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Rumbidzayi Zinyuke
Health Buzz
For many years, Zimbabwe, just like the rest of Africa, has been struggling to eliminate Tuberculosis (TB).
The disease is one of the leading causes of death in the country and the African region has the second-highest tuberculosis burden worldwide, after Southeast Asia.
While a lot of progress has been made in identifying TB cases and ensuring that they are all initiated on treatment, there is still more that can be done.
Particularly with regards to drug-resistant TB.
Drug-resistant tuberculosis (DR-TB) is a form of antimicrobial resistance that is difficult and costly to treat. It is caused by TB bacteria that are resistant to at least one of the existing first-line TB medications, resulting in fewer treatment options and increasing mortality rates.
Multidrug-resistant TB (MDR TB) is caused by an organism that is resistant to both isoniazid and rifampin, the two most potent TB drugs used to treat all persons with TB disease.
Resistance to anti-TB drugs can occur when these drugs are misused or mismanaged. For example, when patients do not complete their full course of treatment, when health-care providers prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs, when the supply of drugs is not always available or when the drugs are of poor quality.
Although Zimbabwe has made sufficient strides to be removed from the list of high-burden countries for drug-sensitive tuberculosis, the country remains on the list for tuberculosis/HIV and multidrug-resistant tuberculosis.
Statistics show that globally, deaths from drug-resistant tuberculosis account for about one-third of all antimicrobial resistance deaths worldwide. Over 150 000 cases of the resistant strain were detected in 2020.
The World Health Organisation however estimates that Zimbabwe only managed to find about 33 percent of estimated DR-TB cases in 2021, which then serves as a wake-up call that there is so much more to be done to find all missed cases in the communities.
According to Union Zimbabwe Trust executive director Dr Ronald Ncube, once a case of DR-TB has been identified, contact tracing is important.
“Contact tracing for drug resistant TB (DR-TB) patients involves identifying people whom the patients have shared living or working space with. This includes family members, workmates and caregivers. The patient is expected to volunteer the names and addresses of these contacts so that skilled health workers can follow them up and screen them for DR-TB.
If they do not have signs or symptoms of TB, contacts can be put on DRTB preventive treatment which is taken daily for 6 months.
If they have signs or symptoms of DR-TB, further tests can be done and sputum collected to test for DR-TB. If the result is positive, the contact is put on the same treatment as the patient,” he said.
Through contact tracing, it is the expectation that any new case of DR-TB is detected promptly.
However, owing to incomplete contact details, hard to reach contacts, contacts across districts and provincial borders, it makes it difficult to track and routinely follow up all contacts.
According to the WHO Global TB Report of 2022, Zimbabwe notified 232 DRTB cases to the TB Programme.
Dr Ncube says with the assumption that each patient has potentially four contacts, this could translate to +/-928 contacts.
While this may seem like a small number, given that it is additional to all other TB patients who are not DR-TB and also require contact tracing, the country would definitely need more resources to trace all such contacts.
To avoid the fatalities that could come with these worrying statistics, there is a lot that the Government, health workers and the DR-TB patients could do to avoid spreading the disease.
The most important thing is for patients to take all of their medications exactly as prescribed by their health care provider.
No doses should be missed and treatment should not be stopped early.
On their part, health care providers can help prevent MDR-TB by quickly diagnosing cases, following recommended treatment guidelines, monitoring patients’ response to treatment, and making sure therapy is completed.
Another way to prevent getting MDR TB is for people to avoid exposure to known MDR TB patients in closed or crowded places.
While TB contact tracing is being done and contacts getting tested, Dr Ncube says there is a chance that some contacts could test positive after an initial negative test.
“Sometimes a person with latent TB infection will test negative to begin with. This is because the bacteria is well contained by the body’s immune system. In the event the strength of one’s immune system is compromised, the bacteria can begin to spread and manifest as TB disease with a positive TB test result,” says Dr Ncube.
But this cannot be a deterrent because with minimal contact tracing, infections will continue to rise.
“If we are unable to catch the TB and DR-TB cases among contacts the disease will continue to spread unabated. The take home message is early detection and prompt treatment to reduce TB circulating in our communities,” he said.
However, costs associated with DR-TB often become a block for patients to access care leading to the spread of the disease.
People with drug-resistant TB face significant economic and social costs and only 1 in 3 access quality care and reaching the missing patients becomes a significant public health challenge.
To address this, WHO reviews the latest evidence to set norms and standards for the diagnosis and care of drug-resistant TB. WHO has been working with countries, partners and civil society to expand rapid molecular diagnosis to detect drug-resistance, and to increase access to better and more effective treatments.
The global health agency has also been working with countries to strengthen drug resistance surveillance since the early 1990s and over the years, research and innovation has led to accelerated development of rapid diagnostics and treatments for drug-resistant TB.
Zimbabwe has since introduced shorter treatment regimens for all MDR-TB patients and this has definitely made adherence to treatment better and improved health outcomes.
The country has also embraced WHO-recommended diagnostics such as rapid molecular tests, that have been deployed in all secondary level health facilities, and the adoption of diagnostic equipment to detect second-line drug resistance has further boosted case detection.
While challenges remain in the identification of DR-TB patients, there is hope that more interventions will continue being implemented for better outcomes.
And we can eventually eliminate drug-resistant TB.
But in the meantime, everyone can play their part to avoid infection or spreading the disease.
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