Time to act now on MDR-TB

Paidamoyo Chipunza, Zimbabwe
(First published in The Herald, Zimbabwe on 26th March 2013): After two grueling years of treatment, Chipo Mhlanga, 48 (not her real name) is one of the first patients in Zimbabwe to be successfully treated of multi-drug resistant tuberculosis (MDR-TB). Speaking from her home in Epworth, Ms Mhlanga said she first showed symptoms of TB in 2006 after caring for four members of her family who had the disease. She said after eight months of treatment, and without screening her to confirm whether the treatment had been successful, she was taken off TB medication by her doctor who declared she was “looking much better.”

“Over the following few months, I was in and out of hospital with fever and a dry cough that would not shift. I grew thinner and thinner, my condition got worse and having lost almost half of my body weight, a neighbor eventually advised me to seek treatment from the Medecins Sans Frontieres clinic in the area, which was treating TB,” she recalled.

Ms Mhlanga said following a visit to the clinic she was diagnosed with a strain of TB resistant to the usual drugs- thus DR-TB. At that time, treatment for drug resistant TB in Zimbabwe was limited and centralized.

“At times, my mother would cough out blood almost half a 20 litre bucket, it was terrible and an experience I would never want to witness on anyone else again,” Ms Mhlanga's daughter 24 year old daughter Judith who was sitting in during the interview interjected.

“I never thought she would survive. I thought we'll lose her one of the days,” she said starring directly into her mother's face. Ms Mhlanga was eventually put on treatment in December 2010 but again hers was not an easy road. She said the treatment involved daily injections and a cocktail of highly toxic pills, which made her vomit, lose appetite and sometimes hallucinate.

The treatment took her two years since then, but gladly, she adhered to it up until the last day resulting in her successfully treated of MDR-TB. “I felt like I had bugs crawling inside of my head when I was on treatment. Sometimes, I felt like stopping the medication but my daughter and my doctor advised against my decision saying it will do no good at all.

“Two years was just too much for me. Worse with the hallucinations and the vomiting, it was really a tough time for me,” she said. Ms Mhlanga's story is typical of what other people with MDR-TB are going through in Zimbabwe. MDR-TB usually develops among patients who have previously failed TB treatment, but current trends shows that the condition can be transmited in its own right as evidenced by it being diagnosed in patients never on TB treatment.

The actual burden of MDR-TB is not known because of inadequate testing machines at all health centres in the country and also because of the stigma surrounding TB in general. Further, treating and managing of MDR-TB is quiet expensive costing an average of US$4 000 to treat one person. However, according to the Aids and TB Unit in the Ministry of Health and Child Welfare approximately 40 patients in the country have MDR-TB.

Government recently introduced the new rapid molecular test, which speeds up diagnosis and therefore significantly shortens the time from TB test to treatment initiation. Through this new testing, TB results are produced in two hours instead of the previous two months with other methods.

The same new TB molecular testing also screens for DR-TB and improves detection in people who might have falsely tested negative through sputum smear. As the country joins the world in commemorating World TB Day in Masvingo, a local non governmental organization and people with MDR-TB has also joined hands demanding stepped efforts in response to the condition.

In their public manifesto launched in Harare today, Medecins Sans Frontieres says if measures to tackle MDR-TB are not significantly stepped up, including research for better drug combinations and treatment scale up, MDR-TB rates will continue to increase. According to manifesto titled: 'test me, treat me' the two new drugs effective against MDR-TB must be used to make treatment much shorter, more effective and less toxic.

“Thos of us lucky to receive treatment must swallow up to 20 pills a day and receive a painful injection every day for the first eight months, making it hard to sit or even lie down. For many of us, the treatment makes us feel sicker than the disease itself as it causes nausea, body aches and rashes. The drug makes many of us go deaf permanently and some of us develop psychosis,” reads part of the manifesto. The service providers also demanded shorter, safer and more effective treatment to save more lives.

“We, the medical staff who provide medical care for people with DR-TB, find it unacceptable that the only treatment options that we can offer people cause so much suffering, especially when the chance of cure is so low,” further reads the manifesto.

MSF head of mission in Zimbabwe Mr Paul Foreman said TB was brought under control a long time ago, but antibiotic treatments developed then haven't been updated in more than 50 years, worse still now that the world is also faced with DR-TB. “The lack of investments and the general indifference to this global health risk is shocking. Getting better treatment is beyond urgent, but we are not seeing anything like the level of prioritization required to make this a reality,” he said.

Regional Director of the International Union Against Tuberculosis and Lung Disease (The Union)'s South-East Asia Office, Dr Nevin Wilson, called for early diagnosis of TB including MDR-TB, availability and accessibility of treatment and care to communities and information dissemination about the disease with all community members. He also said some studies have shown that in some countries, patients have to visit health care providers repeatedly before they are evaluated for TB, thus delaying their diagnosis even after they have sought care.

“Importantly, when patients are diagnosed in the private health services, they are most often not 'notified' to the public health authority. This lack of notification risks the quality of the TB services provided in the private sector, increases the risk for amplifying drug resistance, places a great financial burden on already poor patients and dis-empowers public health authorities from effectively combating tuberculosis in the community,” said Dr Wilson.

He said to reduce stigma associated with the disease, TB should become part of the social conversation within the community.“ This will reduce stigma and discrimination and help people confidently access diagnosis and complete treatment” he said. Dr Wilson said o ensure adherence, patients must be empowered to act positively for their own good and they also need support in form of adequate medication and counseling for them to understand the side effects of treatment failure.

“Patients and communities are central to TB control. An engaged and empowered civil society is fundamental to mitigating the enormous burden that tuberculosis places on individuals, families and communities,” he said.

Paidamoyo Chipunza, Zimbabwe
Citizen News Service - CNS
(First published in The Herald, Zimbabwe on 26th March 2013)

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