Why do people still die from tuberculosis
Introduction:
Tuberculosis, also called TB, is one of the most ancient diseases of mankind, with evidence dating back to over seventeen thousand years from now. With time there have been new developments in the diagnosis and treatment of the disease, but the fact that all over the world people are still suffering and dying of TB cannot be ignored. Tuberculosis is one of the top ten most infectious killer diseases in the world today. Tuberculosis is a worldwide pandemic as stated by the World Health Organization (WHO).
Instead of being just a disease, tuberculosis has gone on to becoming a global problem that can no longer be ignored. In the year 2006, TB killed around two million people which is about double the number of people killed due to malaria and it is the prime reason of death among people with HIV/AIDS. This is a huge tragedy since these deaths are preventable. For a long time the world assumed that they have defeated TB. But just because TB does not make headlines anymore, does not mean it has vanished. The reality is that the disease is worsening, as complacency and lack of adequate tools and funding fuel the disease and the spread of drug resistance. In the 21st century, tuberculosis has emerged as an increasingly untreatable airborne epidemic.
Cause and Symptoms:
Tuberculosis is acquired by inhaling the disease-causing bacteria Mycobacterium Tuberculosis. About ninety percent of the infected people show no sign of the disease but the bacteria is harbored inside their body and risk of developing active Tuberculosis at a later stage becomes very high. If left untreated, one-third to a half of the people who develop TB are sure to die from it. The remaining with active TB shall show chronic symptoms. In turn, the people with active TB can infect other people.
Effective drugs for curing Tuberculosis have been available for more than fifty years, which virtually makes all cases of TB curable, Unfortunately the TB bacteria has developed drug resistance, which has made the treatment much difficult, longer and more expensive. The disease typically attacks the lungs (called Pulmonary TB), but in some cases it also affects other body parts as well (called Extra-pulmonary TB).
TB can be described as Active or Latent. Active TB means that the germs are alive and active in the body can spread from one person to another. Latent TB, however, means live TB germs are present within the body but inactive. It does not spread from one person to another, but latent TB can go on to become active in the future.
It is a communicable disease and gets transmitted through air when people with active infection cough, sneeze, or in any other way spread their saliva in air.
The most common symptoms of active TB are persistent coughing lasting three weeks or longer, that gets progressively worse, loss of weight for no obvious reason, persistent fever, night sweats, coughing up sputum with or without blood, loss of appetite and feeling generally tired and unwell.
Latent TB has no symptoms.
TB is curable and full recovery can be achieved, provided proper and complete treatment is undertaken. People undergoing treatment may even start to feel better within two to three weeks of treatment. But that is not enough. The complete treatment had to be completed. In some cases people fail to complete their full course of and thus develop drug-resistant TB. This type of the disease is extremely hard to cure.
The figure below indicated how the Primary TB goes on to become more on more resistant in form of MDR TB (Multi-drug resistant TB) to XDR TB(Extremely/Extensively drug resistant TB) and finally TDR TB (Totally drug resistant TB).
Multi drug-resistant and extremely drug-resistant tuberculosis represent a big global health problem in the 21st century.
Today's Scenario-
In the 21st century, the TB epidemic is worsening and more people are dying of TB than ever before. Two million people die each year from TB. It is still spreading and continuing to kill. Today the number of people dying from TB is more than AIDS, malaria and tropical diseases combined together.
Tuberculosis has now infected nearly 1.3 billion people all over the world. Of these, around twenty million people have the active disease. Roughly half of them are contagious, each TB patient infecting ten to fifteen other people every year on an average. Every year eight million new TB cases and over two million deaths occur.
Developing countries account for the largest number of new cases of TB (95% of the world total) and deaths caused by TB (98% of the world total). In adults, TB affects in the salary earning period that is Fifteen to Forty-five years. TB is the largest cause of infectious death in women, exceeding deaths due to all combined causes of maternal mortality. Almost 170,000 children die of TB every year.
The problem of Tuberculosis is the worst in South-East Asia where nearly forty percent of the world's TB cases are found to exist. The five countries with the highest prevalence (Ninety-five percent of the total cases in the region) are- Bangladesh, India, Indonesia, Myanmar and Thailand.
