In this interview by SADE OGUNTOLA, Professor Olufemi Adewole, a consultant physician and pulmonologist at the Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) Ile-Ife, Osun State, says apart from HIV, increasing cases of tuberculosis are recorded in individuals with diabetes, which he says can be fatal if not detected and treated early.
The World Tuberculosis Day is meant to raise awareness about the disease and efforts to end the epidemic. Why is it termed an epidemic?
An epidemic is when there is an unexpected increase in the number of disease cases in a specific geographical area per time. This is not the case with TB in most developing countries, including Nigeria, where TB is an endemic disease. This implies that TB is constantly present all the year round in the country. There has been no time there was a zero number of TB cases. TB is always with us and not yet eradicated. The worst is that every day, new cases of TB are being detected.
What are the risk factors of Tb in Nigeria?
Tuberculosis is caused by an organism called mycobacterium tuberculosis. There are different types of this organism but common ones are mycobacterium tuberculosis and mycobacterium Africanum. Most of the time, it affects the lungs more than 80 percent of the time. It could affect all parts of the body, including the abdomen, the liver, kidney, womb and brain.
Basically, individuals likely to have TB are those who recently contracted a case of tuberculosis or those with diminished immunity, the very young under the age of five years and the elderly people. Individuals who live in overcrowded settings; hostels, recreational and correctional homes and IPDs are also at risk. Those with lowered immunity like diabetics; those with HIV, cancers and kidney disease are at increased risk. The chances of an HIV-infected person having TB is quite high, sometimes as high as 50 percent, which increases for each year the person lives. About 10 to 20 percent of new cases of TB might be related to diabetes. Diabetes breaks down the body’s immune system and so they may succumb more to it.
Moreover, people also at a higher risk of TB include smokers, those who are malnourished, and alcoholics. Some people who take certain drugs like steroids to build their muscles or wrongly for other diseases are also at increased risk of developing TB. Some drugs used to treat other diseases are associated with increased risk. Those who have one form of organ transplant or the other are also at risk.
It has been found that some degree of exposure to sunlight is fairly well protective from TB. Sunlight enables the body to produce vitamin D, one of the agents that enable and strengthen the body’s immunity to fight and overcome TB-causing organisms in the body. So, if exposure to the sun is low, that could be a problem for some people and why they may have TB. Of course the list is endless.
Currently in Nigeria, who is most at risk of having TB?
Nigeria is on the list of the World Health Organisation’s 30 high burden countries for TB, occupying the sixth position globally and has the highest disease burden in Africa. Because of the high disease burden in the country, the truth is that everyone living in Nigeria has varying degrees of risk of contracting the disease. Again in Nigeria, the detection rate for the disease is still low, meaning there are many people who have the disease that are not yet detected and commenced on treatment. This enhances transmission in the community. So, in most areas where there is overcrowding and poor ventilation with low socioeconomic conditions, the risk is high. It does not mean that the rich do not also have it. The rich also cry! However, most individuals that come down with TB are within the ages of 15 and 50. It is quite pathetic because this is also the productive age group in the country.
How fatal can TB be?
TB can be fatal, but the good thing is that TB is a completely curable disease. The fact is if somebody is diagnosed on time and treated, the individual can be cured of the disease and most of the time go back to near normal function. Unfortunately people are still dying from TB. In 2021, WHO records that about 1.6 million people died from TB.
It is not supposed to kill, unfortunately, people present late for treatment. By the time they do, complications would have set in; more so if they have other co morbid conditions. Also, the death rate is high among those with drug-resistant TB. But by and large, it is a curable disease, but unfortunately, it is killing people.
TB is deadly worldwide, and it ranks highest among the infectious causes of death, even over HIV. Even during the era of COVID-19, TB contributed significantly to deaths in those with COVID-19. In Africa, the death rate due to TB is quite higher than in most parts of the world. Various hospital-based studies show that it ranges from about 5 to 15 percent among patients that present with TB to the hospital. But it is not a disease that we cannot conquer. Yes, we can.
