Prevalence Of Tuberculosis In The Democratic Republic Of Congo: Epidemiology, Challenges, And Strategies

Country of Choice -Democratic republic of Congo

Disucss about the prevalence of Tuberculosis in the Democratic Republic of Congo.

Global health can be defined as the area of study, research and practices that prioritizes improvement of the health and the achieving the health equity for all the people globally. Accprding to Kickbush , global health can be defined as “an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide” (Kickbusch, 2006). This paper will review on literatures regarding global health and would discuss about the prevalence of Tuberculosis in the Democratic Republic of Congo, the epidemiology of the disease, the current initiatives taken up by the DRC and the challenges faced by the government in implementing those strategies. Finally the report has been concluded with a suitable recommendation.

Review of literature

Globally the rate of the deaths from the non-communicable diseases is increasing day by day, such as stroke, congestive heart failure and cancer. At the same time the number of deaths due to communicable diseases such as tuberculosis, malaria and the vaccine preventable diseases are continuously increasing (Kaswa et al. 2014). They now have to add to the dual burden of the disease such, such as addressing the threats of the communicable diseases and addressing the environmental health risks. As per the epidemiological surveys, diseases due to malnutrition are common in most of the third world countries like Africa, Bangladesh and Pakistan.

Democratic republic of Congo (DRC), is the second largest on the African continent with a population of over 70 million (Henegar et al. 2014). According to The World health organization (WHO), this Sub Saharan country has got the highest burden of Tuberculosis and AIDS. Other diseases that cause mortality are malaria, lower respiratory tract infections, cerebrovascular diseases, measles, ischemic heart disease, diarrheal diseases, low birth weight and birth asphyxia and malnutrition.

The DRC was once known in Africa to have one of the finest clinics, primary health care system and physicians, which have deteriorated over the past three decades. It is mainly due to the political and the economic collapse of the collapse of the country. Now in most of the places in DRC, the hospitals and the clinics lacks proper equipment and often run out of life saving medicines and supplies. An estimate of 70 percent of the people of Congo has no access to proper health care and strengthening of the health care system of the Congolese people. It ranks 6^th out of the 22 countries that accounts for 80 percent of the tuberculosis cases of the world (Henegar et al. 2014).

Review of literature

From the cohort studies and observation by Henegar  et al(2012), a large proportion of people with TB have been found to be HIV positive. Hence both the diseases require a careful follow up. According to Linguissi et al. (2017), the health care providers in Congo are untrained with respect to the recent guidelines of WHO. National TB and HIV programs have been undertaken but they have been considered as two different programs, which call for a collaborative approach. Furthermore lack of proper electronic database, crowded facilities and limited staffing have contributed to the deteriorating status quo of the disease.

There are serious governance and leadership challenges that includes weak public health leadership and management. Insufficient health care legislations, limited partaking of the community in the planning, managing and monitoring of the health services, weak social inter-sectoral action, horizontal and vertical inequalities in the health care system are responsible for the appalling health of the people.  According to Patel et al. (2014), situational analysis of the health status, proper action plans based on the requirements are essential to improve the global health.

Tuberculosis- Key global public health problems in the democratic republic of Congo

Tuberculosis is an air-borne infection that is caused by Mycobacterium tuberculosis and is mainly acquired by the inhalation of the contaminated droplets of air sneezed or coughed by an infected individual. It can be also introduced in human beings by the ingestion of un-pasteurized milk products contaminated by Mycobacterium bovis, which is also known as the bovine tuberculosis. Tuberculosis is mainly transmitted in cramped and overcrowded conditions. In most of the cases individuals have latent tuberculosis (LTBI) that does not display any clinical manifestations. The bacteria can persist in a latent state for many years and the chance of having active tuberculosis reduces with time. This is known as pulmonary tuberculosis. The symptoms of tuberculosis mainly involves generation of bloody sputum, chest pain, lack of appetite, general weakness, weight loss, swollen lymphoid glands, chills, fevers and night sweats. It is often mistaken with pneumonia or bronchitis. TB, if left untreated can be fatal (Kalonji et al. 2014).

Tuberculous pleuritis can occur in some people from the rupture of the disease area located in the pleural space, that is the space between the lining of the chest and the lungs this can be painful. These individuals might suffer from chest pain, non productive cough and fever. The disease may relapse. Tuberculosis weakens the immune system and the bacteria can spread to different parts of the body and may produce weakness, loss of appetite and weight loss (Kalonji et al. 2014). Thus type of tuberculosis is known as Miliary tuberculosis. 

