-fuelled by HIV
If tracing a tuberculosis patient were as easy as treating one Guyana would be TB free, relieved of a disease that has been a scourge in the society since the turn of the 19th century. Patients were isolated for treatment in those days; today they isolate themselves, hiding from the stigma that is still attached to the disease.
Guyana has been fighting a tuberculosis battle that seems never ending − the numbers had dwindled at one time − as new cases emerge in the local healthcare system that is fighting a string of battles − HIV, malaria, dengue fever, high blood pressure, kidney disease, heart disease, etc.
With the emergence of HIV, tuberculosis has resumed an assault on the healthcare system, and continues to pose serious challenges. Guyana’s co-infection (HIV and TB) rates are climbing and have ballooned from around 20 per cent of the HIV infected population to some 30 per cent; TB has found its way back.
The problem is this: HIV infected persons who could benefit from preventive TB therapy treatments are not accessing any because they are not getting tested. But a new strategy is being employed this year and at an opportune time, as Guyana observes its National Week of HIV testing. TB patients who visit the hospitals and treatment sites from November 17-21 are being encouraged to support the initiative, and based on early indicators they are.
It is reportedly a difficult task to get TB patients tested for HIV. One patient rationalized it this way in a recent interview.
“TB is HIV so why take the test; people look at you the same way, you get some of the same symptoms. Imagine battling TB then having to find out that AIDS is a second thing to worry about.”
According to Dr Jeetendra Mohan Lall, Manger of the National TB Control Programme, the numbers on record show that HIV is fuelling the TB disease in Guyana at worrying levels. Frankly, the numbers indicate that TB is now the second leading infectious killer after HIV/AIDS, and because of the weakened immune system the risk of active tuberculosis increases 100-fold in people infected with HIV. The sex, age and geographic distribution of TB actually mirror that of HIV. Nearly 80 per cent of HIV deaths in Guyana are as a result of TB.
Of the 701 TB cases recorded in the system last year, 198 were cases of co-infection (TB and HIV), but the true TB numbers are not really known given the attitudes of patients not to test on either side, despite the fact that the importance of testing for TB in HIV patients has been continuously underscored.
What is TB? Tuberculosis is a disease caused by germs that are spread from person to person through the air, and which can damage the lungs and other parts of the body and cause serious illness and even death. It is treatable and curable, and through the National Tuberculosis Control Programme in Guyana, all essential services and drugs are free of cost.
TB is largely a disease of the poor; persons in the lower socio-economic brackets are mainly affected.
An estimated 14 per cent of Guyana’s population (approximately 115,800 persons) is infected with the TB bacteria of which close to 3,000 are active cases (persons who are ill), and the annual incidence of TB is around 93 per 100,000 persons.
Former head of the local TB programme, Dr Moti Lall observed recently in an interview with this newspaper that no serious provision had been made for the continuation of a formal TB programme in Guyana after the programme at the Best Sanatorium officially ended in 1986. This left Guyana in a vulnerable position, he said, noting that TB returned with a vengeance fuelled by the emerging HIV epidemic in the early 1990s. According to him, the vulnerability set the stage for an explosion and by 2002; more than 600 new documented cases appeared each year.
“There is no doubt that the increase in TB in Guyana throughout the 1980s and the 1990s paralleled the increase in HIV infections, but though the co-infection rate is alarming the incidence rate appears to have been stabilized,” Dr Moti Lall added.
Stabilizing the disease
Dr Mohan Lall spoke of the hurdles that still face the local TB programme such as hard-to-reach areas, particularly those pockets of people that are concentrated in the hinterland areas. Though the national TB programme has been rolled out in all ten regions there are still gaps to be filled, but he pointed out that more cases are being detected, treated and cured.
Funding had been somewhat limited in the past but Guyana recently received a boost in its TB treatment programme with close to US$7M in funding from the Global Fund. Dr Mohan Lall notes that that figure will create more room for the programme to expand, in addition to the creation of new aspects of it. The immediate focus, among other things, is to have the TB programme integrated into the primary health care system, to expand the nutritional component of the programme and to deepen partnerships with other local supporting agencies such as the Guyana Red Cross.
“The aim has always been to stabilize TB and that is exactly what we have done over the years. Guyana’s TB programme is active and is on the move; we are targeting patients, finding them and treating them, next the goal is to reduce the numbers of new cases,” he said.
Diagnostic and laboratory capacities for TB have since been established across the country and testing sites have increased within the last decade; there are now 16 such sites stretching from the city to New Amsterdam and Essequibo, to Mabaruma and Mahdia. All hospitals across the country have the capacity to treat TB, and there is an infectious disease ward at the Georgetown Public Hospital.
The number of TB cases over the years has been stable, according to Dr Mohan Lall. He said DOTS has been integral to the success seen over the years in TB, pointing out that the country now has a complement of some 45 dedicated DOTS workers that perform community outreach work.
He added the funding over the years has resulted in the programme being expanded.
