Tuberculosis: a health crisis in the making

First Published: 2004-11-06

AIDS is the leading cause of death in the Bahamas. And tuberculosis is the leading cause of death for people with AIDS.

These facts, together with the emergence of drug-resistant TB, have led to concerns about a health crisis in the making.

TB is the world's most serious infectious threat, sending millions to their grave every year; mainly in poor countries of Africa, Asia and Eastern Europe.

About a hundred new cases of TB were reported here in 2001 (the latest figures we could find), mostly among HIV infected persons. Health officials say a third of people who are HIV positive are also infected with tuberculosis. And 70 per cent of people with TB are also HIV positive.

TB mainly affects people with poor nutrition or illnesses like AIDS that lower the body's immune system. Also at risk are alcohol/drug abusers and those working in long-term care facilities like prisons and nursing homes.

One local doctor, whose practice focuses on these kinds of patients, told Tough Call recently that she sees at least one or two new cases of TB every month.

And a recent Amnesty International report pointed to high rates of infectious diseases, including TB, at Fox Hill prison – made worse by a lack of proper medical care.

The Amnesty report noted that "the risk of cross-contamination for infectious diseases such as TB to other prisoners and prison workers is dangerously high."

According to the latest available figures, 32 per cent of the prison intake population (over 150 people) tested positive for TB during a three-month period in 2001.

To make matters worse, HIV positive prisoners sometimes live in cells with prisoners suffering from TB. And prisoners with TB or other illnesses are not routinely separated from the mainstream population.

According to the National Institutes of Health in the United States, a third of the world's population carries the TB bacillus and as many as 10 per cent of those carriers will develop active infection in their lifetime.

Worldwide, TB kills 2 million people each year, mostly in poor countries.

And when those numbers are extrapolated, the spread of HIV/AIDS appears likely to fuel a global TB crisis that could infect one billion people in the next 20 years, experts say.

More than 40 million people are living with HIV/AIDS worldwide – more than half a million in the Caribbean and about 6,000 in the Bahamas. In fact, we have one of the highest HIV infection rates in the region.

Worldwide, some 3 million people died from AIDS in 2002 – 42,000 of them were in the Caribbean and about 600 in the Bahamas. Many of these people died from tuberculosis.

Once known as consumption, TB is an ancient disease. It was a leading cause of death in the developed world until the 1950s when it was brought under control by new drugs. But the incidence of the disease began to rise again in the late 1980s – concurrently with the AIDS epidemic.

You catch TB by breathing airborne bacteria spread by infected people. Many who are infected do not become overtly ill, but carry dormant TB germs in their bodies.

Avoiding combined infections of HIV/AIDS and TB is a two-fold task, world health experts say. First, the public must be educated in prevention.

Second, the diseases must be identified early and properly treated.

So it is all the more surprising that the incident we are about to relate could ever have happened:

"We have an employee with Stage 4 AIDS who visits the clinic each week for treatment and tests," the manager of a large retail firm told us recently.

"In February he developed a cough that got worse. But it was not until he visited a private doctor in June that he was diagnosed with TB. We sent him back to the AIDS clinic (which operates under the auspices of Dr Perry Gomez, chief of internal medicine and infectious diseases at the PMH) and he was immediately admitted to hospital.

All of our employees had to get TB tests. But it was not until I spoke to the Minister of Health directly that a government nurse came by to talk to us and find out about our test results.

"Then on October 5 we received a letter from Dr. Gomez' office saying the employee was fit to work. We sent him back to the private doctor who reported that he was still contagious and needed at least another three months of treatment before returning to work.

"We have since written Dr. Gomez asking for clarification, but have not received a reply. This is a scary situation and our staff are very concerned by the whole thing. What do you do?"

Well, it is true that TB is usually spread between family members, close friends, and people who work or live together. People with active TB of the lung can infect a dozen other people just by coughing, sneezing or talking, experts say.

But unlike AIDS, a low-cost cure does exist. A person with active TB must complete a six month or longer treatment course. And it is important that all the medicine be taken exactly as prescribed.

Failure to do so has led to the appearance of drug-resistant strains that make treatment more expensive and lengthier than before. Once someone has developed drug-resistant TB they can transmit it to others, leaving those newly infected with fewer treatment options.

The most common way to check for TB is the tuberculin skin test. But it is thought that up to half of people treated for TB on the basis of a positive skin test do not have the disease at all. Similarly, the test often fails to detect people with latent TB.

A paper presented to a meeting of the British Thoracic Society recently showed that doctors often misdiagnosed TB, despite symptoms such as coughing up blood.

Prevention of HIV/AIDS is largely a matter of avoiding sexual behaviours that expose a non-infected person to the blood, semen or vaginal secretions of an HIV-infected person.

Treatment today is aimed at reducing the body's viral load, supporting the immune system and avoiding infection. While AIDS cannot be cured, it can be managed with a "cocktail" of drugs. It has become a chronic disease that people can learn to live with.

But for many, TB is still the first sign of illness associated with HIV infection, and active TB is considered an AIDS-defining disease. So experts say it is important for those with HIV to be screened regularly for TB, beginning when the HIV diagnosis is first made.

In spite of the seriousness of this subject, we were unable to get the perspective of health officials despite numerous attempts over the course of an entire week. Dr Baldwin Carey, the director of public health, did not respond to phone calls or to faxed questions. Dr Gomez and others were said to be travelling.

As one lawyer put it, "It seems that where the government is involved with managing or regulating health affairs, the public is not given the protection or information that we should expect to receive."

The column 'Tough Call' by Larry Smith is published in The Tribune every Thursday and is reprinted here as a courtesy. Mr. Smith founded and successfully grew an advertising agency over 20 years. Under his direction Media Enterprises diversified into short-run commercial printing and publishing, and is now the largest non-fiction book wholesaler in the Bahamas. He has 30 years experience as a journalist and publicist and has contributed numerous articles and columns to the Bahamian press. A former reporter at the Nassau Guardian, local correspondent for Reuters and editor at the Bahamas News Bureau, he conceived and edited the Bahama Almanac (published 2000 by Media Enterprises), wrote the commentary for Mike Toogood's Portrait of an Archipelago (published 2004 by Macmillan Caribbean), and edited the Bahamas Environmental Handbook (published 2002 by the government). In 2003 he took a year's leave of absence from Media Enterprises to lead a transition management team at the Nassau Guardian after the paper was acquired by local investors. After leaving the Guardian he was contracted by the Tribune as online manager/editor and columnist. He has a degree in political science and journalism from the University of Miami. Mr. Smith can be contacted at: larry@tribunemedia.net

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