Tuberculosis- Key global public health problems in the democratic republic of Congo

Treatment of tuberculosis requires antibiotic treatment for about 6 months. TB is treatable unless it is a drug resistant TB which is difficult to control and is mainly caused by the indiscriminate use of antibiotics and the second generation antibiotics fails to cure the multi-drug resistant tuberculosis.

Rationale for choosing this disease

Multidrug Resistant Tuberculosis (MDR-TB) is a serious threat to the people of Congo that jeopardizes the efforts of the world in controlling TB (Kaswa et al. 2014). It is the major cause of the mortality due to many reasons.

• In the last two decades of the history of DRC, the political and the civil unrest have shattered the health care system of the country and have paved the recrudescence of Tuberculosis (TB) (Kaswa et al. 2014).
• Lack of health literacy among the people of Congo residing in the sub-urban region has also contributed to the spreading of the diseases (Linguissi et al. 2017). In the rural areas most of the people do not have the ability to perform the basic tasks of reading medical information on the medicine bottle, or do not have any knowledge regarding the precaution or the preventive measures. In most of the cases they are not aware of the facilities that are available for them.
• Superstitions and dependence on the traditional healers or herb medicine for treating tuberculosis have closed the doors for health literacy, especially in the tribal population.
• Lack of proper infrastructure and health care facilities, overcrowded dwelling places, lack of proper waste management techniques, lack of proper sanitation, hygiene have contributed to the transmission of Tuberculosis. Lack of proper roads and transport system makes it difficult for the Congolese residing in the rural region to get access to the health care sites for vaccination.
• Inequalities exist in the socio-economic status and the access to the basic social services. The socio economic condition of the country has long been shattered by wars and political disturbances.
• Tuberculosis is one of the most common causes of death from infectious diseases among the people of Congo and has also become a global emergency. An estimation of 9.6 million of new TB cases worldwide has been reported by WHO (Linguissi et al. 2017). About 281 per 1000000 people die out of TB in the sub Saharan Africa and an estimated 1.2 million out of 9.5 million of cases were found to be HIV positive cases and the combined effect of both the deadly diseases are having a devastated effect on the population (Henegar et al. 2014).
• Furthermore the synergistic effect of both TB and AIDS are having a devastation impact on this low income country, Congo. In order to deal with this high burden the gaps in the structural, operational factors in the health care needs to be identified. This provides the rationale for choosing this disease for discussion.

Current strategies implemented by the government

Government has introduced strategies for controlling the increasing amount of mortality and morbidity among the Congolese.

• The initial strategies taken up for managing tuberculosis is the National tuberculosusis Program (NTP) that was established in the year 1962 with the objective of reducing the mortality and the disability from TB by effective treatment regimen. Under this program the TB centers were set up for the referral diagnosis and community programs. One noteworthy initiative of this program is the initiation of the DOTS therapy for the eradication of TB (Kurbatova et al. 2014).
• The Union has collaborated with the National tuberculosis program (NTP) of the Democratic republic of Congo for developing and implementing a program for the integrated care for tuberculosis patients living with HIV (International Union against Tuberculosis and Lung disease. 2016). The program introduced TB screening and management of the patient co-infected with HIV. The co-infected patients had been provided with cotrimoxazole preventive therapy (CPT) and if possible on antiretroviral treatment (ART) (International Union against Tuberculosis and Lung disease. 2016). They have also introduced systems for the measurement of the CD4 counts at all sites with equipment such as microscopes for sputum smear microscopy (Desikan 2013). They have also provided training to the health care staffs involved in the implementation of the National program that combines in-service training in the centers of excellence.
• The government has adopted Millennium development goals (MDGs) for reducing the mortality and the morbidity due to tuberculosis (WHO, 2017). The National Program against Tuberculosis (NTP) have also revised its strategies and have adapted the new Stop TB strategy with targets 70 % detection rates and 85 % of success in treatment (Patel et al. 2014).
• The government has also brought together the NGOs, national TB and the AIDs programs staffs and the WHO experts. Femmeplusis an example of an NGO for integrating the Tb services in to community based HIV reforms in Kikwtit and Kingshasa, for the poor and the vulnerable groups.
• The USAID has funded the Democratic Republic of Congo-Integrated Health Project(DRC-IHP), with the aim to progress the basic health condition of the Congolese people residing in 80 health zones. Especially those with “TB burden”. The provincial health divisions have been working to increase the staff work force. This project has introduced the Directly Observed Treatment, Short-Course” (DOTS) approach in the Kalenda region of the DRC. The DRC-IHP project is also responsible for financing the transportation cost of the TB commodities to the treatment centers (Shanks et al. 2015). They have also launched the community awareness program for educating the local residents regarding the symptoms of the disease and the availability of the treatment.
• Recently The United Nations Development Programme has been introduced in the democratic republic of Congo, for strengthening the fight against TB. UNDP has funded US$7,896,557 for controlling this epidemic (UNAIDS 2013) .

