The World TB Day which is held annually on March 24 is intended to promote awareness, and knowledge of the seriousness of the disease and to motivate for action to be taken against TB worldwide. 135 years ago after discovery of the kochs bacillus, TB still remains an epidemic in much of the world today despite the effective cures which have being made available for decades. This lethal killer of human beings in history still prevails despite the many scientific breakthrough.
Despite discoveries to combat the diseases, today tuberculosis has manifested with a vengeance and has become the deadliest infectious disease in the world and has become the number one leading killer causing 3 million deaths per year amongst and it has created serious implications to the world economy, as it kills or disables mainly young people who form the productive sector of the economy so much so that the WHO has declared tuberculosis as a global emergency in 1993 and could affect around 90 million people worldwide within the next decade.
Tuberculosis, appearing in forms resistant to multiple drugs (MDR TB) that cannot be cured by once effective medicines together with its deadly ally, the human immuno deficiency virus (HIV) has emerged as one of the most potent threats to the existence of mankind and the biggest threat to the world economy.
Why can’t tuberculosis be eliminated? Simply, it is due to the low priority that tuberculosis has been assigned by health policymakers. In many low to middle income countries, any less than 1 % of the annual health budget is allocated for tuberculosis –why this silence? Is it because Tuberculosis is something to be swept under the carpet. The tragic consequence is, because of inadequate funding, inefficient tuberculosis control programmes which have actually led to a worsening of the world tuberculosis situation.
This is because the patients are not cured but do not die of the disease either, leaving a pool of inadequately or improperly treated patients disseminating multi-drug resistant tuberculosis in the community. In other words, in a poor tuberculosis control programme, many patients will die of the disease, but there will also be half treated half dead patients disseminating the disease to healthy people. Also, if there were no tuberculosis drugs at all in a country, there would be no multi-drug resistant tuberculosis for it is the improper use of anti-tuberculosis drugs that creates multi-drug resistant tuberculosis.
In the wrong dosage, wrong combination or the wrong number of the drugs, due to ignorance, patients, because they have not been told the correct dosage or combination or because, if the patient has to buy the drugs (as happens when the patients, because they have not been told the correct dosage or combination or because, if the patient has to buy the drugs (as happens when the patient consults a physician privately.) he/she may buy less than the prescribed amount of drugs or take lesser than the prescribed dose, to make the drugs last longer, or because he has no money to buy all the drugs, because they may produce poor quality drugs which may not have the correct quantity of drugs in them.
However, all is not that gloomy. It has been shown conclusively in countries poorer than Sri Lanka, such as Nepal and Bangladesh. (with per GNP of around US$200, compared to a per capita GNP of US$ 840 for Sri Lanka) that more than 90% of Tuberculosis patients can be cured and the emergence of multi drug resistant tuberculosis controlled if the treatment of tuberculosis patients is completely supervised. In other words, if someone (Nurse, health volunteer worker, public health worker a relative) actually supervise the patient swallowing the drugs.
Tuberculosis patients (or for that matter any patient) has a bad habit of forgetting to take their drugs when, they feel better, or throwing their drugs away when they feel better. The very efficacy of modern anti-tuberculosis drug is in a way disadvantageous, because patients feel normal too soon, leading them to forget to take their medication or to take it irregularly. Directly supervised treatment circumvents this hurdle and has now been shown to be the only way rampant tuberculosis can be controlled.
As Tuberculosis has been declared a global emergency many efforts are being made to find new effective solutions and strategies in service, design and delivery to eliminate this global menace which are appearing in various forms.
New tools, drugs and strategies which are being researched and tried out bringing effective results.
The DOTS Strategy (Directly Observed Treatment short cause
Represents a major breakthrough in controlling tuberculosis. No other TB control strategy comes close to being as effective and are affordable as DOTS.
The advantages to the community by using the DOTS strategy are numerous.
