According to World Health Organisation Global TB report 2015, tuberculosis (TB) was one of the top 10 causes of death worldwide. TB was responsible for more deaths than HIV and malaria. In the same year, there were an estimated 10.4 million new TB cases worldwide of which 5.9 million were men, 3.5 million women and 1 million children.

In Rwanda, the fight against TB has been fairly successful over the years as statistics indicate that cases have declined from 7,230 in 2011 to 5,763 in 2016.

However, even with this progress, health experts say TB still remains a challenge, not only in Rwanda but also worldwide, and requires more efforts to end the epidemic.

What is TB?

According to Lucie Uwinkesha, an environmental health officer at Kabarore Health Centre in Gatsibo District, tuberculosis is an infectious disease caused by a bacterium called mycobacterium tuberculosis. It generally affects the lungs, but it can also develop outside the lungs.

"That one that affects the lungs is known as pulmonary tuberculosis. The symptoms in pulmonary tuberculosis include a prolonged cough exceeding two weeks, chest pain, fever, weight loss, loss of appetite, fatigue and night sweats,” she says.

Uwinkesha notes that sometimes people affected by this disease may cough out some blood in small amounts in their sputum.

Extra pulmonary TB, on the other hand, occurs when the infection spreads outside the lungs such as in bones or nervous system, she says.

Uwinkesha says like any other air-borne disease, pulmonary tuberculosis spreads through air when an infected person with active tuberculosis in their lungs coughs, sneezes, speaks or spits.

"Other people may inhale the droplets in big volumes and contract the bacteria, thus become infected,” she says.

Why TB remains a big challenge

According to WHO, in 2016 TB was the top cause of death worldwide, killing around 1.4 million people.

Dr Patrick Migambi, the division manager of TB at Rwanda Biomedical Center (RBC), says there are about 9.6 million TB cases globally, which calls for a lot of work to ensure TB cases go down.

"Although in Rwanda we have registered good progress in the reduction of TB prevalence, there is still a challenge. One of the causes of this challenge is because Rwanda is bordering four TB high burden countries,” he says.

Rugambi notes that worldwide, there are 13 high burden TB countries, among them Kenya, Burundi, Tanzania and Uganda.

"What this means is that if we are not working together as a region, even if we have made good progress in fighting TB, we will not be sure that the trend will continue downwards,” he says.

According to Migambi this is because TB is an air-borne disease that can easily be transmitted to another person.

"Another problem is that the detection rate for children under the age of 15 is also still a challenge. The reason is that the way the common signs and symptoms are diagnosed in children is different from adults.

"In children, especially those below five years of age, TB is often missed or overlooked due to non–specific symptoms and difficulties in diagnosis. This has made it difficult to access the actual magnititute of the childhood TB. Clinical similarities with other common childhood diseases also contribute to the challenge,” he explains.

Only 7 per cent of all TB cases in Rwanda are children, says Migambi.

Need for social support

One of the key components of implementing the WHO End TB Strategy is to provide social support for TB patients. This includes nutritional support, psycho-social support, financial support and rehabilitation of patients with TB.

Migambi says there are two kinds of TB, one being multi-drug-resistant tuberculosis (MDR).

"We provide nutritional and financial support for this group. The reason is that the MDR TB patients are prone to resistance to treatment with at least two of the most powerful first line anti-TB medications.

"As health workers, it’s our responsibility to make sure that such patients adhere to treatment everyday to reduce the contamination,” says Francis Kazungu, a general practitioner in Kigali.

The other type is extensively drug-resistant TB (XDR TB).

"With such patients, when they start treatment, we provide them transport and nutritional support to help them adhere to treatment. We follow up to make sure they have completed their treatment,” adds Migambi.

The Ministry of Health is also planning to also provide support for TB patients with severe and moderate malnutrition.

Where to get treatment for TB

According to Dr Yves Mucyo, the in-charge of multi-drug-resistant TB at RBC, all health facilities offer screening as well as diagnosis for TB.

"For those who have been screened but need to be examined better, the health workers communicate with other health facilities for diagnosis and send the response back to where patients have been screened.

"Patients do not need to make unnecessary trips looking for screening facilities all the facilities offer that service,” he says.

He, however, says the chest test requires x-ray machines which can be accessed only in district hospitals.

"When they have already screened and found out that there is need to perform a chest x-ray, patients are referred to the district level for that. There are 47 district hospitals, excluding private hospitals, which have such x-ray machines,” says Migambi.

Last year, 94 cases of TB-drug resistance were diagnosed.

Migambi says there are two specialised centres in Huye and Kibagaba district hospital to handle such cases.

"Although it is hard to ensure that we eliminate TB, we try to sensitise people about its treatment and prevention. If there is persistent cough for two weeks, one should visit a health facility for a check-up so they can be put on treatment early,” says Migambi.

He notes that when found with TB, one needs to start treatment within two days.

"Around 90 per cent of people come early for treatment but there some cases where patients come when they are very sick (late stages). So, improving public awareness about the condition is vital,” he says.

Risk factors and prevention

According to Uwinkesha, a number of factors make some people more susceptible to TB infection. The most risk factor globally is HIV, whereby 13 per cent of the people with TB infection are infected as a result of HIV.

This is even worse in sub-Saharan African countries where TB is also linked to overcrowding and malnutrition.

"Prevention involves screening of people that may be at high risk such as those in a household, workplace, social contacts (children under 5 years old) and healthcare providers of the people with active pulmonary tuberculosis,” she adds.

However, Kazungu says another way of TB prevention is early detection and treatment of the cases, immunisation/vaccination of children at an early age with BCG (Bacillus Calmette -Guerin vaccine).

He notes that in order to reduce exposure in households where someone has infectious TB, the following actions should be taken whenever possible.

"The house should be adequately ventilated. Anyone who coughs should be educated on cough etiquette and respiratory hygiene. TB patients should spend as much time outdoors as possible,” he says.

"If possible, a patient should sleep alone in a separate, adequately ventilated room, spend as little time as possible on public transport as well as in places where large numbers of people gather together.”

Uwinkesha explains that cough etiquette and respiratory hygiene means covering one’s nose and mouth when coughing or sneezing.

"This can be done with tissue, or if the person doesn’t have tissue they can cough or sneeze into their upper sleeve or elbow, but they should not cough or sneeze into their hands. The tissue should then be safely disposed of,” she says.

Uwinkesha notes that educating people about TB prevention, as well as ensuring that those who need TB treatment receive it as soon as possible is essential.