In six months, a TB infectious patient can be cured, provided the treatment regimen is strictly followed, but some patients barely hang on for two months, which is why the introduction of the DOTS (Directly observed treatment) course in 2002 was timely. Adherence to treatment lies at the centre of the DOTS programme, as health workers fan out across the country watching patients drink pill after pill − some patients escape the visits by hiding out or relocating.
Still, there is a doggedness that seems to define local DOTS workers because they hunt patients down like Richard (not his real name) who slipped out of the system after one month of treatment because he “was tired of being fed tablets day in and day out.” But he was swallowing the pills a year later (this September) while imprisoned on a larceny charge; he had no qualms about it then.
Richard traces his TB infection to a cocaine block he frequented a year ago while he was an addict, recalling that he spent hours smoking in a pool of sickness (mostly HIV and TB).
He coughed for a year, sometimes spitting blood but rejecting that he was sick.
Then he broke down; headaches, endless sweating and weight loss, and eventually checked himself in at the public hospital. He was placed on treatment, then defaulted, but restarted while in prison this year. He is clean now, a recovering addict and a TB patient.
“It is like I am new man back from the dead and believe me, I was dead to those who care. I knew what TB was but hated the fact I could be one of those people living with it because it has a stigma like HIV and it feels like that,” Richard said.
Diagnosing TB
Tuberculosis is contagious as infectious persons expel the bacteria into the air when they cough and sneeze, sometimes even talk and spit depending on their condition. Persistent coughs or coughs that produce discoloured or bloody sputum that usually lasts for about three weeks at a time, are the first signs of TB infection.
There are also slight fevers, chills, fatigue, loss of appetite and weight, and night sweats, which indicate that a person might have contracted the disease. A person with advanced TB can cough up blood.
TB infection and TB disease differ. TB infection occurs when a person has been exposed to the TB germ but does not fall ill; the germ remains inactive in the body for years while TB disease is when the immune system has been weakened, thus allowing the germ to penetrate resulting in the person becoming sick with TB. Therefore, a person may have a TB infection without developing the disease.
Dr Moti Lall said that nearly 90 per cent of persons who are exposed to TB become life-time carriers − some of them never show any symptoms − as their immune systems successfully create a physical wall around the TB bacteria, preventing it from doing any damage. In effect, the immune system creates TB prisons; the immune system becomes the warden and the TB bacteria become the inmates (the bacteria are alive but exist within the immune prisons).
This is referred to as latent infection, and persons with latent infection do not transmit the infection to other people.
However, HIV, among other infections, weakens the immune system, and a person with latent infection can contract the disease, as the prison walls become fragile and the TB bacteria escape. It is at this stage that TB can be transmitted to others, Dr Moti Lall explained.
In Guyana the BCG (Bacilli Calmette-Guerin) vaccine is administered at birth as a preventive measure to TB − it is mandatory that all babies receive the vaccine within days of their birth. But Dr Moti Lall notes that its effectiveness is limited and that the protection of the vaccine is short-lived. He is firm though, that no parent should risk a child not receiving the vaccine.
Four tests are available locally to detect TB: chest x-rays, which would show if any damage has been done to the lungs; the more common sputum test, where the TB bacteria in sputum (cold) is visualized using a microscopy; a skin test and the culture test. Patients with TB are treated with a combination of anti-TB drugs for a period of 6-8 months; those who fail to adhere to treatment are usually not cured, and in some cases develop Multi-Drug Resistant (MDR) TB.
MDR is creating a bit of a bother locally. Dr Moti Lall, who now heads the Guyana Chest Society, notes that at the clinical level they have seen a few cases here − not much to raise an alarm but enough to be bothered about. He said that many of the patients who develop MDR are HIV infected, adding that the TB drugs work faster in patients who are not HIV infected.
MDR refers to TB bacteria that are resistant to two of the main anti-TB drugs (usually isoniazid and rifampicin).
TB stigma
Eustace Reece, a recovering TB patient, understands what being diagnosed with TB and having to tell others feels like.
He was kicked out of his home a few months ago and forced to take up residence at the night shelter after disclosing his status.
“People fear dis thing real bad and I realize how much when it hit me,” Reece said while pointing out that he had always been the cautious type since before contracting TB.
He listed his health conscious attitudes as being careful not to cough without covering his mouth, never speaking directly in another’s face, and routinely washing his hands.
Reece has no idea how he contracted TB, but he admits that his nutritional status had been poor for a while.
He said his immune system was likely weakened by his poor diet, which he currently does not worry about, owing to three hot meals from the night shelter. There is also the option of a monthly food hamper from the Guyana Chest Society.
As far as he is aware no other occupant of his home, commonly referred to as his contacts, has contracted TB. For three months now he has not seen his home; he is apprehensive about going back, yet yearns to see it again.
Since he left, no one has contacted him or sought him out, and he knows that it so because he enquired.
Reece is frank, admitting that had he been in the same position he likely would have reacted the same way, and would have rejected the idea of being close to someone who was infected with TB. He is stunned though, that people at the night shelter are not the least bit bothered by his presence though they are aware that he is infected. But Reece was initially isolated at the shelter for about two weeks − infectious TB patients like him become non-infectious within 2-3 weeks of treatment, and they are usually cleared to live with their families while on treatment.