Sustaining and completing tuberculosis (TB) treatment is a challenge for many people affected by TB. The treatment takes six to eight months, requires regular trips to medical facilities, and can have many side effects. To support people affected by TB in rural and remote areas of Lao PDR, HPP Laos establishes psychosocial support structures at household level: A TRIO consists of the TB client and two family members or close friends. The TRIO ensures daily medication intake, and further supports the TB client to improve their nutrition. For this purpose, HPP Laos trains TRIO members in nutrition awareness and home gardening, and provides them with seeds, tools and small animals. Improved nutrition supports the recovery process and strengthens people's overall health, thus boosting their immune systems and helping to prevent reinfection.
Mr Mao Yengyang from Phaday village, Bolikhan District, is currently completing his second TB treatment. This time, he is confident he will recover as he has the support of his family as well as HPP Laos. He shares his story with us as he wishes for many more people to find the support they need to sustain their TB treatments.
"In 2009, I was coughing heavily and non-stop. However, as I did not want to turn to the public health care system, I did not have my health checked. I thought my condition would not be that serious, and I treated myself with traditional means such as injecting ampicillin and smoking opium. Many people had told me that smoking opium would cure my condition and make the symptoms disappear. However, opium would only give me short periods of relief, and I became addicted to it. At this time, village and district authorities came to our village to take opium addicts to the local hospital for treatment. I was one of the people who were sent to Bolikhan District Hospital for this purpose. After 3 or 4 days of staying at the hospital, my cough became worse. The doctor had me tested for TB which returned positive. At the hospital, they told me about the disease and the importance of sustaining treatment for 8 months. I was discharged from hospital and sent home with 3 months of medication and instructions to take it on a daily basis. Afterwards, I would have to return to hospital to get a new prescription. However, after I finished the first 3 months, I did not go back to the hospital for several months until the doctor called me to come back. Yet, I did not take this second round of medication regularly as my cough was gone and I thought I had already recovered. In late 2019, my bad cough came back but I did not get a health check. In June 2020, the village authorities announced that HPP Laos would come to our village to find TB cases and to interview households. The next day, the team arrived, and I told them about my condition. My sputum sample was collected for diagnosis and the project team told me I was infected with TB. Three days later, I received medication. This time is different from my previous experience because HPP Laos arranged for my wife and my child to monitor my daily medication intake. A Project Officer calls my wife and my child every day to see if I have taken my medication. I am so grateful that the project team is here to support my treatment, and that this time, I am set to fully recover from TB. I would like to thank the HPP Laos project team as well as the doctors and nurses who have helped me to understand TB and its treatment."
On 24 March, the world commemorates World TB Day, and this year’s theme is ‘It’s Time’. TB is the leading infectious killer of people with HIV and the second leading infectious cause of death for adults globally. Now, more than ever, it’s time to accelerate action and efforts to test, treat and terminate TB.
TB kills more than two million people a year, impacting the poorest of families, communities and countries. World TB Day was launched to raise public awareness on the causes, effect and impact of TB around the world.
Fighting disease and health promotion is a central theme underscoring the efforts of the Federation Humana People to People and its members in the global south, so we join hands in celebrating this important commemoration. Our members have been actively involved in TB programming for more than 15 years now in high burden countries across Africa and Asia. Education has been a priority focus for the response to TB, but this must be coupled with accurate information and communication, as well as solutions to enhance the fight against TB. Ninety-eight per cent of TB deaths occur in the global south.
Humana People to People works in alignment with the United Nations (UN) Sustainable Development Goal (SDG) 3, which calls for an end to TB by 2030. In addition, the World Health Organisation (WHO) End TB program aims to achieve a 95% reduction in TB deaths, 90% reduction in TB incidence rates, and zero catastrophic costs. To this end, we adopt a community-centered approach to TB programming including behavior change, health systems strengthening and TB treatment. This is achieved by integrating innovation-driven approaches through family-based support engaging a TRIO system (infected person and two family members); door-to-door screening; and health education with nutrition support.
