Tuberculosis – The Invisible Pandemic

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March 24th, World Tuberculosis Day, marks the anniversary of a momentous occasion- the discovery of the bacterium which causes tuberculosis in 1882. More than a hundred years after its discovery, tuberculosis is still a global health crisis. It is the leading cause of death from a single infectious disease agent, killing close to as many people per year as COVID-19. Last year, tuberculosis killed 1.4 million people.

Tuberculosis or TB, occurs all around the world, but in 2019 a mere 30 countries accounted for 87% of new TB cases. Of these, eight countries accounted for two thirds of the total: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh, and South Africa. We see roughly 12 million new infections per year.

Hypothetically, anyone could fall ill with tuberculosis. In reality, this disease disproportionately affects those who live at or below the poverty line. Poverty can exacerbate every aspect of living with TB, from infection to treatment.

Image: Countries with more than 100 000 tuberculosis cases.

A disease of poverty

Tuberculosis spreads via droplet transmission from infected people. It stands to reason that the ideal conditions for TB to spread would be a space where people live cramped in extremely close quarters. Unfortunately, this is the reality for many impoverished people living in these high-burden TB countries. In India, for example, huge slums are commonplace in urban cities. Dharavi, considered to be one of Asia’s largest slums, is found in Mumbai and has a stunning population density of over 277 136/km2. For reference, Manila is currently classified as the most densely populated city in the world with a density of around 46 000/km2. Sanitation is also a huge issue in housing conditions like these. Most do not have access to clean running water, and in many cases several houses will have to share a single small washroom. Rural areas also suffer from this lack of infrastructure and sanitation. Another factor increasing the risk of sickness is simply income. Under-nutrition increases the risk of falling ill with tuberculosis. With many making less than the equivalent of US $1.90 a day, regularly affording nutritious food is a luxury.

While getting ill is extremely easy in these conditions, getting a diagnosis is proportionally difficult. In some settings, individuals with TB face heavy stigma. This leads to denial and hence delay in diagnosis. Even if that were not the case, affordability is again an issue. Doctors can be expensive, and universal healthcare is not the standard in most countries. If people can’t go to a doctor and get a diagnosis, they have no way to receive treatment. Although many countries have made efforts to set up more diagnostics and treatment centers to identify and help TB patients, these centers are often underfunded and understaffed. Many healthcare workers in Lagos, Nigeria expressed their frustrations with a system that left them unequipped to help those in need- they were not given money for necessary repairs, had to pay out of pocket for patients to be able to eat, and did not have the technicians and tools to complete diagnostic tests efficiently.

Photo: Woman in a Chittagong slum, Bangladesh.

Lengthy treatments

Tuberculosis treatment is not a cheap affair. Although in many high-burden countries first-line medications are free or heavily discounted, the direct cost of medicines is not the major expense for many TB patients. On average, 80% of costs incurred come from direct non-medical costs and income loss. Non-medical costs can include things like transportation to get to health centers or well-balanced meals. Even on the medical side there can be other hidden costs: for example, in China, many TB patients are prescribed protective drugs to combat the liver damage done by TB treatment, and these drugs are not free. There is also an issue with antibiotics being over-prescribed, which increases the risk of drug-resistant TB. And it’s worth noting that we’ve only looked at drug-sensitive tuberculosis so far. 10% of patients will develop resistance to the first-line drugs and treatment for drug-resistant TB can be far more painstaking

The second-line medications needed to treat drug-resistant TB are unrealistically expensive. Frequently these drugs are not fully subsidized, putting them out of reach of people who cannot afford them but depend on them to be cured.

The length of treatment is also a problem. Treatment goes on for six to twelve months, but people might start to see improvement in their symptoms before the course is done. In this situation, they may be inclined to stop taking their medicines for multiple reasons. The cost is obviously one. Another is the need for them to get back to work as soon as possible. Often people will ‘save’ their remaining pills for any future illness- many are unaware that antibiotics are not multipurpose medications. Not completing the full course of antibiotics leads to the development of drug-resistant TB which, as mentioned previously, is even more difficult to treat. It can take twice as long, and the medications are far more expensive.

Photo: Tuberculosis antibiotics combination therapy – Rifampicin, Isoniazid, Pyrodoxine.

Tuberculosis treatment requires consistent coaching and regular follow-ups to ensure patients are on track with their medications. Lack of awareness can also create obstacles in simply being able to find treatment- in India, although treatment is free at government hospitals, many are unaware of this and tend to spend huge amounts in private hospitals.

Effects of the COVID-19 pandemic

The COVID-19 crisis has disrupted every aspect of life, and TB treatment has not been spared. Severely reduced TB case notifications have been reported from high-burden countries, and while lock-down has been effective in stopping the spread of COVID-19, it has impacted people’s ability to seek care for tuberculosis. Concern regarding COVID-19 has also dissuaded TB patients from going to healthcare centers out of fear of contracting the virus, and many also avoid doing so out of fear that they will be assumed to be COVID-19 patients and ostracized as such. Hospital and personnel resources are also being diverted from tuberculosis care in order to keep up with the massive demands of the pandemic.

A study from the Imperial College of London’s School of Public Health illustrates how even short lock-downs could have long-term effects on TB incidence and mortality. They estimate that a suspension of TB services for even a few months could cause an additional 1.2 billion TB cases over the next five years. Another study from the London School of Hygiene and Tropical Medicine estimates that the negative impact on healthcare services will likely lead to 110 000 additional deaths in India, China, and South Africa alone. In the worst-case scenario, they estimate 200 000 additional deaths.

What can be done

There is clearly a lot of oversight in current TB care that needs to be rectified. Governments need to provide more funding to TB diagnosis and treatment clinics so that they have the resources they need to diagnose, track, and follow up with patients. Pharmaceutical companies need to make their products affordable for those whose lives depend on them. Treatment for any form of TB needs to be more accessible and affordable. A greater effort needs to be made to educate patients about the importance of seeking care and taking medications, as well as making them more aware of the options that are available to them.

On a larger scale, poverty as a whole needs to be addressed for life to improve for tuberculosis patients. Things like food, shelter, and job security are necessary for tuberculosis patients to be able to successfully recover and resume healthy lives.

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