Following is a list of countries with the highest incidence of TB worldwide (in alphabetical order):
Some facts about Tuberculosis (Courtesy: World Health Organization)-
ð 6 million people die every year due to HIV/AIDS, TB and malaria; of those, nearly 2 million deaths are due to TB
ð TB is curable yet five thousand people around the world die of TB everyday
ð Ninety-eight percent of all TB deaths occur in the developing countries and affects mainly young adults in their most productive age
ð TB is the leading killer among HIV-infected people with weakened immune systems; a quarter of a million TB deaths are associated with HIV, a majority of them occurring in Africa
ð TB is a leading killer among young women, especially in Africa
ð If left unchecked, within 20 years TB will kill a further 35 million people
ð Global TB incidence is still growing at 1% a year due to the rapid increase in Africa; intense control efforts are helping incidence fall or stabilize in other regions
ð The poorest and malnourished are the most vulnerable victims of tuberculosis all over the world
ð Two billion people which is equivalent to one-third of the world's total population, are infected with the disease
ð One in every ten people infected with the TB bacilli shall become sick with active TB
ð TB is contagious and spreads through the air like the common cold. A single person with active tuberculosis infects an average ten to fifteen people every year
ð TB is a worldwide pandemic. Though the highest rates per capita are in Africa (a quarter of all TB cases), half of all new cases are concentrated in the six Asian countries (Bangladesh, China, India, Indonesia, Pakistan, Philippines)
ð 8.8 million new TB cases occurred in 2003 with 80% in 22 countries
ð Multidrug resistant tuberculosis has spread its roots in literally all the countries surveyed recently by W.H.O. and its partners
ð 425 000 new MDR TB cases occur every year with the highest rates in the former USSR and China, where up to fourteen of all new cases have failed to respond to the standard drug treatment
Figure: This map shows the number of new TB cases around the world.
Graph: TUBERCULOSIS INCIDENCE TRENDS IN NINE AREAS OF THE WORLD
In today's date, we are well aware of how the disease can be cured. We know how tuberculosis has to be treated and how to prevent it from recurring in the future. Provided all that we know now about the disease and having all facilities at hand, the staggering number of two million deaths every year due to tuberculosis is a bit too much to accept and live with. This situation is unacceptable. People are now much more knowledgeable about the disease unlike in earlier times. We know how it is caused and we have the technologies to diagnose it and the drugs to treat it. We have an extensive public health infrastructure on which to build our TB control programs and we have more resources than ever before to deal with the problem. Yet the epidemic is worsening as there are other complications at work that make beating tuberculosis infection more difficult.
Some of the main reasons are:
- Very small percentage of all cases undergo diagnosis:
The rest go unnoticed. Many cases remain undiagnosed due to lack of diagnostic facilities, especially in rural areas, as well as lack of awareness on the part of people to get themselves tested. The most effective way to fight TB is to stop it at its source. But if a large percentage of TB cases never come to light, there can never be any hope of controlling this widespread disease.
- Fewer than half of the people diagnosed with TB are cured:
The vast majority of the world's TB cases are not supervised during treatment. Many patients having started treatment do not complete the course. Only 30 to 50 percent of those diagnosed with TB are cured. The rest continue to suffer and infect others. Each uncured patient infects approximately 10 to 15 persons each year.
- Tuberculosis bacteria have become resistant to Anti-TB drugs:
Multidrug Resistance TB (MDR-TB) develops when the drugs to cure TB are not taken in the correct combination and consistently over the prescribed duration. MDR TB is rapidly spreading. It is believed that more than fifty million people may have already been infected with the drug resistant TB bacteria. Multi drug resistant TB needs more than a hundred times more expensive treatment.
- Tuberculosis and HIV have combined forces:
HIV and TB have become partners. The HIV deteriorates a person's immune system to fatally lower resistance to any infection including Tuberculosis. As HIV increases, so does TB. In countries like India, Myanmar and Thailand which are the worst hit by HIV, a collateral epidemic of TB is following post AIDS.
- Poor socio-economic conditions:
Rich or poor, anyone can get TB. However adverse socio-economic conditions like poverty, over-population and poor standards of nutrition as seen mostly in the South-East Asian countries create conditions that fuel the spread of the disease. As a matter of fact TB traps people in a vicious loop of disease and poverty.
- Increasing population movements:
Today, millions of people are on the move; some in search of jobs, political refuge or simply for a better standard of living. Fatal diseases like tuberculosis move along with them, which makes contamination easier and treatment even more difficult. The co-infection of TB with HIV is another major additional risk among such people.
- Low rates of awareness about TB:
The dearth of awareness in communities regarding the need for early diagnosis and immediate treatment of tuberculosis has fueled the epidemic. Many people are still unaware that the early symptoms like fever and cough and loss of appetite need prompt diagnosis and they also need to know that this disease can be cured.
- Tuberculosis still occupies a low priority with governments:
In many developing countries, a significant portion of health budgets is expended on expensive medical facilities and services, from which only few privileged people benefit and the poor and needy are neglected.
Tuberculosis is the prime killer of people living with HIV; precisely up to half of all deaths of HIV patients are due to TB. A patient with both diseases can be four times more likely to die during TB treatment than someone being treated for TB alone. Infection by HIV is the greatest risk factor known for progression from latent tuberculosis infection to active TB and rapid progression to active disease after recent tuberculosis infection or re-infection. W.H.O. estimates that thirty two percent of all new TB cases in African countries now occur among HIV-infected individuals. The spread of HIV is fuelling the rise of TB in dangerous ways.