More than 20 TB prevention and treatment projects were implemented across nine countries in the global south by our members in 2019; these are Angola, Congo, Botswana, Laos, India, Malawi, Mozambique, South Africa and Zimbabwe. Projects applied a community-centred approach, working with the most vulnerable including adolescent girls and young women in the remotest locations.
This year alone, TB efforts by our members resulted in the screening of 390,000 people, testing of 24,000 people and referral of 5,000 patients for TB treatment. Key to all project efforts was enabling communities to own HIV and TB, breaking down associated stigma, better understanding disease symptoms, and adopting measures to live positively with a support structure and continued awareness and behavior change.
TB in time of COVID-19
Global pandemics are the new threat to human life, affecting all sectors of society - from individual, to household, community, national, regional and international levels. According to the United Nations, the number of outbreaks per year around the globe has more than tripled since 1980. Factors such as climate change, large concentrations of populations and excessive travel have increased our vulnerability to pandemics today, compared to 100 years ago.
An infection in one end of the world can make its way to the remotest location in another part of the world in a very short time as seen with COVID-19, popularly known as the coronavirus, the world’s latest disease threat. From an initially slow yet chronic health crisis in Wuhan City, China where it emerged in December2019, to a devastating outbreak, declared a public health emergency of international concern and soon after a pandemic by the World Health Organization (WHO) on 11 March 2020.
As of 21 March 2020, WHO globally recorded 267,013 confirmed COVID-19 cases, 11,201 deaths and 185 countries with cases. The virus poses a danger not only to those already infected but has the potential to heavily impact existing healthcare systems that are already overstretched, underfunded, weak and fragile, particularly in the global south.
COVID-19 is a new virus that can be passed on to anyone, regardless of age, gender or socio-economic status. The older generation is at greater risk of contracting COVID-19, especially those experiencing respiratory problems, says WHO. However, over the last few days, new studies emerging from USA, UK and Italy have seen COVID-19 also affecting the younger generation, meaning that this population group may be very vulnerable to infection as well.
It is yet to be established by scientists or researchers how COVID-19 will affect people with TB, although there is a definite risk from a health perspective, given the respiratory discourse of both diseases. Furthermore, it is true to assert that thousands of people have succumbed to COVID-19 through pneumonia, the lung disease, long associated with TB.
In resource-limited settings and poorer countries with rural populations and increased population density, COVID-19 remains a severe threat; this is exacerbated by scarcity of clean water, poor nutrition and lack of access to medical facilities. Awareness and prevention efforts are therefore critical to avoid infection or cross-infection.
The global response
At a global level, governments are proactively fighting COVID-19 through detection and surveillance strategies, contact tracing, social distancing and isolation, travel bans, shutting borders and public education. In New Zealand, France and many European countries, self-isolation is now self mandatory; India has called for nationwide curfews, with a lockdown in Delhi and suspension of public trains in Mumbai, while the Olympics move closer to postponement. The New York stock exchange is now fully electronic and lawmakers in the U.S. have created a relief plan, whilst Germany has called for limited gatherings of two people only, with stores and restaurants now closed in the UK.
In Africa and Asia, governments have imposed travel restrictions and self-quarantine measures on countries worst affected by COVID-19. However, given that these countries have limited health resources, the most effective strategies rely fully on simple actions carried out by us at individual, household and community level, including schools and workplaces.
Here are some basic protective measures against COVID-19, as advised by WHO:
Wash your hands frequently with soap for 20 seconds
Cover your mouth and nose with your bent elbow when coughing and sneezing
Maintain social distance with anyone who is coughing or sneezing
Avoid touching your eyes, nose and mouth
Avoid crowded spaces and social gatherings of people
Seek medical care if you have a fever, cough or breathing difficulties
Stay informed and follow advice given by your health care provider
Humana People to People stands in solidarity and with resilience in the fight against TB and COVID-19. Stay safe, stay hygienic. Together, we will win this battle!
