Tuberculosis (TB) is a complex and difficult disease. That is why the fight against this age-old affliction has not been won. It is highly infectious and, if left undiagnosed and untreated, puts our employees and our local communities at risk. As the global public and private sectors and civil society mark World TB Day on 24 March, Dr Brian Brink, chief medical officer at Anglo American explains why in the longer term we need an effective vaccine, improved diagnostics and better medicine to tackle this deadly disease.
A disease that knows no boundaries
TB has been around for centuries and is prevalent in the developing world and disadvantaged communities. Worldwide there are about nine million new TB infections each year. Of these, only six million are properly diagnosed and treated, which means that three million are “missed” by health systems and therefore do not get the required TB care. Approximately 1.3 million people lose their lives to TB each year; 320,000 of these also suffered from AIDS. People should not be dying from a curable disease today.
That said, TB bacteria are resilient, often remaining live and airborne for several hours in aerosolised droplets from the cough or sneeze of an infected person. As confined spaces are ideal breeding grounds, there is little wonder that overcrowded and poverty-stricken communities report a high TB incidence rate. In southern Africa, where Anglo American has many of its operations, disadvantaged communities often live in close quarters to the mines with little sanitation and poor nutrition. As a result, TB thrives, often going undetected and untreated for a long time.
Tip of the iceberg
TB is difficult to diagnose as it can manifest in the human body in a number of ways. A particular problem is that of latent infection – approximately two thirds of the South African adult population have been infected with TB at some stage in their life, but have controlled the infection through an effective immune response. A small proportion of those infected will progress to active TB disease, but it is difficult to separate these few out by conventional means. In disadvantaged settings, a person with pulmonary TB is likely to infect 10 others before he or she is diagnosed and treated.
Medication to cure TB requires strict adherence for a six-month course of treatment. Poor adherence could cause the treatment to fail altogether or result in Multi-Drug Resistant (MDR) TB. Worldwide about 500,000 people develop MDR TB each year and only one in four of these sufferers are diagnosed and properly treated. The MDR TB treatment programme is prolonged, expensive and difficult, often with disabling side effects from toxic drugs.
MDR TB is a huge threat worldwide and we have to stop it now. That means no failures in finding, treating and curing TB in populations at high risk – a massive improvement in performance is required. We must reach the missing 3 million people and ensure they receive quality care.
And this is only the tip of the iceberg.
The face of AIDS
The face of AIDS in southern Africa is TB – the most common opportunistic infection that affects people living with HIV. Since the onset of the HIV/AIDS epidemic, the incidence of TB has escalated dramatically. Among the 22 high TB burden countries that account for 80% of the world’s TB cases, South Africa has the highest incidence of TB infection and the highest burden of TB/HIV co-infection. Contrary to the worldwide trend of falling TB incidence, the rate of new infection in South Africa has been increasing. Only recently, with the scaling up of effective antiretroviral therapy for HIV infection, are there signs that the country will be able to reverse the trend.
Digging deeper
TB is an acute problem in the mining sector, because occupational lung disease in the form of silicosis predisposes affected individuals to TB infection.
The World Bank cites the following statistics to demonstrate how mineworkers are exposed to multiple factors that compound their risk of TB infection:
- Mineworkers are at twice the risk of the general population, because of migrant labour
- Mineworkers with HIV face three times the risk
- Mineworkers with silicosis are at six times the risk
- Mineworkers with silicosis and HIV are at 18 times the risk
Mining companies have to work hard to eliminate all of these risk factors if they want to make progress in stopping TB. At Anglo American’s current mines, we have reduced the incidence of silicosis to almost zero. Great attention is paid to the living conditions of employees and our HIV prevention and treatment programmes are at the leading edge of current practice.
Finding treatments and systems that work
In the longer term, we need an effective TB vaccine, improved diagnostics and better medicines. While we wait for these developments, we need to work towards a population-based prevention and treatment plan using the tools we have got. We cannot simply rely on individuals to present with TB in the early stages of active disease; we have to go out and look for TB if we are going to catch it in time.
Improving performance in TB management requires much better health information systems and electronic patient records. It is time to use the new information technologies available today to help standardise TB management and treatment protocols, to ensure adherence and to secure complete follow up in all cases.
By using cloud-based information technology, the difficulties with referral of patients from one treatment site to another distant site can also be overcome. Anglo American’s Dr Jan Pienaar has developed such a system called “theHealthSource” – see here http://bit.ly/1hVTnWC. The use of this system in HIV and TB management has been a major contributor to bringing the TB incidence at our Thermal Coal mines down from 937 per 100,000 population in 2006 to 340 per 100,000 in 2013. We are seeking to share this system widely within the mining industry and with government health services as a significant contribution towards managing the TB and HIV epidemics in Southern Africa.
Another area of strategic focus for us is strengthening healthcare systems in under-serviced rural areas and building partnerships to improve access to quality healthcare. Anglo American has been a strong supporter of the Global Fund to fight AIDS, TB and Malaria since its inception (see www.theglobalfund.org). The World Health Organisation-hosted Stop TB partnership (see www.stoptb.org) is also making massive strides in awakening governments, the private sector and civil society to the pandemic. In the search for an effective TB vaccine, we are working with AERAS, a non-profit biotech that is bringing new vaccine candidates to clinical trial (see www.aeras.org).
However, we must do better. Although Anglo American’s TB incidence rate is in line with the national average in South Africa, this is still not good enough.
Game plan: Get everything right
An important part of the solution is getting everything right. This means stepping up TB and HIV case detection, initiating early treatment, ensuring adherence, tracing contacts, improving living conditions, mitigating the detrimental social consequences of migrant labour, ensuring cross-border continuity of care and harmonising treatment protocols across multiple different health service providers.
In this day and age, there is no reason why people should be dying of TB. With early diagnosis and early, effective treatment for both HIV and TB, supported by an integrated health information and management system and with continuity of personalised care, it can be beaten.