A. Cures the patients
No other TB control strategy has consistently demonstrated such high cure rates. Dots produces cure rates as high as 95 percent, even in the poorest of countries. TB programmes not using DOTS often cure only 40 percent of their patients.
B. Prevents new infections
DOTS Makes it virtually impossible to cause a patient to develop the incurable forms of TB that are becoming more common. Other treatment strategies are actually causing multi-drug -resistant TB, and may be doing more harm than good.
Cost effective
A six month supply of medicines for DOTS cost only $ 11 per patient in some parts of the world. This can be less than the price of a few bottles of aspirin. The World Bank has ranked the DOTS strategy as one of the most cost effective of all health interventions.
DOTS have been demonstrated to add as many years of life as currently available protease inhibitors to HIV positive people. Yet, the medicines used for DOTS are only one hundred percent of the cost.
Nearly 80 percents of those ill with TB are in their most economically productive years of life. These youthful TB patients represent a workforce nearly as large as the number of people employed by the world’s 20 biggest international corporations.
Protects international travellers
There is no other feasible way to protect the world’s 500 million annual international travellers from TB. The only safeguard is to use DOTS more widely to reduce the number of infectious.
Stimulates economies
The DOTS strategy offers relatively quick payoffs to the economies of developing countries. Studies in India and Thailand have shown that a small investment in the DOTS strategy can save their economies billions of US dollars.
DOTS has been successfully implemented in a wide variety of conditions, including Sri Lanka, India, Tanzania, Guinea, China.
Implementation of “Stop TB Strategy"
Has greatly expanded the Tuberculosis diagnosis and treatment services and has saved millions of lives.
Development of new tools is a major component of the revised global efforts to stop TB Progress has been made in this area. They are now in the evaluation process and will be incorporated in to the TB control programme in the near future. New and powerful drugs for the Chemotherapy of Tuberculosis are also been developed and progressively introduced in to the treatment regimen.
Systematic Strategy for screening and monitoring high risk zones
Where the population is concentrated such as,
a) Garment Industries
b) Factories
c) Prison Institutions
d) Rehabilitation Camps
e) Elderly Peoples Institutions
f) Orphanages
g) Mental Asylams
h) Low income communities residing in congested areas.
Changing of the campaign terminology strategy
In the campaign such terms as TB suspects, defaulters, control, Campaign tend to criminalize and patient unfriendly, Therefore in the control of Tuberculosis consideration is being given to use terms which are more humane and patient friendly which will make the patient more co-operative.
Greater involvement of NGO’S/ CNAPT
In recruiting and mobilizing volunteers for treatment and supervision which will make Tuberculosis programmes efficient.
Compared to other South Asian countries, Sri Lanka is for ahead in terms of quality of life, life expectancy, literacy maternal mortality. This is a constant source of amazement to developed countries, who wonder how we can maintain such indices comparable to developed countries
The Ceylon National Association for the Prevention of Tuberculosis (CNAPT) initiatives in Sri Lanka
It has been recorded that in countries poorer than Sri Lanka, such as Nepal and Bangladesh, (with per capita GNP of around $ 200, compared to a per capita GNP of US $840 for Sri Lanka) more than 90% of Tuberculosis controlled treatment.
However, compared to other South Asian countries, Sri Lanka is far ahead in terms of life expectancy, literacy, and maternal and infant mortality. This is a consistent source of amazement to developed countries like Japan, who wonder how we maintain indices comparable to a developed country despite the previous civil war. The answer lies in the solid infrastructure and the standard of literacy and education of our population. It would be tragic if the TB situation in Sri Lanka were allowed to deteriorate, in spite of possessing such a record of healthcare.
This is where the CNAPT steps in Educating the public is one of the most important aspects of TB eradication. The CNAPT has been at the forefront of the campaign for the education of Sri Lankans. Over the last 70 year, the CNAPT has worked in partnership with the Ministry of Health for and a diverse range of civil society partners to promote knowledge and understanding of the disease amongst the vulnerable section of the population and improving access to proper medical care.