What are the signs and symptoms of TB? How can cough associated with TB be differentiated from that from other causes?
The commonest form of TB is that which affects the lung called pulmonary TB. Its cardinal symptoms are coughing with sputum, weight loss, night sweats and low grade fever. The sputum could have blood in it. For most individuals, the blood in the sputum is the first thing that will draw their attention to the fact that the cough they are having is not just ordinary. So, if you have a cough, and you have blood in your sputum, you really have to consider TB among other possibilities and so you should get tested. However, for certain set of individuals, children especially, and those who have HIV in them, sputum production may not be prominent even if they have pulmonary TB. A cough of any duration can be TB, so we don’t need to wait for long before getting tested.
One other important symptom is weight loss. If the weight loss is not in concordance with the degree of loss of appetite, it is more than just losing of appetite. And of course, a complaint of excessive night sweats that leave the bed sheet and pillow case wet, in absence of other medical conditions is highly indicative of TB. A low grade fever is also a problem in individuals likely to have TB. The fever is not like that with malaria, which is a high grade fever. It is felt more in the evenings. Some may also get tired easily, feel breathless and some occasionally have noisy breathing as the disease progresses.
Apart from the lungs, the symptoms also depend on the parts of the body affected. If it affects the brain, it can lead to epileptic or seizure disorders and even result in unconsciousness. It can affect the heart causing the heart to stop working well, and when TB affects the female or male reproductive tract, it may cause infertility. So, basically the symptoms of TB depend on the parts of the body that it affects. But commonly, the lungs are affected.
The theme for the World TB Day is ‘Yes, we can end TB’. Is this not a mirage based on what you see in Nigeria?
Ending TB is a goal, an aspiration that is pursued with definite timelines. The ‘End TB’ strategy aims to reduce the number of people suffering from TB by 90 percent by 2030 while reducing deaths from the disease by 95 percent and protecting families from the negative impact of the disease. But we have about 1.6 million people that will die from TB in 2021 and over 10 million estimated cases. To end TB, we have to reduce infection rate, death rate from TB and remove all forms of catastrophic costs for the patient. To achieve these, the annual decline in global TB incidence rates must accelerate to 10 percent per year by 2025. Secondly, the proportion of people with TB who die from the disease (the case-fatality ratio) must decline to 6.5 percent by 2025. For this to happen, we need to create more awareness for people to get tested and treated if they have TB, encourage leadership and political will for local investments in TB control. There must be an expansion of access to care for all categories of individuals with TB and universal health coverage. Most of our TB treatment-related programmes are donor-funded. This should change.
Of course, we need to encourage and adopt local innovations in TB for diagnosis and monitoring of treatment of patients with TB. This is definitely going to be cheaper and cost-effective, more patient-friendly and more timely. We have quite a number of them. For example, a local innovation uses sweat to detect TB. If this is adopted, it will make testing easier, since you don’t need to wait until you get sputum which some people may not get or which some people consider messy. People who have the likelihood of having TB disease can now receive preventive treatment so that the disease does not develop.
Treatment is available for all forms of TB, including drug-resistant forms, and it is free. Again, treatment duration is getting shorter. Patients with TB can be treated now for four months if it is drug-sensitive; and for those with drug resistance, they do not need injections again and can be treated from home or in the community.
I think we need to see TB not just as a public health issue but a developmental challenge as well. TB affects more people in the productive age group. Imagine the loss when even 10 percent of the productive age group is affected and cannot work; the economic loss is huge. Studies suggest that on the average, three to four months of work time is lost, resulting in average lost potential earnings of 20 to 30 percent of annual household income. For the families of those that die from the disease, there is the further loss of about 15 years of income because of the premature death of the TB sufferer. So, more collaboration is required to tackle this menace; everyone needs to be engaged to end TB.