Challenges 

Although several strategies have been taken to control the prevalence of this deadly disease, the rates of the case fatalities have increased threefold in DRC. It has been found that more then 400 000 cases of TB cases requires treatment but the cure rates are as low as 30 % (World Health Organization, 2015). Although favorable outcomes can be achieved in 80 % of the cases but the increase in the number of deaths reduces the overall effectiveness of the program. Major challenges are:-

Lack of Accurate information on TB and TB/HIV infections in DRC

HIV and the TB control programs work as separate entities with different protocols and case management strategies. The Republic of Congo National TB Control Program (NTCP) faces major operating and organizational issues and identification of the issues would make is easier to implement collaborative programs (Linguissi et al. 2017).

Lack of integrated TB and HIV care in DRC

It has to be remembered that the chance of contracting TB in HIV positive patients is much higher in comparison to the normal patients, that is out of 1313 new TB patients 29 % have been found to be HIV positive (Shanks et al. 2015). There is a lack of a coordination body for both the programs, lack of common surveillance process and lack of collaborative approach for addressing the programs.

Lack of proper diagnostic methods

Another limitation is the lack of a proper, cheap and easy to use screening tool for detecting the active TB in adults and children. Advanced technologies such as PCR and GeneXpert MTB/RIF assay are not readily available in the rural areas (Lawn and Zumla 2012). But these rapid diagnostic techniques have not been implemented in Congo and the diagnostic technique is still confined to microscopy that is time consuming.

Rationale for choosing this disease

Poor infrastructure

Inadequate staffing, poor infrastructure, resources and limited diagnostic equipment pose threats to the successful integration of the TB services, in the economically constrained DRC (Linguissi et al. 2017).

International agencies

International agencies like WHO and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have been funding for the tackling the TB/HIV co-infection,  but as a  sub- Saharan African country it can be difficult to stick to the WHO guidelines or the generic recommendations might not be suitable for a given country (USAID, from The American people, 2017). For example as per the WHO guidelines, ionized based preventive treatment is recommended for the TB persons, but this has not yet been implemented in Congo. Furthermore DRC has to depend on outside donors for the implementation of any National programs. The global fund has funded the tuberculosis program in DRC.

The USAID health program initiated by the U.S government is the primary sector in Congo and has spent almost $182 million in the eradication of the communicable diseases like TB It had been serving approximately 24 million of people in nearly 178 health zones of DRC (USAID, from The American people, 2017).  The USAID have been providing both financial and technical assistance for the planning, implementation, surveillance and the evaluation of the local and the provincial annual operational plans for identifying the health related challenges. They have been improving the availability of important medicine (Kiefer et al. 2012). They also have been improving the financing of the DRC government by leveraging the funds from other countries. Other health actors involve WHO and CDC that are collaborating with NGOs and health care organization to design guidelines for managing TB in DRC.

• To develop appropriate framework for TB/HIV collaboration, integration and implementation.
• To establish a proper coordinating body for effective collaboration.
• Proper monitoring and assessment of the implemented plans.
• Conduction of joint surveillance system.
• Introducing HIV prevention methods.
• Ensuring control of TB infections in the in health care settings.
• Introduction of isoniazid prevention therapy.
• Proper funding for establishing TB/HIV collaborative programs.

Conclusion

In conclusion it can be said that although DRC had been trying its best to recover from the burden of the disease by adopting several health care strategies in collaboration with WHO or countries like U.S, the prevalence of TB could not be controlled completely. There are major bottle necks that come in front of any government intervention strategies rendering them inactive. USAID controlled by the U.S government plays an important role in the management of TB in DRC, but the government still needs to identify the synergistic relation between HIV and TB and there for a collaborative model is required for controlling this deadly disease. The government has to work on the infrastructure so that people get access to equal care.

Current strategies implemented by the government

In this module I have understood that global health is not only related to the health of population across the world but also refers to the ways how health across the globe could be addressed. While studying about the global health I have come across the complicated diseases and the conditions that the world is facing, especially the burden of diseases in most of the developing countries. In this report we had been discussing about the impact of tuberculosis in the republic of Congo. While going through various papers I have found that although the international organizations such as WHO have taken several measures or the government have adopted several strategies starting from National tuberculosis program or Millennium development goals but unfortunately none of the programs has brought about marked reduction in the death rate due to tuberculosis.

