Every Day is TB Day

World TB Day was on March 24.  If this were a blog about HIV/AIDS, I could write about the progress that Haiti and the rest of the world is making.  However, this is a blog on tuberculosis and a fight we are losing.  More than two billion people, one third of the world’s total population, are infected with TB bacilli, the microbes that cause TB.  People living with HIV are at greater risk.  For Haiti, much more remains to be done.

The statistics above were released as part of the 13th annual report on global control of tuberculosis, produced by the World Health Organization (WHO) in a series that started in 1997.  The 196 countries and territories that reported data in 2008 account for 99.6% of the world’s estimated number of TB cases and 99.7% of the world’s population.

First, the global picture.  Although a cure for TB has existed for more than half a century, it is one of three leading causes of deaths worldwide due to infectious diseases.  A total of 1.77 million people died from TB in 2007 (including 456 000 people with HIV), equal to about 4,800 deaths a day.  In 2007, there were 9.27 million new TB cases of which 80% were in just 22 countries. Per capita, the global TB incidence rate is falling, but the rate of decline is very slow - less than 1%.  TB thrives on poverty and instability, disproportionately affecting the poorest of the poor.  In the United States, on the other hand, TB rates reached a record low in 2008.  Even here though TB affected our most vulnerable - minority and immigrant populations.

Alarmingly, there were an estimated 511,000 new cases of multi-drug resistant TB – hard to treat, expensive to cure.   Extensively drug resistant TB, even more difficult to treat, has also been documented in more than 50 countries.

I had known about tuberculosis before living Haiti, but did not really understand how devastating it was before visiting the Partners in Health Hospital.  I remember asking if I needed a mask to enter the TB ward.  The reality is that if one is well nourished and has a healthy immune system, TB is not easy to contract.  Unfortunately, that is not the world we live in.  Many individuals in Haiti are sick, malnourished, sharing sub-standard shelter, or have compromised immune systems from HIV/AIDS or other conditions.  I distinctly recall meeting a man named Isaac who had needed surgery to remove on of his lungs, which TB had destroyed.  Isaac was the kind of person who never hurt anyone in his life, but when it comes to infectious diseases, that doesn't matter.

Courtesy of USAID, here is a summary of TB in Haiti.   Haiti has the highest per capita TB burden in the Latin America and Caribbean region.  After HIV/AIDS, TB is the country’s greatest infectious cause of mortality in both youth and adults (5,400 deaths in 2006).  Haiti is among the eight priority countries identified by the Pan American Health Organization for TB control in the region.

According to the World Health Organization’s (WHO’s) 2008 Global Tuberculosis Control Report, Haiti had and estimated 28,290 new TB cases in 2006. Of these, 44 percent were new pulmonary sputum smear-positive (SS+) cases.  Although Haiti falls short of the WHO targets of 70 percent case detection and 85 percent treatment success rates, the DOTS (directly observed treatment, short course) case detection rate is 55 percent, up from 22 percent in 1998.

The DOTS treatment success rate is 81 percent and has remained stable at an average of 78 percent over the last five years. DOTS coverage is estimated at 91 percent, up from 55 percent in 2004, but in some highly dense metropolitan settings, such as areas in Port-au-Prince, coverage can be as low as 13 percent.  The most populated department in Haiti, Ouest (West), has 34 percent of the country’s population but only 25 percent coverage.

Since 1998, the Ministry of Health (MOH) has supported the DOTS strategy in order to strengthen the national TB program, the Programme National de Lutte contre la Tuberculose (PNLT), and approved national guidelines and norms for TB control in 2002. However, the program lacks political and financial support from the government, and there is a lack of skilled technical human resources at the central level of the PNLT.  A major problem in combating TB is that co-infection with HIV can run as high as 30 percent in some urban areas.  Conversely, 20 percent of HIV-positive adults in Haiti are infected with TB. Strong stigma and cultural barriers attached to TB also interfere with case detection and adherence to treatment.  Multidrug-resistant (MDR) TB has increased from 1.4 percent in 2004 to 1.9 percent in 2006.  In partnership with three USAID-supported nongovernmental organizations, the MOH has taken steps to implement DOTS clinics in all 10 geographical departments in Haiti.

Between 2003 and 2005, USAID funds for TB programming in Haiti averaged $1.8 million per year.  USAID’s approach in Haiti complements the priorities of the PNLT.  The major areas of USAID activities reinforce TB-HIV/AIDS program building within the national DOTS program and establish links between TB and HIV services in order to continue to increase case detection and improve treatment completion rates.  Through the Santé pour le Développement et la Stabilité d’Haïti Project, USAID provides a continuum of care for co-infected patients based on the national norms.

Three Haitian non-governmental organizations (NGOs) receive support through this project: International Child Care/ Anti-Tuberculosis Crusade (ICC/CAT); Center for Health Development (CDS); and CARE.  This new integrated community care and support project supports the provision of TB detection and limited DOTS treatment services in clinics and communities nationwide, serving approximately 50 percent of the Haitian population. In the past, the Tuberculosis Coalition for Technical Assistance had also supported the PNLT with technical assistance. 

In the face of political turmoil and socioeconomic instability, TB control in Haiti has progressed in recent years. USAID support has led to improvements in TB control  The international community provides significant support for TB control in Haiti. Other partners include the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Partners in Health, Management Sciences for Health, and the U.S. CDC. In 2003, the Global Fund awarded Haiti $14.6 million for TB control and prevention. NOTE: You can find much more recent Global Fund information on Haiti here.

What does the world need to win the fight against TB?  First and foremost, we must have a vaccine.  There are over 50 tuberculosis vaccines being tested, but this is a very long and very expensive process.  We also need better drugs - it is unacceptable that treatment should last well over six months.   We also need better diagnostics so we can learn as soon as possible who needs to be treated.  Above all, we need the long term will to see this struggle through.

Thanks for reading. We welcome your thoughts.

Bryan