Consequences:
The social and economic impacts of this curable disease on the people around the world have gone beyond tolerance. Individuals and families are compelled to bear unreal costs. Expenses for laboratory, tests, medicines, doctors' fees, travel amount to maybe double or more of their annual incomes.
The social consequences are also extremely discouraging. Tuberculosis destroys family life; children become orphans at an age when they are supposed to enjoy the goodness of life. The disease has become a social stigma which brings along immense mental and emotional hardships. People lose support of the society and this leads to tragic consequences in many cases. Patients who are isolated and rejected by their family or society go into depression or other states of mental illness.
The worst part is that the massive numbers of deaths and illness due to tuberculosis, combined with inhuman consequences, still continue to be persistent in spite of a cheap, effective and efficient cure available since many years.
Treatment and Prevention:
Tuberculosis prevention and control efforts primarily rely on the vaccination of infants and the detection and appropriate treatment of active cases of the disease. The World Health Organization has had success to a certain level with improved treatment practices and a resultant small decrease in number of TB cases.
The only currently available vaccine (as of 2011) is Bacillus Calmette Guérin (BCG). This vaccine is effective against disseminated disease during childhood years but has been inconsistent in providing protection against contacting pulmonary tuberculosis. Nevertheless it is the most widely used vaccine all over the world as a basic prevention measure. More than ninety percent of all children in the world are being vaccinated. But unfortunately, the immunity induced by it to the TB bacteria decreases after about ten years.
To successfully treat TB, the main aim will be to decrease and prevent drug resistance of the TB bacteria. For this, we need to use the currently available tools more efficiently and accelerate the development of new tools for the future. Tuberculosis control mechanisms need to undergo so simple improvements and modifications such as expanding the use of underutilized technology, which will lead to a certain change and enormous impact. Fixed dose drug combinations for the disease have existed for over twenty-five years now, and could help ensure that more patients complete treatment. But sadly, only fifteen percent of the total patients are using these combinations.
We also need new drugs, vaccines and diagnosis methods as well as creativity in tuberculosis control and management of TB cases. Better diagnosis methodologies have been developed and are already available. New vaccines and drugs for TB are also being worked on and soon will be made available. What is required more is the commitment to fight this disease and the resources needed to do so. Improved methods of prevention and control of tuberculosis are the most effective way to eliminate drug resistance completely. In order to be convinced that drug resistance does not pose a greater threat, we need to devise and employ a number of equally important approaches in the right direction. These approaches include improved basic TB control, increased utilization of underutilized technologies such as fixed dose drug combinations, and newer technologies and innovations in health systems.
At the same time, we should expand access to multi drug resistant TB and extremely drug resistant TB treatment and diagnosis for those who already have drug resistant TB. A good amount of the most innovative solutions for this can come through partnerships and from the private sector. A large figure of two billion people carries the TB bacterium. Thus, to cure the disease a comprehensive approach is needed. Companies should also explore opportunities to work together and pool complementary technologies to ensure new tools are used in the most effective and efficient manner.
So by proper treatment and surveillance, we can prevent the development of drug-resistance of TB, which has become practically an incurable illness in 21st century.
Conclusion:
In spite with some advances, progress in the direction of eradicating Tuberculosis has been slow, and new breakthroughs are required to eliminate the disease worldwide. Better vaccines have to be developed. Fortunately, several are in the early stages of testing. A type of vaccine, which is almost the same as most of the vaccines being used today, may be given to people who have never had TB. This will prevent them from contacting the disease even if they come into contact with it. The other type of vaccine could enhance natural immunity in persons with latent disease. Yet another form of vaccine could introduce specific biological molecules into the body of people with active TB to support the infected person in the fight against the disease.
The current diagnostics are certainly a big step forward but better tools still need to be developed. A possibility that may be considered is utilizing the white blood cells. White blood cells, also known as lymphocytes or T-cells hold an important and pivotal role in the immunity towards tuberculosis. For future purposes the presence and amount of different types of white blood cells may enable physicians to determine when all the tuberculosis bacteria have been killed or, even more beneficially determine the stage when a person with latent disease is on the verge of developing active disease and therefore needs to be treated. This method could also help determine how long drug resistant TB needs to be treated and cured.
Apart from this, there must be strong leadership worldwide to ensure that these advances, along with the experience in dealing with the deadliest epidemic known to man, result in TB control programs in which all nations can participate.
Greater intensification of actions is required to control and ultimately eliminate the disease from the world. All countries should now devote their focus of actions in the four major directions, namely- constant scale up of early diagnosis and proper treatment procedure, development and enforcement of strong health system policies, establishment of connections with the broad development policy, and promotion and intensification of research measures.
Thus, in the 21st century, Tuberculosis is not merely a disease but rather a progressive killer. But the situation can be changed and in the coming years the disease can not only be cured but also completely eliminated from the world.