On the move against TB
– on the road to elimination
LIKE many countries around the world, developing and developed, TB is still a big public health problem in Guyana.
It is a global public health problem and lives ominously alongside HIV. But Guyana has developed a response that has brought TB to a stage where we have begun to see reversal in the incidence rate of TB and in mortality linked to TB.
We truly then can say, we are on the move against TB. We can truly say we are on the road to elimination. As with HIV and Malaria, we have embarked on a trajectory of elimination of TB in Guyana.
These must be considered today as fighting words, a bold declaration, a courageous platform, but I believe that TB, the ancient disease, can be stopped, is stoppable in Guyana and around the world.
I believe we have not used our scientific knowledge enough and we have not fully recognized globally that TB is truly an important public health threat that also is a threat in our efforts to end poverty.
But today I want to highlight the fact that TB’s persistence and its acceleration over the last 30 years around the world has not only been driven by HIV, it has also been driven by the fact that there are increasingly better chances for the spread of TB, unless we recognize the catalysts and remove them from their potentiating roles.

We are familiar with the significant role HIV plays in spreading TB.
We must also recognize that diabetes is also a significant potentiating factor. This year I would like to highlight the role diabetes has played in increasing transmission of TB around the world. Diabetics are prone to acquiring TB. With the increasing pandemic of diabetes, TB has found another partner in tragedy and misery around the world. Some 11% of persons with TB in Guyana are also diabetic. This is an issue I will discuss in greater details over the weekend.

CALL ON GLOBAL COMMUNITY
On World TB Day 2011, I call on the global community to address persisting global constraints if we expect to overcome the TB scourge that have plagued humankind since ancient times.
While it is true that the developing countries have bigger TB epidemics than developed countries, TB has plagued humankind whether they live in rich or poor countries.
Locally we in Guyana have taken responsibility to address the Guyana TB epidemic. But there are a number of constraints that serve as difficulties in our fight against TB. These are difficulties that are not within our capacity as a developing country to address. Unless globally we are prepared to overcome these difficulties, the global TB problem cannot be solved and elimination will be impossible.
Millions of lives, particularly in developing countries will continue to be sacrificed because we did not make the commitments that are within are capacity to do. I, therefore, would like to highlight a few of the constraints that limit our response.

•         Old medicines and long treatment period: The current regimen for standard TB treatment involves four different medicines taken over six to nine months. These medicines are old medicines and have been in use for the last 50 years. The long period of treatment is simple unbearable for too many TB patients. The four medicine combination treatment, taken ideally under daily monitoring by DOTS, is burdensome for both patients and care providers alike. It is a serious constraint, as it leads to non-compliance among persons being treated for TB. These persons are at high risk for developing resistant strains of TB, leading to multiple drug resistant (MDR and XDR) strains of TB. Even though there are still a small number of persons in Guyana with MDR, this is a big and growing problem in the world, with more than 2% of all cases now classified in the world as MDR and XDR TB. The global threat of MDR and XDR is frightening because all the gains that we have made in the last decade can be squandered if we are not in a position to address the problem with newer, more potent medicines. In this regard, there is a need for more robust efforts to develop newer medicines for TB that will enable shorter treatment periods and more potent cure rates, that will enable us to stop MDR and XDR and that will address more adequately latent TB which affects almost 2 billion persons around the world. With investment from Global Fund and other public entities, there are stronger Public-Private Partnership arrangements to support the development of newer TB medicines. While at this time, the possibility of newer, more useful medicines still seems a distant possibility, that possibility is greater than it has been for several decades now. Globally, WHO, Global Fund, UNITAID and other groups will have to promote more aggressive research to remedy this situation early so that we have a real chance of eliminating TB.

•         Adult medicine formulations for children are unworkable: Children are treated with the same medicines as adults, with various adjustments made for their size. There is a need for medicine formulations to treat children under 15 years old. Even though the number of children with TB is small in Guyana, globally, more than 20% of all TB cases are among children. The lack of TB medicine formulation for children is a serious constraint. At this time, there is very little evidence that much effort is being made to produce paediatric medicines for TB. It is my position that this is a moral issue and we are failing in the test of responding to the needs of our most vulnerable population – our children.