In 1948 when tuberculosis (TB) was prevalent in Sri Lanka, the Ceylon National Association for the Prevention of Tuberculosis (CNAPT) was formed as a government approved non –government organization (NGO), aimed to launch a nationwide TB programme via basic education, programme support and international cooperation. 70 years ago when medical treatment was at its infancy and TB was rampant with no definitive cure, Dr. J.H.F. Jayasuriya, Chairman of the Rotary Club, Colombo; sponsored a voluntary organization to combat TB through the auspices of the club. An inaugural meeting was held on 17th June 1948, thus heralding the beginning of the CNAPT.
In 2008 the CNAPT, with financial assistance from the Global Fund for AIDS, TB and Malaria (GFATM) sponsored a Knowledge, Attitude and Practice (KAP) study, to better understand the gaps in education and the lapses in public behavior that obstruct the national efforts in TB eradication.
This study was undertaken in collaboration with the medical personnel of the Respiratory Disease Control Programme of the Ministry of Health, the Centre for Social Survey and the University of Sri Jayewardenepura.
With the intention of spreading knowledge regarding TB, its spread, prevention and management as well as to inform the public on how and where to get the help and information required, the CNAPT, with the assistance of the Global Fund, also started a Health Education Programme.
The primary target group of this education campaign were schoolteachers who aim was to take advantage of their strategic position and spread the message to their pupils and through them to the society at large.
The international community, WHO NGOs and the Sri Lankan Government have done a great deal for the prevention, treatment and management of the disease while also educating the public. Help is available but people need to be informed where assistance and information is available.
People need assistance and when we extend a hand others will willingly grasp it. The CNAPT aims to promote the concept of extending a helping hand by seeking community, public and volunteer assistance. Tomorrow will be better only through our efforts.
Despite the achievements, many TB patients remain undiagnosed. Escalated community involvement coupled with the harnessing of related elements could be the answer to combating this lethal disease and the CNAPT is committed to being a forerunner in fulfilling this goal.
Emphasis on research and development to improve knowledge and skills for diagnosis, treatment and prevention, plus expansion of existing methods may facilitate CNAPT’s goals. The association has tried to educate all sections of the public through technical publications, workshops and seminars. We attempt to combat TB.
Despite the CNAPT’s achievements many TB patients remain undiagnosed. Escalated community involvement coupled with the harnessing of related elements could be the answer to combating this lethal disease.
Special hospital facilities were non-existent for children afflicted by TB The CNAPT remedied this by constructing three children’s wards: Welisara Children’s Ward (1952) Hawake Memorial Ward, Kandana (1955) and Clarence Nathnielz Memorial Ward, Welisara (1960) which provided a total of 165 beds exclusively for children. The total cost of Rs. 900,000 was raised through the efforts of the CNAPT.
Health education
Since its inception the association has concentrated heavily on health education. The objective of the programme was to convey to the public that TB could be cured, patients must take prescribed treatment and those with suggestive symptoms be screened for they must take prescribed treatment and those with suggestive symptoms be screened for the disease.
The programme also included lectures to specifically targeted groups, talks via electronic media, participation at public exhibitions and the distribution of TB related literature. The appointment of permanent health educators furthered this cause.
The proximity of the Health Education Centre to the Colombo Museum make it accessible to any visitors of the Museum who wish to visit CNAPT’s Health Education Centre.
Due to rapid advancement of TB medical treatment many functions of the CNAPT have been made redundant and today the association concentrates primarily on promoting health education. A drop in TB incidence has necessitated the closure of many chest hospitals and TB wards. The BCG vaccination administered at birth has almost negated TB in children and has resulted in the closure of the children’s wards. The reduction of the duration of treatment from 4 years to 6 months has made it easier for patients to carry on with their everyday routines with the least amount of inconvenience and the stigma attached to TB has all but disappeared.
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