TB or not TB?

Many of you who know me, especially my fellow MPHers, know that I have a ridiculous obsession with Tuberculosis.  It's truly a fascinating and quite complicated disease posing many issues in the way of both treatment and prevention.  South Africa has one of the highest rates of TB in the world mainly due to its massive population of individuals infected with HIV.  TB treatment and prevention is one of South Africa's Department of Health's top priorities, which is why CMMB has recently started their TB project which consists of going door to door to screen people for the disease.  Naturally I gravitated to this project and I have been trying to use what I learned in my Masters program and what I gained from my experiences working in TB in Kenya to contribute its development

TB Poster in Grey Hospital Clinic KWT

I know finding and treating someone with TB seems simple enough, but its really a quite complex process.  The first round of screening is a questionnaire about TB related symptoms.  If someone appears to have symptoms, then our field workers collect sputum and send it to be tested.  But, of course, that can't be the end of it.  Because TB is difficult to detect, the standard procedure is to collect 2 samples from each patient on 2 separate days, meaning two trips to each person's house for our field workers.  Once this step is complete, the samples are sent to the lab where they are observed under the microscope.  From this the lab gives you a positive result (they saw TB bacteria under the microscope) or a negative result (no TB seen here!).  Simple right? Wrong.  Now there is the issue of using microscopy to diagnose TB.  It really isn't that great of a test.  For one, TB is easy to miss under the microscope not to mention the many issue that can arise with sample quality and contamination issues.

So what do you do if a patient has a negative lab result but suffers from TB symptoms?  Some of the rural clinics in my area say "that's it, nothing more we can do" while others will refer the patient for an xray and doctors visit.  However this happens at another clinic, which adds cost and travel time for patients that have little time or money to spare.  At every turn TB control becomes more and more difficult.

Sign on Exam Room Door Zwelitsha Clinic

Now lets say your patient's test comes back positive.  Great! They have TB so let's start them on treatment, problem solved.  If only it were that simple... First off, to cure TB a person needs to be on treatment for at least 6-9 months.  That's taking a pill every single day for at least 180 days straight.  If you start missing doses then your problems get WAY worse.  Improper TB regimens lead to drug resistance, and let me tell you, drug resistant TB is not something you want to mess with.  You'll have to go back on treatment for much longer and you're going to have to take more drugs than you did before.  Drop the ball again, you are likely to cause further resistance leaving you with very few options for treatment.

Much more than making sure that drugs and doctors are available goes into successful TB treatment and prevention.  You have to think about the barriers patients face when it comes to accessing these services.  Do I have transport to get to the clinic? Can I afford the associated costs? Can I leave work? Am I worried about stigma if someone sees me in the TB section of the clinic? How will I make sure I I have a continuous supply of medication?

The list seems ENDLESS.  My hope is that through this program we can address and eliminate many of these barriers by bringing clinic services directly to the people in our communities and having a well-defined referral system for the services that are beyond the scope of what CMMB can provide.  Establishing this should make for a VERY busy year.