•         Opportunity to improve access to TB testing through a better diagnostic tool: For more than 100 years, we have relied on the same tests for TB. The skin test called mantoux test only identifies persons who have been exposed to TB (latent TB) but does not distinguish persons with active TB. The sputum microscopy test is a very good test (gold standard), but misses about half of the cases. X-Rays help doctors to make diagnosis. Culture (or growth) of the bacteria is another test, which is a very good test, but requires skilled technicians and high level infrastructure and technology. Other than the mantoux test, all the others require health workers with certain skills and availability of physical infrastructure and technology. In addition, these tests do not provide rapid results and require some time before test results are available. This limits access to testing and makes access to diagnosis weak in most primary health care settings. There is better news on this front since a newer test that would provide more rapid results is now available, although not yet on a commercial basis. Guyana is monitoring the availability of this test because we believe it will improve further the accessibility to testing in Guyana.

•         A better TB vaccine can bring us to the end of TB earlier than present prospects: The BCG vaccine is a good vaccine and has served to limit the epidemic in Guyana and in many countries, but it is unlike most of the vaccines we use in Guyana which provide protection for life. While it has provided relatively good protection for our children, it has provided virtually no protection for adults. More research is needed to accelerate the availability of a new TB vaccine.

Let us commit ourselves to a far more extensive effort globally and in Guyana as we join other countries in the world to observe World TB Day.
Together with our sisters and brothers in every country, we are observing the day by ensuring that the Guyanese people are very aware of the seriousness of TB. But we join people all over the world in the fight against TB in 2011, with a different perspective, moving from earlier positions of simply hoping to slow the increases in TB cases, to now embarking on a trajectory of elimination.
TB is an ancient disease, going back to biblical times. Then it was called phthisis and the name tuberculosis came later.
Early writings about TB (when it was called phthisis) can be seen in the examples of Susruta, the great Indian physician (600AD) and Avicenna (780AD) who first discussed the increased risk of diabetics for phthisis.
But it was not until March 24th 1882 that the scientist, Dr. Robert Koch identified the bacteria, Mycobacterium tuberculosis, as the cause of TB. Today, we observe World TB Day every March 24th, commemorating the discovery, but also using the commemoration to spread awareness and using this occasion to give an account of the fight against TB.

The Global TB Status
There are at least 9 million new infections and approximately 1.7 million deaths because of TB each year around the world. Globally, TB is the # 8 cause of deaths. In the age group 15-59 years, TB is the # 3 most prevalent cause of death and in women TB kills more women than maternal mortality. Among persons living with HIV, TB is the #1 cause of death.

On the road to elimination of TB in Guyana
In Guyana and around the world, we have made progress in our fight against TB. In spite of the persistence of TB, we clearly have the possibility of elimination of TB. We are, therefore, encouraged by the theme chosen for the observance of World TB Day: On the Move against TB – Transforming the Fight towards Elimination. Guyana has already developed strategies that pursue a trajectory of elimination for HIV and Malaria.
The MOH believes that the burden of disease of TB can be reduced and eliminated but only if all stakeholders play their roles. These stakeholders must include:
•         Governments
•         Health Workers and Health Systems
•         Technical and Development Partners, such as PAHO/WHO and CDC
•         Private Sector
•         Non-Governmental Organizations
•         Citizens

The Challenge of Increasing Cost
The fight against TB is not without its cost. Indeed, the cost to stop TB is overwhelming for any country, but the cost of dealing with social and economic tragedies that accompany TB is far more overwhelming and impoverishing. Whether it is a poor or a rich country, stopping TB now is feasible. Trying to stop it later might be an impossible task. In Guyana, we estimate that the present cost for treating a TB patient is about $US350 in Guyana. In other developing countries, they have estimated cost at about $US700. But if we need to treat a patient for more than six months, these costs become greater.
If patients must be treated with 2nd line medicines in cases where the TB is resistant to standard medicines, a possibility that increases with time, the cost could rise to more than U.S.$3,000 per patient for the period of treatment.
Presently, the TB programme costs about $500M per year.
We are extremely grateful for international partnerships that have contributed to Guyana developing a comprehensive STOP TB Programme, one that is on the road to elimination. These include Global Fund, PEPFAR through CDC and FXB and PAHO/WHO.

Making Education and Awareness a Bigger Priority
Educating people and spreading awareness must be a priority for the National Programme. In spite of the fact that we have expanded our awareness and education programme, there is still generally inadequate awareness of TB among our people.
In 2011, we will complete the 2nd KAPB for Guyana. The first Guyana KAPB (Knowledge, Attitude, Perception and Belief) survey among the Guyanese people was completed in 2008. We expect to find a significant improvement in the TB knowledge of the population in this new study since much awareness and education programmes have been completed since 2008.
The truth is there is more knowledge about HIV than there is about TB, even though TB has been around much longer than HIV. Guyana must ensure that each citizen is knowledgeable about TB.
The 2008 KAPB Survey had shown that about 89% of persons surveyed knew of TB.  When checked per Region, the survey showed that the Regions with the highest basic knowledge of TB were Regions 5, 7 and 8. The Regions with the lowest basic knowledge were Regions 2 (58%), 6 (86%), Region 4 (90%) and Region 9 (90%).
For knowledge of symptoms, about 70% of the population knew the main symptom of TB. For the main transmission route, about 76% of the population showed knowledge.
One alarming finding of that study was that about 42% of the population though it was a shameful thing, demonstrating a great deal of stigmatization associated with TB.

