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TB control activities hampered in certain districts: National programme director

26 May 2022

  • Notes lack of adequately trained manpower and mal-distribution across districts
  • Urges evidence-based approaches in TB diagnosis, care, prevention 
BY Ruwan Laknath Jayakody The lack of adequately trained manpower and mal-distribution across districts has hampered tuberculosis (TB) control activities in certain districts, Health Ministry National Tuberculosis Control Programme Deputy Director N.C. Pallewatte noted. These concerns were raised in an editorial on “Stepping forward for ending tuberculosis in Sri Lanka” which was authored by Pallewatte and published in the Journal of the College of Community Physicians of Sri Lanka 28 (1) in May 2022. Tuberculosis is a curable disease. With the use of correct drugs and dosage within the correct duration, tuberculosis can be completely cured and the further spread of the disease can be prevented. The above mentioned WHO report adds that since 2020, more than 60 million deaths have been prevented with the correct treatment. Tuberculosis is still prevailing in Sri Lanka. Annually, on average, 8,000-9,000 cases are reported to the National Programme for Tuberculosis Control and Chest Diseases (NPTCCD). Such patients are reported from all the Districts. However, as mentioned in the NPTCCD’s “Tuberculosis epidemiological review in Sri Lanka 2020”, more than 40% of the total case burden is from the Western Province, and the Colombo District accounts for nearly 25% (around 2,000) of the total tuberculosis cases. The effects of urbanisation, overcrowding, internal migration for jobs, poverty, and unhealthy lifestyles such as alcoholism and smoking may have contributed to the development and spread of tuberculosis.  However, per the NPTCCD’s “Tuberculosis database”, paediatric tuberculosis remains low (3% of the total case burden), yet high proportions are reported in Districts such as Kandy, Nuwara Eliya and Batticaloa. Sri Lanka maintains very low levels of multi drug resistance forms of tuberculosis which reflects the availability of a well functioning, properly monitored, tuberculosis control programme. Comorbidity with HIV is also limited to a very few patients (33 patients in 2020). Mandatory screening of HIV patients for tuberculosis and vice versa helps to detect and manage co-infection early, and to thereby reduce the number of deaths. The country continues to have nearly 85% of treatment success rates throughout the past several years. Yet, Sri Lanka still faces major challenges in reducing the prevalence, incidence and mortality of tuberculosis. According to the NPTCCD’s “Tuberculosis database”, although the loss to follow up rate has been brought down to very low levels with the dedication and commitment of the health staff (3.7% in 2019), the death rate among tuberculosis patients remains high (7.1% in 2019). Old age, co-morbidities and delayed diagnosis contribute to this high rate of deaths. To overcome the challenges and to accelerate the progress concerning the reduction of tuberculosis, Sri Lanka has adopted the Global End Tuberculosis Strategies in 2015. This Strategy was designed with a broad vision of “Zero deaths, disease and suffering due to tuberculosis” and aims to end tuberculosis as an epidemic by 2035. The countries are expected to reduce the incidence rate by 90% and the absolute number of deaths by 95% from the 2015 baseline values by 2035. The WHO’s “Global tuberculosis report 2015” noted that the catastrophic cost borne by families affected with tuberculosis should be zero during the process towards ending tuberculosis. Ending tuberculosis is not the responsibility of a single agency or a person as everybody in the society has a role in the prevention and control of tuberculosis. The commitment of the political leadership as well as the need to end tuberculosis as a priority by the Government is essential in this regard. The development and spread of tuberculosis depends on multiple factors including social and economic determinants.  Poor access to diagnostic and treatment services especially in localised settings, poverty, stigma, and cultural beliefs and myths may hinder seeking care for tuberculosis. Support from multiple partners including Government Ministries and institutions such as Local Government Authorities, social services, non-Governmental organisations, the civil society and community-based organisations is of utmost importance in addressing these issues including the elimination of poverty and empowering the community.  Though each stratum of the society is affected by tuberculosis, it is seen more among vulnerable populations including people who are under incarceration, and economically and socially marginalised populations. The approaches for ending tuberculosis should go hand-in-hand with promoting and protecting human rights, ethics and equity. Its success depends on the careful planning based on country needs with a good monitoring mechanism to assess the progress and to take timely mitigation actions. The NPTCCD’s current “National strategic plan for tuberculosis control 2021-2025” was developed to address the drawbacks on achieving the targets set for 2020 and already implemented under six main objectives. To lower the incidence of tuberculosis, the control of the spread of the disease through early detection and timely treatment is a must.  As such, the NPTCCD aims to improve case finding and successfully treat 50,000 cases of tuberculosis including 3,000 children during the five year National Strategic Plan period. Steps were taken to strengthen tuberculosis diagnostic facilities by widening the usage of WHO recommended rapid diagnostics islandwide and by including both x-ray and sputum examination as the initial diagnostic tests facilitating the early diagnosis of drug sensitive and drug resistant tuberculosis.  The NPTCCD continues to acquire WHO-qualified, quality assured, anti-tuberculosis drugs from the Global Drug Facility and ensures that quality drugs are prescribed at the consumer level. The treatment of the latent tuberculosis infection is one of the key components in reducing the incidence of tuberculosis and limiting the spread of the disease. Sri Lanka has included the management of latent tuberculosis as a National Policy and its implementation has been in progress island-wide since January 2022.  The NPTCCD hopes to expand the provision of tuberculosis preventive treatment in the coming years and expects to successfully treat, on average, 11,600 eligible persons, annually. The private sector has been identified as the first contact for health services for most of the patients with respiratory diseases.  However, according to the National Strategic Plan, significant delays have been observed between the first contact and the diagnosis of tuberculosis. In this regard, the NPTCCD is aiming to engage the private sector as well in tuberculosis diagnosis and care, with a target of improving the referral of 30% of the notified tuberculosis cases from the private sector. It is of utmost importance that evidence-based approaches are taken in tuberculosis diagnosis, care and prevention. Special emphasis is given in the National Strategic Plan for operational research and for the findings to be used for policy decisions on tuberculosis control. The sustainability of funding is also essential for maintaining the tuberculosis services and care.  According to the National Strategic Plan, with the improvement of the organisation and the management facilities with adequate monitoring and evaluation at all levels, tuberculosis control activities can be revitalised and strengthened. The current Covid-19 pandemic has created a significant impact on the path towards ending tuberculosis. Though services are maintained continuously throughout the period, clinic attendance was reduced tremendously in all districts due to frequent lockdowns and travel restrictions. People having respiratory symptoms were reluctant to seek care due to perceived stigma. Microscopy services were disrupted due to the fear of handling sputum samples. Active screening activities were not conducted.  As a result, according to the Health Ministry’s “Care pathways, care delays and correlates of care delays among pulmonary tuberculosis patients attending District Chest Clinics in Sri Lanka”, case finding was reduced by 1,176 cases in 2020 and bacteriologically confirmed cases by 805 cases when compared to 2019. The provision of Directly Observed Therapy was also affected, resulting in poor drug adherence, late conversion and possible reduction in treatment success.  With the re-establishment of the services and efforts taken to sustain quality services in a sustainable manner with adequate infection control, the country is back on track for ending tuberculosis, and the supportive systems, commitment and dedication of all healthcare workers, support rendered by multiple partners in tuberculosis care, will help to overcome hurdles and make this journey a success, Pallewatte elaborated.


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