To learn more about our global and national efforts in fighting TB, HIV and AIDS, and malaria, check out www.humana.org.
Our TC TB project in Bolikhamxay has found 69 TB clients up to date, and 25 people have already completed their treatment. Every TB case is different, and some are easier to find than others. Field staff, Village Health Workers and Health Centre staff have become more confident and experienced with collecting and transporting sputum samples, and thus more and more good quality samples arrive for GeneXpert testing in Pakxan. The project has therefore seen an increase in cases identified by GeneXpert which is very positive.
However, sometimes, samples test negative and yet people continue to experience TB symptoms. In these cases, HPP Laos field staff and Village Health Workers closely follow up and stay in contact with people for three or four weeks. If symptoms persist, HPP Laos supports presumptive TB clients to be checked by chest X-ray in a province hospital, and organises transport for them. Mr Vieng Sihalat from Ban Viengkham in Pakkading District is one person affected by TB who was diagnosed in this way:
Villagers attending a TB screening session with Ms Moukdaline Keoviset
Mr Vieng Sihalat, 29 years, in his home garden
“I attended an awareness meeting of the HPP Laos TB project in my village. I did not know about TB symptoms before, and I compared them to what I was feeling like. As I did have symptoms and wanted to be tested, I gave a sputum sample, but the test result was negative. I still had symptoms and the HPP Laos team continued to follow up with me, and finally I was checked and diagnosed by X-ray. The HPP Laos team supported me to access treatment and gave me eight ducklings and vegetable seeds for gardening. I learned new things about vegetable growing from the field staff, and they taught me how to raise ducks as a source of protein.”
Ms Syda is 55 years old and lives in Nongdang village, Bolikhan District. She was diagnosed with TB through HPP Laos’ active case finding project. The field staff supported her to access treatment through her local Health Centre in September 2018. She completed her treatment in March 2019. She says:
“Now I am happy that I have recovered from TB. The project came to help me by checking my health. If there had been no project, maybe I would have already passed away. I would also like to thank the nurses and doctors who helped me get better. Through the TB project, I received ducks and chickens, and so I have been able to improve my nutrition and protein intake. Now I’m feeling very well and eating very well. Recently, I have been able to start working again.”
In its second implementation year, the TC TB project in Pakkading and Bolikhan Districts continues to screen for presumptive TB cases and to support TB-affected families with treatment adherence and improved nutrition. Since the start of the project in July 2018, 40 TB cases have been detected. 19,563 people were screened for TB symptoms and 741 presumptive cases were identified. The latter can give their sputum samples at village level instead of having to travel to sometimes far-away Health Centres – medical staff, in conjunction with HPP Laos field staff collect sputum samples at presumptive cases’ doorsteps and transport them to laboratories for diagnosis.
Medical staff and HPP Laos field staff are examining a chest X-ray of a presumptive TB client
Health Centre staff are collecting sputum samples at villagers' doorsteps
The team are continuously monitoring their progress and learnings and have implemented improvements over the past months. For instance, instead of time-consuming door-to-door screenings, the Field Officers have intensified contact investigation in order to look for potential TB cases more strategically. With this approach, Field Officers visit households which were affected by TB within the past two years. They screen all household members and trace their social networks as well as other regular contacts such as colleagues or fellow students to verify whether they might show TB symptoms.
Screening for TB symptoms through contact investigation of former and current TB clients allows for efficient presumptive case finding
HPP Laos field staff are supporting Health Centre staff in increasing the quality of sputum samples collected
Another way of increasing the efficiency of finding TB cases is to strengthen GeneXpert diagnosis. District laboratories use sputum smear microscopy which, as a diagnostic method, has a high failure rate. In Bolikhamxay Province, GeneXpert is only available in Pakxan Hospital and sputum sample transport from village to province level – via Health Centres and district laboratories – is challenging. HPP Laos is working with local health authorities to improve sample logistics and to increase the share of samples tested by GeneXpert.
