Education is the Most Powerful Tool to End TB

Dr. Nirupa Misra. B. Pharm.M. MedSc.PhD

Tuberculosis (TB) is an infectious disease that most often affects the lungs and is caused by the bacterium (Mycobacterium tuberculosis). TB is spread through the air when people with lung TB cough, sneeze or spit. A person needs to inhale only a few germs to become infected. TB can also infect the spine, brain, kidney and skin.
TB is a serious public health issue in South Africa and is South Africa’s leading cause of death. Although effective treatments are available and the country has made considerable progress in fighting the disease, much more is needed to bring TB under control. The South African government is committed to screening 90% of those at risk of contracting TB, ensuring that 90% of suspected cases are correctly diagnosed and treated and ensuring that 90% of those treated are cured.

Latent TB Infection

Most people will not go on to develop the TB disease and some will clear the infection. Those who are infected but not (yet) ill with the disease cannot transmit the infection. People with latent TB infection don’t feel sick and aren’t contagious. Only a small proportion of people who get infected with TB will get the TB disease and have symptoms. Babies and children are at higher risk. The Bacille Calmette-Guérin (BCG) vaccine is given to babies or small children to prevent TB, however, the vaccine prevents TB outside of the lungs but not in the lungs. Certain conditions can increase a person’s risk for tuberculosis disease such as those with compromised immune systems, such as people living with HIV, malnutrition or diabetes, or people who use tobacco, have a higher risk of falling ill. Unlike for a TB infection, when a person has the TB disease, they will have symptoms.
Since these may be mild for many months, it is easy to spread TB to others unknowingly.

Common Symptoms

The symptoms depend on where in the body TB becomes active. While TB usually affects the lungs, it can also affect the kidneys, brain, spine, and skin as well as other organs. Common symptoms of TB are prolonged cough (sometimes with blood) for more than two weeks, chest pain, weakness, fatigue, unexplained weight loss, fever, and drenching night sweats.

Infection Prevention

The following steps can help prevent tuberculosis infection and spread:

• Seek medical attention in instances of symptoms like prolonged cough, fever and unexplained weight loss since early treatment of TB can help stop the spread of the disease and improve the chances of recovery.
• Testing for TB infection in those at increased risk, such as individuals who have weakened immune systems or where there has been close contact with people who have TB in the household or workplace.
• Completion of the full course of the prescribed TB treatment.
• In cases where TB has been diagnosed, good hygiene when coughing, including avoiding contact with other people and wearing a mask, covering your mouth and nose when coughing or sneezing, and disposing of sputum and used tissues properly, must be practised.

Diagnosis

In accordance with the World Health Organisation (WHO) guidelines, the detection of multidrug- resistant tuberculosis (MDR-TB)/rifampicin-resistant TB (RR-TB) requires the bacteriological confirmation of TB and testing for drug resistance using rapid molecular tests or culture methods. Tuberculosis is particularly difficult to diagnose in children.

Treatment

The tuberculosis disease is treated with antibiotics. Treatment is recommended for both TB infections and the disease.

Drug Sensitive TB

The most common antibiotics used for drug sensitive TB are: rifampicin, isoniazid, pyrazinamide and ethambutol for two months, available as a combination tablet followed by rifampicin and isoniazid combination tablets for four months. To be effective, these medications need to be taken daily for six months. It is dangerous to stop the medications early or without medical advice. This can allow the TB bacteria that are still present to become resistant to the drugs. TB that doesn’t respond to standard drugs is called drug-resistant TB and requires more toxic treatment with different medicines.

Multidrug-resistant TB

Drug resistance emerges when TB medicines are used inappropriately, through incorrect prescription by health care providers, poor quality drugs, or patients stopping treatment prematurely. Multidrug- resistant tuberculosis (MDR-TB) is a form of TB caused by bacteria that do not respond to isoniazid and rifampicin, the two most effective first-line TB drugs. MDR-TB is treatable and curable by using second-line drugs. However, second-line treatment options require extensive medicines that are expensive and toxic. In some cases, more extensive drug resistance can develop. TB caused by bacteria that do not respond to the most effective second-line TB drugs can leave patients with very limited treatment options. MDR-TB remains a public health crisis and a health security threat.
Historically, treatment for drug resistant tuberculosis had a long duration (18–20 months) with a daily injection for six months together with a handful of tablets. The treatment journey was long, requiring hospitalization for at least six months with many patients experiencing severe side effects. The introduction of three new agents to treat TB in the past few decades resulted in the removal of the toxic injection for most patients and allowed them to be managed on a 9–11-month all oral treatment regimen. In 2022, new WHO guidelines prioritized a 6-month regimen as a treatment of choice for eligible patients. The shorter duration, lower pill burden and high efficacy of this novel regimen can help ease the burden on health systems and save precious resources to further expand the diagnostic and treatment coverage for all individuals in need. South Africa is currently transitioning to the 6- month regimen for most patients with rifampicin resistant tuberculosis with the long 18–20-month regimen used in cases of severe disease and extensively drug resistant tuberculosis.

TB Preventive Therapy

It is essential that TB preventive treatment (TPT) is scaled up to reduce the burden of TB in South Africa. Previously, TPT was offered only to people who were at the highest risk of progressing to TB disease after exposure (i.e., children younger than five years of age, and all people living with HIV, regardless of age). However, to achieve TB elimination, it is imperative to implement TPT more comprehensively for everyone with significant TB exposure and all other individuals at high risk of TB.

In most instances, people who should be offered TPT will share a household with at least one person who is concurrently on TB treatment. Therefore, where possible, a ‘family-centred’ approach to TPT initiation and adherence support should be adopted by integrated healthcare worker teams or health services where possible. It is also important to consider the context of the household, and to offer similar regimens to affected household members, where possible.

The TB test and treat approach: It is essential to rule out TB disease before initiating TPT. Therefore, all individuals (adults, adolescents, children and infants) should always be evaluated for TB disease before initiating TPT, including testing for active TB disease. Thereafter, the next decision, in the presence of significant TB exposure or TB risk, is to either offer TB treatment (in the presence of disease) or to offer TPT.
In South Africa, the current TPT options include isoniazid and rifapentine given once weekly for three months (3HP), daily rifampicin and isoniazid for three months (3RH), daily isoniazid for six months (6H) or daily isoniazid for 12 months (12H). As a rule, shorter treatment options should be offered where feasible and available. If 3HP is not available (or contra-indicated), 3RH or 6H should be offered for people who tested negative for HIV, and 12H for PLHIV (6H for children with HIV) and 3RH for children < 25 kg in South Africa, 3RH should therefore be used, unless contra-indicated.

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Bibliography

1. Global tuberculosis report Geneva: World Health Organization; 2023. Licence: CC BY-NC- SA 3.0 IGO.
2. Republic of South Africa, Clinical Management of Rifampicin Resistant Tuberculosis, A Clinical Reference Guide, November 2019
3. Republic of South Africa, Clinical Management of Rifampicin Resistant Tuberculosis, Updated Clinical Reference Guide, September 2023
4. Republic of South Africa, National Guidelines on the Treatment of Tuberculosis Infection, February 2023
5. World Health Organization, Rapid communication: Key changes to the treatment of drug-resistant tuberculosis, May 2022