Many different ideas have been tried or suggested. Some believe that the only hope lies in new drugs and vaccines. However, there are other ways to help improve TB control programmes.

Effective treatment for TB was first developed in the 1950s, but it is still often not available to many sufferers around the world. There are three main activities useful in controlling TB in developing countries…

Finding the Patient The first step is to identify the people who come for health treatment who may have active TB. All patients with a persistent cough lasting for more than two or three weeks should be tested. This is usually done using microscopes to search for the TB bacilli in the sputum (spit) of infected patients. Testing can also use X-rays – which will show the presence of TB in the lungs – and tuberculin tests. Both are expensive and not very accurate in identifying patients with active disease. All these techniques require simple training.

Treating the Patient TB bacilli are not easy to treat. They quickly become resistant to any one drug. Because of this, a mixture of at least three drugs is usually given. Treatment is long – usually between six and twelve months.

TB of the lungs can be cured in nearly all cases. Once treatment begins, the patient will no longer infect others.

Caring for the Patient  Successful treatment of TB involves long treatment with different drugs. It is very important for health staff to understand this. They must explain how important it is for patients to complete their treatment. Patients often feel better after just a few weeks of treatment and stop taking their drugs. Maybe they cannot afford the medicine, or cannot be bothered. Although they feel better, the TB bacilli are not killed. Sooner or later the active disease returns. New treatment is needed but may not be available. TB programmes try to prevent this situation by supervising patients and checking that they continue treatment.

When a patient fails to finish the course of treatment, the TB bacilli may become resistant to the drugs given. Then a treatable disease may become life-threatening – not just to the patient, but to others they may infect.

THE WAY AHEAD

Straightforward measures can improve all three of these activities. Here are a variety of helpful ideas suitable for any community…

Finding the Patient

  • Increase the training of health staff and the number of available microscopes. This does not have to mean laboratories in every health unit, as long as transport to the central labs is efficient and the results are returned quickly.
  • All health workers and health staff must be more aware of the problem of TB so that they test more suspects.
  • The general public needs to be more aware of TB so that more people come forward for testing.

Treating the Patient

  • Each patient needs treatment with the most appropriate mixture of drugs for that patient (following the guidelines given by each country).
  • Patients and their families should be helped to understand the use of anti-TB drugs.
  • Prevent the build up of resistance to anti-TB drugs by their correct use.
  • Prevent the theft and unsupervised use of anti-TB drugs.
  • To prevent confusion, all anti-TB drugs within a country should come from the same source with the same packaging whenever possible.
  • Use the newer varieties of drugs whenever possible – although more expensive, in the end short-course chemotherapy gives better results and is more cost-effective.
  • Only use combinations of drugs that have been proved to prevent drug resistance and to cure nearly all patients. Drug resistance is always due to bad treatment.
  • Reduce the length of hospital stay to one week (or no stay at all) for most patients, unless they are very sick.

Caring for the Patient

  • Increase general health education about TB in both health workers and the public.
  • Take measures to improve the supervision and motivation of all health staff.
  • Involve community health workers in community supervision.
  • Improve communication between health staff and patients.
  • Design programmes of treatment that are easy for patients to use at home.
  • Carry out programmes of treatment on a regional basis. This makes it easy to refer patients to different health units and different districts. Do not run TB programmes in isolation.
  • Improve home visits and back-up programmes.
  • Improve the availability of health care to all patients in various way

    - physical (distance from health centres)
    - economic (making sure treatment is available to even the poorest)
    - cultural (providing, for example, sympathetic female staff for female patients when appropriate).
  • Provide counselling for both staff and patients who have to deal with the distressing effects of TB and AIDS. In many areas the link between the two diseases is already so strong that people often think of them as one disease. Consider introducing some type of counselling before a sputum test, because a positive result may often indicate that the patient is also HIV positive. Train counsellors in AIDS control programmes in TB issues.

HIV infection issues

The development of TB is often the first sign that a person has HIV infection. An HIV test will prove this, though sometimes other medical signs may indicate that HIV infection is likely.

Treatment of TB in HIV-infected patients requires the same drugs which will control (but not usually cure) TB infection. Multiple drug resistance may be more common in HIV-infected patients who forget to take their treatment regularly.

There is also evidence that TB in an HIV-infected person may speed up the development of AIDS. However, the cause of death in a patient treated for TB is likely to be from other complications of AIDS.

The idea of giving preventative medicine to healthy people, known to be at risk of developing active TB, is a useful one. The treatment (usually isoniazid) is given for six months – usually to people known to be HIV infected and who test positively for TB infection. For most countries the numbers involved are so huge that the money and organisation required make it almost impossible. However, there is no doubt that this preventative treatment would be worthwhile and cheaper than providing TB treatment. Various trials are being carried out to see whether this is possible. The three important parts of TB control – finding the patient, finding the right treatment, and caring for the patient – must all be working well throughout the country before such a programme could begin.

Dr Paul Saunderson has worked in Uganda for ten years with Tearfund and is currently Director of Leprosy and TB Control at ALERT in Ethiopia. He would be happy to correspond with readers – write to…

ALERT, PO Box 165, Addis Ababa Ethiopia.


DEFINITIONS

BACILLI            a particular kind of rod shaped bacteria

PULMONARY  associated with the lungs

PANDEMIC      world-wide

RESISTANCE  ability to fight off disease

TB                     tuberculosis


Do’s and Don’ts in TB

  • Do always examine the sputum if the symptoms – such as a persistent cough – suggest TB.
  • Do make sure the patient understands that a full period of treatment is needed, even though symptoms will soon clear. (If possible, give the patient a leaflet explaining this.)
  • Do be kind and sympathetic – the patient is more likely to come back for drug supplies and to continue treatment.
  • Do examine all family and home contacts, especially if they are ill.
  • Do put the name of the patient in the tuberculosis register and give them a treatment card with the next date for attendance. Make sure they understand and will remember the date.
  • Do send someone to their home if the patient fails to come back on the date.
  • Do check regularly on your supplies of anti-TB drugs and make sure you don’t run out.
  • Don’t forget that anyone with a bad cough may have TB, especially if they have fever and loss of weight.
  • Don’t forget to test the sputum.
  • Don’t ever give a single drug alone – always use the recommended combination of drugs.
  • Don’t forget to follow up patients who fail to come back and persuade them to complete treatment.

Taken from the book Clinical Tuberculosis (reviewed on page 14) with kind permission of TALC and the authors.