Wed, 24 Mar 1999

Tuberculousis remains a deadly disease

By Chris W. Green

JAKARTA (JP): When Dr. Robert Koch announced his discovery of TB bacillus on March 24, 1882 in Berlin, tuberculosis (TB) was raging through Europe and the Americas, killing one in seven people. Koch's discovery brought with it the hope for controlling this fearful disease.

But progress has been very slow. Effective anti-TB drugs did not appear until the 1950s. Many parts of the world are still without effective treatment. Since 1882, TB has killed more than 200 million people.

Dr. Gro Harlem Brundtland, director general of the World Health Organization (WHO), recently described Asia as "the epicenter of the world's TB emergency".

"If we cannot control TB in Asia," she said, "we will never stop TB globally."

Indonesia ranks third globally in the number of TB cases, after China and India. The WHO estimated that there were 200,000 people with active TB in Indonesia. Active TB can be passed on to others just by coughing, sneezing or even just talking.

But TB can be cured. Treatment for TB should cost no more than US$20 (Rp 180,000) per patient. Unfortunately, it is not that simple. Patients must take several different drugs, and must continue the treatment for up to nine months. The problem is that after about two months, their symptoms disappear and they feel fine. At this stage, many become bored with taking the medicine and give up the treatment.

The result of this is not only that they are at risk of falling sick and becoming infectious again; failing to complete the treatment raises the risk that the TB bacteria will become resistant to the drugs they are taking. If that happens, those drugs are no longer effective in combating their disease.

TB that is resistant to two of the most common -- and cheap -- drugs used in the treatment is called Multidrug Resistant TB or MDR-TB. Treatment of MDR-TB is much more difficult and expensive.

Since MDR-TB is primarily caused by inconsistent or partial treatment, the WHO has devised a strategy for detection and cure of TB called Directly Observed Treatment, Short-course (DOTS). Once infectious cases of TB have been detected, health and community workers and trained volunteers observe and record patients swallowing the correct dosage of anti-TB medicines for six months to eight months. This strategy has been proved effective with cure rates as high as 95 percent in even the poorest countries.

Although DOTS has been implemented in Indonesia, the WHO estimated that by 1996, the program had spread to cover less than 14 percent of the population.

Where it has been introduced, it has been judged successful, but the WHO describes the expansion of coverage as "slow".

The first element of the DOTS strategy is to identify people who have infectious TB. According to Mrs. Suparjo Rustam, Chairwoman of the Indonesian Association for Elimination of Tuberculosis (PPTI), this is hampered by a stigma which is attached to the disease. Many still believe TB to be incurable, even caused by black magic. And some are afraid that they will be fired from their jobs if it is known that they have TB.

The result is that people with active TB are often hidden by their families. To counter this, "we must actively search for people with infectious TB," said Mrs. Suparjo. PPTI is training 1,000 volunteers this month in five areas of Jakarta. Their task will be both to disseminate the facts about TB and also to find people suffering from active TB.

Case finding requires a sensitive approach. Family and neighbors are encouraged to identify possible sufferers so that they can be treated. The volunteers then undertake the next step of the DOTS strategy -- that of helping to ensure that the patient completes the course of treatment.

PPTI has proved that this system can work. Two years ago, a pilot scheme was tried in two of Jakarta's poorer parts. The scheme mobilized 60 volunteers, and they identified 129 people with active TB.

Mrs. Suparjo has great expectations for the wider program which is now starting. She hopes that each of the new volunteers can find 20 cases, and thus identify most of the estimated 20,000 cases in Jakarta. This, she believes, is the most difficult part of the strategy.

But the follow-up is just as crucial. Patients can obtain treatment free from the PPTI clinic in Central Jakarta. But to ensure that they are committed to completing the treatment, they must sign a statement with their neighborhood chief in order to qualify for the free drugs.

According to Dr. Tjandra Yoga Aditama, a lung specialist at the Persahabatan Hospital, Jakarta, it is also essential that the volunteers who will supervise the treatment are themselves fully committed -- and supported.

"More attention needs to be given to the volunteers used to observe the treatment," he said. They are rarely even recompensed for their out-of-pocket expenses connected with this task. To address this concern, Tjandra reported that the Persahabatan Hospital ran a trial with 30 TB patients, which involved family members working with hospital staff to monitor the treatment. In cases where the commitment of the family members started to drop off, the hospital staff took over. Tjandra considers this program has been successful and it has been extended.

This level of supervision of treatment is essential, as Dr. Tjandra noted from his own experience. Among his patients, as many as 10 percent developed MDR-TB as a result of poor compliance with the treatment. Treating such patients can cost over Rp 60,000 per day, and effective in curing less than 60 percent of cases.

Several years ago, it appeared that a combination of new drugs with the DOTS strategy could rid the world of TB. But this was set back by the arrival of Human Immunodeficiency Virus (HIV), the virus that causes Acquired Immune Deficiency Syndrome (AIDS). HIV and TB form a lethal combination, each speeding the other's progress. One-third of the increase in global incidence of TB in the last five years can be attributed to HIV.

According to WHO statistics, TB is the leading cause of death of HIV-positive people. While there are no similar statistics for Indonesia, there have been at least five cases where TB patients have been diagnosed as being infected with HIV. And since it is known that many people are dying of AIDS without being diagnosed, it is sure that some of those whose cause of death is recorded as TB in fact died of AIDS. It is, therefore, essential that doctors in Indonesia, and especially the 350 lung specialists, are made more aware of the threat of AIDS. They must be trained to look for other clues that may indicate the presence of HIV infection in their patients.

To commemorate Koch's discovery, in 1982 the WHO denominated March 24 as World TB Day. And as we now commemorate that day, we are reminded once again of the terrible threat of this disease, which despite earlier hopes of eradication not only remains with us, but is also now taking more lives than ever before. As the WHO notes, reliable diagnosis, adequate drug supply, effective supervision of treatment and systems to record progress are essential elements of a successful strategy to conquer TB. But they simply cannot have a widespread impact on the disease without political commitment. Clearly to develop and maintain such commitment in Indonesia at present represents a major challenge.