Tuberculousis remains a deadly disease

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.