Expanding Diagnostic Capacity
Presently there are 20 TB testing sites for Guyana in all ten Regions. In 2011, we will establish three new sites at Kamarang, Mahaicony and Supply (East Bank Demerara).
Guyana is introducing a new digital x-ray system to be used at the TB Clinic in Georgetown.
Guyana will also try to introduce the new Rapid Test for TB as soon as it becomes commercially available.

Improving Treatment Access
Treatment for TB is available in all twenty of these sites and also at other hospitals. There is free access to all available TB medicine in Guyana, including treatment with 2nd line medicines.

The Risk Factors
Several risk factors are known. These include:
•         Persons living with TB are at higher risk to develop TB
•         Persons with diabetes have lowered immunity in general and are very vulnerable to developing TB
•         People in prisons
•         Persons with low body weight (10% or so below BMI of 18)
•         Homelessness
•         Alcohol and substance abuse

Multi-Drug Resistance (MDR)
Every country has now documented cases of MDR. This is a new global challenge and represents a serious public health threat. In Guyana, we have not yet experienced a high level of MDR cases, although we have documented about five cases so far. For this reason we will have to introduce greater vigilance and ensure that there is 100% compliance with medication among those who are being treated.

The TB Situation in Guyana
Since monitoring TB cases in 1980, Guyana has seen an increasing number of cases each year. There were poor reporting and many cases were undiagnosed during the 1980s and early 1990s. With expanding diagnostic capacity and improved health information systems, the number of TB cases increased every year since 1980. Some of the increases were due to better testing capacity and better gathering of data.
Between 2007 and 2010, Guyana began to see a reduction in incidence of TB. In 2007, the incidence rate was 93 persons per 100,000 persons in the population. This dropped to 89 per 100,000 in 2010. The reduction appears slow, because the testing capacity and reporting have improved. Under-reporting has been reduced significantly and this is one reason why the incidence rate appears to be only slowly being reduced.
Guyana today has an active DOTS (Direct Observation of Therapy) programme where health workers go to persons with TB where they live and ensure they are taking their medicines. In 2007, about 60% of all TB patients were being treated through the DOTS programme. At the end of 2010, the rate had increased to 78% being treated through DOTS.
More than 91% of all TB patients were tested for HIV in 2010. About 25% of all persons with TB test positive for HIV. Indeed, about 70% of all TB deaths in Guyana are because of AIDS.
In 2010, there were 60 TB deaths in Guyana. The rate of TB mortality in 2010 was about 8 per 100,000 persons in the population. This is less than half of the TB mortality rate ten years ago. This reduction in TB mortality has resulted from better and earlier diagnostic and treatment capacities in the country.

Our Goals
1.      100% detection rate in all regions by 2015
2.      Reduced incidence rate to less than 60 per 100,000 persons by 2015
3.      Reduced TB mortality rate to less than 4 per 100,000 persons by 2015
4.      DOTS coverage rate increased to 100% per 2015
5.      No increase in MDR by 2015
6.      100% knowledge of TB in all adults

Conclusion
Guyana has come a long way in our struggle to stop TB. It is an ancient disease, but it confronts us with modern challenges. Modernity has indeed exponentially increased the risk. This is one ancient creature that has not only survived manmade conditions, where many other species have become extinct, but has learned to use modern manmade practices and behaviour its vehicle to prosper.
But TB is treatable. It is curable. It is stoppable. I believe we have the capacity in Guyana to stop TB in our lifetime, in this generation. But we can only do so if as a Nation we recognize that this is a task that is beyond the realm of the Ministry of Health and health workers. It is a responsibility of all citizens of Guyana. It is our civic obligation and so today on World TB day, we must ensure that the goal of ME TO YOU – REACH ONE SAVE ONE – is equally our mantra for TB as it is for HIV: Every Citizen Must Know the Facts about TB.
This is but our civic duty as a Guyanese. Like the variation on the 2011 World TB Day theme being used in the USA, I say: TB Elimination: Together we can.