Uganda registers improvement in Tuberculosis treatment success

By Esther Nakkazi

Uganda was in the for a celebratory World Tuberculosis day last month after the country recorded improved treatment success and increased TB diagnosis capacity.

Treatment success is about 82 percent of the TB patients in Uganda from 75 percent in 2018 although public health experts want a 90 percent treatment success and advise that to get to that all regions should be at the same level.

The Karamoja region in North Eastern Uganda is one of the high burden regions with a TB prevalence rate ten times higher than the national average. The treatment success rate in the Karamoja region was below 50% until an emergency response was declared in 2019. 

“Even in Karamoja sub-region 80 percent of all people treated for TB were cured in the last reporting period, up from 52 percent successfully treated at the start of 2020,” said USAID Uganda Mission Director Richard Nelson at Uganda’s World TB Day National Commemoration event in Moroto. 

TB is the world's deadliest infectious disease, infecting about 10 million people and killing 1.5 million globally each year. Uganda is among the 30 high burden TB and HIV countries in the world.

As dangerous as TB is, it is treatable and curable but in Uganda TB disease still causes illness in about 90,000 Ugandans annually including 1,500 people who get infected with drug-resistant TB. And in Uganda, about 15,600 people died from TB in Uganda in 2019.

Furthermore, in 2019, of the estimated 1,500 multidrug-resistant TB (MDR-TB) cases, only 559 were diagnosed and notified to the National TB and Leprosy Program (NTLP)

“The treatment coverage rate has improved in Karamoja improving the national rate and ending deaths due to TB has improved,” said Dr. Jane Ruth Aceng, the Minister of Health during the National World TB & Leprosy Day events held in Moroto District found in Karamoja region.

The region also became the home of the U.S. government's Accelerated Control of TB in Karamoja program or PACT Karamoja supported by the United States Agency for International Development (USAID) launched last year.

USAID's PACT Karamoja program is a $7.5 million agreement (2020-2025) that aims to address the Karamoja Region’s high TB prevalence and low treatment success rates by supporting locally generated solutions to mobilize health facilities, village health teams, and community members for accelerated screening, testing, identification, and successful treatment and prevention of TB.

In 2018, the U.S. launched the Global Accelerator to End TB to support countries in reaching the ambitious global targets of diagnosing and enrolling 40 million people on TB treatment and enrolling 30 million on TB preventive therapy by 2022.

“Everyone who is sick should get treatment. This will minimize the risk of passing the infection to others and reduce deaths in the community due to TB,” said Dr. Stavia Turyahabwe, the Assistant Commissioner for the Tuberculosis Leprosy Control Unit at the Ministry of Health.

While there is progress many people who are sick are unaware and deaths from TB are an estimate as most of the cases are not followed up. In 2019, 65,897 TB cases were diagnosed and notified to the NTLP (75 percent); this means that approximately 25,000 cases were either not diagnosed or diagnosed and not notified to the NTLP.

The government has decided to step up awareness and improve TB treatment-seeking behavior. According to the Ministry of Health in Uganda, only 46% of the population is aware of TB and about 40% of the people with signs and symptoms of TB do not seek care for TB services.

“We are instituting mortality TB audits. Although we cannot stop death completely, we can save some lives by understanding the circumstances around death,” said Dr. Turyahabwe.

She said death is occurring in the first few days of initiation of treatment but this is due to delayed diagnosis, limited awareness of the disease and not completing treatment.

“We are also encouraging our facilities that have big numbers of patients to have clinic days so that patients come on appointment and are seen on specific days and share information among themselves,” said Dr. Turyahabwe. This will improve adherence and reduce stigma.

Supported by USAID and other development partners, Uganda has also made milestones in the Treatment Success Rate of Multidrug-Resistant TB (MDR-TB) treatment due to increased roll-out of GeneXpert machines, decentralization of MDR-TB care to regional referral hospitals, and improvements made to the specimen transport system.

Uganda also has the national TB Supranational reference laboratory which is responsible for testing samples that are suspected to be MDR of those that are supposed to have sensitivity for different drugs. The Supranational reference laboratory receives samples from over 22 countries across Africa and is a regional center of excellence, receiving samples for reference testing. 

“We have expanded diagnostics like GeneXpert technology from less than 50 machines to over 280 GeneXpert instruments. Although we continue to use our conventional methods of smear microscopy for follow-up with patients on TB treatment, the GeneXpert technology has eased so much in this finding of tuberculosis,” said Dr. Diana Atwine, the permanent secretary at the Ministry of Health.

However, the Ministry acknowledged that an increased rollout of GeneXpert instruments is required and strengthening of the specimen transport system is required as well as increasing access to X-Ray and radiology services in the country including making the services available at the community level through targeted outreach programs would create better outcomes.

Among the challenges, Uganda is facing is increasing mortality among TB/HIV co-infected patients.
About 8,500 people died of TB/HIV in 2019. The ministry of health intends to improve case finding and treatment of people co-infected with TB/HIV and reduce deaths.

Dr. Atwine said they have introduced testing for TB using urine for people living with HIV who are severely ill and unable to produce sputum which too has eased the diagnosis.

In the Karamoja region, while officiating at the World TB day, Dr. Aceng urged community leaders to support the TB program for sustainability. The Ministry of Health which she heads also wants more community engagement and has implemented a National TB Civil Society Organization (CSO) Engagement strategy as well as approved the National Community TB Operational Guidelines in 2019.

With the engagement of community actors studies have demonstrated that these can contribute to increased TB case-finding, TB Preventive Therapy (TPT) uptake, TB treatment support and retention, and awareness about TB. For example, in 2019, 25 percent of TB cases notified in three USAID-supported districts were referred by community actors.

“As individuals, raise awareness about TB, encourage people to seek help early, and support those in care to complete treatment. Support every person with TB to complete treatment for TB,” said U.S. Centers for Disease Control and Prevention (CDC) country director for Uganda Lisa Nelson speaking at the event in Moroto.

Over the last 12 months, there was a 43 percent increase in the number of TB cases identified and a more than doubling in the number of cases successfully treated compared to the prior year. 

This is an important milestone to achieve during the first year of PACT Karamoja implementation amidst COVID-19 in a region with a high burden and past low performance, said Nelson. 

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