with some officials in the National TB and Leprosy Control Programme and WHO Nigeria to see how she could access drugs under the pilot programme”, Olayide continues. “However, approvals for this process could take some time. On the other hand, she also contacted a US-based Non Governmental Organisation who were willing to support her treatment. However, that would require travelling to the United States.”
So, while awaiting enrolment on the pilot programme of the National TB and Leprosy Programme, she pursued the option of seeking comprehensive treatment outside the country. Unfortunately, she was refused a US Visa.
And on Saturday, January 15, 2011, Abigail, having battled with tuberculosis for more than four years, finally succumbed. She died leaving behind concerns and critical questions about Nigeria’s TB response and its potential to contend with MDR-TB.
What is the size of Nigeria’s MDR-TB burden? What are we doing to ensure we routinely test patients to know those with MDR-TB? What facilities are on ground to respond to detected cases of MDR-TB?
“We do not test patients to know whether or not they have been infected with MDR-TB before showing up at our centres. We are not able to test for MDR-TB routinely unless if the regular treatment fails. If treatment fails, we suspect that the person has MDR-TB by first asking whether they took the drugs as prescribed and if they tell you that they took the drugs as prescribed, then we send them for culture and drug susceptibility test (DST) to establish if it’s a case of MDR-TB or not”, says Onwujekwe, one of Nigeria’s most consistent TB researchers.
Tuberculosis drug susceptibility test (DST) should ordinarily be done on a routine basis. But it is not. “This is not because we are concerned about cost”, says Onwujekwe. “If our politicians know the implication of having our name on the list of countries with high cases of MDR-TB , they will spend anything to address it.”
Well, Nigeria is already on that list. And so are many countries for that matter, according to the WHO. But how can we cope with the challenge of this variant of the tuberculosis bacteria and rescue the rising population of people with MDR-TB from imminent death in our country?
Patients with MDR-TB are coping in many countries. If Abigail were a UK citizen or living in the UK, for instance, it is likely she would be alive today. Paul Thorn alluded to this possibility at an MDR-TB experience sharing session in 2009 in Geneva.
“I am alive today because I am British, living in Britain where there are provisions for people like me to stay alive despite being infected with MDR-TB. But a lot of people are dying of MDR-TB across the world; they are dying not necessarily because MDR-TB is a killer, they are dying because of where they were born and what part of the world they live in”.
Thorn, currently one of the faces of MDR-TB and a vocal TB treatment advocate is an attestation to the triumph of political will and a coordinated response over an infectious and difficult-to-treat tuberculosis.
By itself, TB is already bad news being one of the world’s worst killers, accounting for 9.4 million cases and 1.7 million deaths in 2009, according to the WHO. Treatment for TB is also not simple, since it requires at least eight months of taking a combination of unpleasant tasting pills with equally unpleasant side effects.
And because some patients default in adhering to treatment instructions and others stop treatment completely the moment they start feeling well (even when they still have several pills to take), cases of drug resistance TB (DR-TB) will continue to develop.
Cases of multi-drug resistant (MDR-TB) and extensively drug-resistant (XDR, TB) which mean that the TB infection is resistant to the first-choice drugs, require that the patient, instead, be treated with a larger cocktail of “second-line” drugs, which are less effective, have more side effects, and take much longer times (sometimes two years) to effect a cure. Experts say XDR -TB is resistant to the three first-line drugs and several of the nine or so drugs usually recognized as being second choice.
There are even cases of Totally Drug Resistant TB (TDR-TB) with 12 patients already diagnosed in India late 2011 and 15 diagnosed in 2009 in Iran. As the name implies, these cases of TB cannot be treated with any of the known first line and second line drugs.
The WHO predicts there would be 2 million MDR-TB or XDR-TB cases in the word by 2012. This is a gloomy picture in every sense. And according to Onwujekwe, Nigeria should not be prominent in this picture if she had given her fight against TB all the seriousness it deserves.
“Multidrug-Resistant TB was declared an emergency in Nigeria in 2006 but it is not just enough to declare an emergency, we need to take an emergency step as well as sustainable steps to address the emergency”.
But it is not all gloomy for the most populous black nation in the world. A landmark achievement for Nigeria as the world marked the 2012 World TB Day last Saturday was the announcement that the country now occupies the tenth spot on the list of high burden countries.
“That is some good news considering the fact that we were occupying the fourth position. It shows we are making progress”, says Onwujekwe.
But he is quick to add: “However, we have to celebrate with caution because we are still grappling with MDR-TB”.
The celebration of the country’s progress can be sustained if the 40-bed facility recently commissioned in Lagos to cater for patients with MDR-TB lives up to expectation. The celebration could peak if the facilities in Ibadan and Calabar as well as the 60-bed facility in Zaria are able to consistently carry out effective screening and treatment of patients with MDR-TB.
“For the first time we have a marshal plan against MDR-TB. We have facilities and enough drugs to place 101 patients on admission for eight complete months and another 12 months after discharge”, says Onwujekwe.
Could this so-called marshal plan have saved Abigail if we had it in place earlier? Could it ensure we do not lose more people to MDR-TB?
The answers we may never know for sure. But perhaps we can safely say, “most likely”.
But like Onwujekwe noted, there is a constant fear; “those we are likely going to be treating in the MDR-TB facility may have infected people with a TB strain that is already resistant even before commencement of treatment. How do we track these people and ensure they are screened and placed on treatment early?”
That is the bigger question which constant awareness and mass TB screening would likely resolve.