More action needed to tackle multi-drug resistant TB in Ghana

Bernard Appiah, Ghana 
(First published in Joy Online, Ghana on 24th March 2013): What appeared to be a routine visit to the hospital in late February 2013 to seek medical treatment for persistent cough with blood turned out to be different for sixty-eight-year old Maame Akua (not the real name). “I was just sick and went to the hospital only to be told later after some tests that I have tuberculosis (TB),” says Akua. “Since then I have been going to the hospital daily to take medications there every morning, and I’ve been advised to do so continuously for two months before I can take other TB medicines at home for four months.”

Tuberculosis, a disease caused by a germ called Mycobacterium tuberculosis, commonly affects the lungs, and is spread by people who have active form of the disease to others through the air they breathe.

Akua says the disease has disrupted her livelihood, making it very difficult for her to even get money for transportation to the hospital. "The nurse at the hospital sometimes give me money to enable me buy food and pay for transportation fare," she says, adding that if she does not go for the medicines regularly, a stubborn cousin of the disease awaits her: multi-drug resistant tuberculosis (MDR-TB).

But while people taking medicines for treating TB are at increased risk of getting MDR-TB if they fail to take the medicines as directed, people who have not taken TB medicines can also get MDR-TB if the germ resistant to the TB medicines is spread through the air. Tackling MDR-TB menace in Ghana has some opportunities and challenges.

“The development of MDR-TB is exacerbated by clinical and programmatic mismanagement of TB. For example, providers may not prescribe the proper regimen, may use low-quality drugs, or patients do not receive adequate treatment support,” says United States Agency for International Development (USAID) report released in 2013.

“MDR-TB is much more difficult to diagnose and treat, requiring specialized laboratory expertise and infrastructure and an 18- to 24-month regimen of expensive drugs with potentially toxic effects.”

Dr. Nii Nortey Hanson-Nortey, Deputy Programme Manager of the National Tuberculosis Control Programme says a study conducted between 2006 and 2008 in Ghana showed that of 324 people-- like Akua--diagnosed first as having tuberculosis, 0.3% had MDR-TB whereas of 21 patients previously treated for TB, 19% had MDR-TB. “This implies MDR-TB is more common among previously treated cases than new cases,” Hanson-Nortey tells India-based Citizen News Service (CNS).

Dr. Frank Adae Bonsu, Programme Manager, of the National Tuberculosis Control Programme adds that the estimated MDR-TB cases among notified TB cases average annually at 410 cases and that last year Ghana confirmed 38 MDR-TB cases. “Relative to other countries this is low, but to the Ghanaian every single case is important and very devastating to the individual and family,” says Bonsu

But there are challenges in identifying and treating MDR-TB.

Multiple studies tell us that patients have to visit health care providers repeatedly before they are evaluated for TB, thus delaying their diagnosis even after they have sought care, Dr Nevin Wilson, Regional Director, The International Union Against Tuberculosis and Lung Disease (The Union), South-East Asia Office, tells India-based Citizen News Service (CNS).

Bonsu says the major challenge in Ghana previously had to do with the country infrastructure capacity to detect and manage the cases but since 2011 with increased funding from the Global Fund, the fundamental challenges of laboratory diagnostics have been addressed, adding that the main impediment is the absence of an infectious disease hospital capable of admitting and caring for patients.

Bonsu says that even though Ghana as a policy would in the short-term adopt community-based approach to care, stakeholders urgently must think of establishing an infectious disease hospital that may serve other purposes for new and emerging infectious diseases, including severe acute respiratory syndrome or SARS.

Hanson-Nortey adds that another challenge is the preference among some health care workers to repeatedly treat TB with first line medicines, when they should do further tests to determine whether patients have MDR-TB, which usually require second line TB medicines.

The lack of awareness of the disease and the tendency not to seek early treatment because of TB-related stigma also impede TB control, experts say. “We have been creating platforms for chiefs and opinion leaders to talk to community members because the culture is such that the stigma is very strong,” says Mrs Josephine Agbo-Nettey, Executive Director, Integrated Development in Focus, a non-governmental organization that won an international award (Tuberculosis Survival Prize) in 2009 because of its work in prevention and control of TB through innovative engagement of community members.

Agbo-Nettey says when people becomes lean and cough persistently for more than two weeks, there is a perception in their communities that they have done something wrong to incur the wrath of the gods, so such people do not want to come out early to seek treatment.

Through Integrated Development in Focus, 300 people were referred to hospitals for testing, resulting in 99 of them being found to have tuberculosis, she says, adding that all of them have been cured of the disease and are now part of the advocacy team.

But behind the challenges in the control of TB and MDR-TB, are some opportunities.

Agbo-Nettey says her outfit has incorporated MDR-TB into its activities. “In the communities, because of MDR-TB, they have formed community clubs made up of members who support people diagnosed as having TB," she tells Citizen News Service, further indicating that some of the club members go as far as using their own money to take patients with TB to hospitals daily for the first 2 months. Thereafter, people trained as health educators in communities, who also act as supporters of patients with TB, liaise with hospitals and sometimes pay for their own transportation to go for the medicines weekly or monthly from the hospitals and give them to the patients in their communities.

Some hospitals also have TB treatment supporters who sometimes accompany patients home. Diana Aku Cofie, TB Treatment Supporter, at the Ussher Policlinic in Accra says because of the potential of MDR-TB, once a patient is diagnosed as having TB and starts treatment, “I tell them to take their medicines as directed and to avoid such lifestyles as drinking alcohol and smoking,” she says. “Sometimes when I accompany a patient home and there are people at home who are curious of my visit, because of stigma I lie that the client is a friend I have missed for a long time, and just wanted to know where she lives.”

Diana adds that she has received training from the from the National Tuberculosis Control Programme on how to counsel patients. Bonsu says the national TB programme has established a working group that has finalised MDR-TB treatment guidelines, and planned a comprehensive training programme for health staff in 2013.

Medicines for treating MDR-TB have been procured and a clinical central management team to support periphery management of MDR-TB cases has been established in Korel-bu Teaching Hospitals, says Bonsu, adding that budget has been made available to improve some of the laboratory infrastructure and work will shortly start on facilities in Western region and Nalerigu Baptist Hospital in the Northern region.

In the mean time, Bonsu says Korle-Bu teaching hospital is temporarily using a facility to run an outpatient clinic for the few people with MDR-TB who have started treatment.

Nortey-Hanson adds that regional referral clinicians have been identified in each regional Hospital to manage MDR-TB. "Health professionals should avail themselves to be trained and have a positive outlook," he says. Martha Gyansa-Lutterodt, Director of Pharmaceutical Services at the Ghana Health Service and Chief Pharmacist of Ghana's Ministry of Health says in addition to patients going to hospitals to take their medicines in the first two months, community pharmacists could also be actively engaged to help with implementation of the intensive treatment of patients with TB. Such a strategy has proved successful in the control of TB in that country, according to the 2013 USAID report on tuberculosis. Gyansa-Lutterodt adds that industrial pharmacists could intervene if they are adequately resourced to manufacture medicines for treating TB and MDR-TB.

"Massive political commitment is needed, to motivate and protect health staff to take up the challenge of managing MDR-TB cases," says Bonsu. "A dedicated budget to support patient care should be made available to support National TB control programme MDR-TB related activities to secure and protect health of all Ghanaians from this threat, which can easily be passed on through breathing 'air.'"

Bernard Appiah, Ghana 
Citizen News Service - CNS
(First published in Joy Online, Ghana on 24th March 2013)