One of the implications of this knowledge is that global health education enables a person to follow a healthy lifestyle and incorporate changes in the atmosphere or the environment required to achieve the goals. The expression “global health” is mainly used to delineate the issues that are concerns of the whole world and not a single region. Any measure that has to be taken for a country should also address the world or can be implemented in other nations (Williams et al. 2016).  I have understood that there had been global health issues that are larger than the scope of a single nation. The transmission of plague, cholera, small pox and cholera can be linked to the transborder travel and trade. The recent cases of Zika virus, Ebola virus reminds us of the continuous impact of the transborder transmission of the diseases (Williams et al. 2016).

Knowledge of global health is necessary as it would allow analysis of the policies and the strategies taken up by the organizations to eradicate the clinical issue and it would also help to identify the loops and the gaps left in the strategies or to improve them. Further more knowledge regarding the global health also enables a person not to repeat the same mistakes such as a country might take precautions like mass vaccination beforehand, on hearing the spread of an endemic in the neighboring countries. Education for global health can only be given through mass campaigns, educational program and mass media. Internet and television have provided scopes for the news to reach even the remotest corner on the earth.

Challenges

Furthermore the study of this module gives us a clear picture of the working strategies of various international organizations like World health organization, The United Nation’s development program. This module would also provide information regarding the different environmental hazards. This would help us to be alert against any health crisis by the promotion of proper health education, proper sanitation and personal hygiene, proper screening and effective treatment. In a nutshell this would increase people’s quality of living and life expectancy rate of the population. We have understood that a stronger focus is needed in developing the precaution and the intervention strategies for addressing health in both the developing countries. The support strategies should be able to support social justice and equity.

References

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Henegar, C., Behets, F., Vanden Driessche, K., Tabala, M., Bahati, E., Bola, V. and Van Rie, A., 2012. Mortality among tuberculosis patients in the Democratic Republic of Congo. The International Journal of Tuberculosis and Lung Disease, 16(9), pp.1199-1204.

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Kalonji, G. M., De Connick, G., Okenge Ngongo, L., Kazumba Nsaka, D., Kabengele, T., Tshimungu Kandolo, F., … Giet, D. 2016. Prevalence of tuberculosis and associated risk factors in the Central Prison of Mbuji-Mayi, Democratic Republic of Congo. Tropical Medicine and Health, pp.44, 30.

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Kickbusch, I., 2006. The need for a European strategy on global health.

Kiefer, S., Knoblauch, A.M., Steinmann, P., Barth-Jaeggi, T., Vahedi, M., Maher, D., Utzinger, J. and Wyss, K., 2017. Operational and implementation research within Global Fund to Fight AIDS, Tuberculosis and Malaria grants: a situation analysis in six countries. Globalization and health, 13(1), p.22.

Kimbrough, W., Saliba, V., Dahab, M., Haskew, C. and Checchi, F., 2012. The burden of tuberculosis in crisis-affected populations: a systematic review. The Lancet infectious diseases, 12(12), pp.950-965.

Kurbatova, E.V., Taylor, A., Gammino, V.M., Bayona, J., Becerra, M., Danilovitz, M., Falzon, D., Gelmanova, I., Keshavjee, S., Leimane, V. and Mitnick, C.D., 2012. Predictors of poor outcomes among patients treated for multidrug-resistant tuberculosis at DOTS-plus projects. Tuberculosis, 92(5), pp.397-403.

Lawn, S.D. and Zumla, A.I., 2012. Diagnosis of extrapulmonary tuberculosis using the Xpert® MTB/RIF assay. Expert review of anti-infective therapy, 10(6), pp.631-635.

Linguissi, L.S.G., Gwom, L.C., Nkenfou, C.N., Bates, M., Petersen, E., Zumla, A. and Ntoumi, F., 2017. Health systems in the Republic of Congo: challenges and opportunities for implementing tuberculosis and HIV collaborative service, research, and training activities. International Journal of Infectious Diseases, 56, pp.62-67

Patel, M.R., Yotebieng, M., Behets, F., Vanden Driessche, K., Nana, M. and Van Rie, A., 2013. Outcomes of integrated treatment for tuberculosis and HIV in children at the primary health care level. The International Journal of Tuberculosis and Lung Disease, 17(9), pp.1206-1211.

Shanks, L., Masumbuko, E.W., Ngoy, N.M., Maneno, M., Bartlett, S., Thi, S.S. and Shah, T., 2012. Treatment of multidrug-resistant tuberculosis in a remote, conflict-affected area of the Democratic Republic of Congo [notes from the field]. The International Journal of Tuberculosis and Lung Disease, 16(8), pp.1066-1068.

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World Health Organization, 2015. Global tuberculosis report 2015. World Health Organization.