When is a cough more than just a cough?

A group of researchers, including two from the Centre for International Health (CIH), recently published a paper investigating the health care-seeking behaviour of Tanzanians with a cough. It was based on data from a large national tuberculosis prevalence survey undertaken in Tanzania. One of the authors, Professor Sven Gudmund Hinderaker, explains that such large national studies are important because the results provide such a broad overview of the national population. This particular study was one of the first such large national surveys to be undertaken in Africa.

The World Health Organisation (WHO, 2013) estimates for tuberculosis (TB) are alarming: in 2012, there were about 12 million cases of TB world-wide, and almost 9 million of them were new cases that year. Most of these have the infectious pulmonary type of disease. According to WHO, the estimated TB burden for Tanzania is about 176 cases per 100 000 people. However, based on the above mentioned survey, new, updated (and higher!!) estimates will soon be published.

How are people with TB identified?

In order to control the tuberculosis epidemic, the sources must be identified. This means “finding the coughers”.  Early identification and cure of TB is critical to helping to control the disease by reducing the spread of infection (i.e. via coughing).

In Tanzania, patients with TB are identified when individuals suffering from symptoms consistent with TB present themselves at health facilities. Presumptive TB is considered present when individuals have a cough lasting longer than 2 weeks. They might present other suspicious symptoms such as coughing blood.

Dr. Mbazi Senkoro, the paper’s first author, explains that the Tanzanian survey results revealed that only 31% of people who have symptoms suggesting TB actually sought treatment from the health care services. Furthermore, only 42% of this 31% sought further health care at sites with TB diagnostic capacity (i.e. overall, only 13% of those who should have been seeking attention). This means that many do not seek help in the earlier disease phases and only do so much later after they have already spread the bacteria in their workplaces and, most heavily, in their own households over some time.

How to encourage more “coughers” to seek health care?

Senkoro highlighted the National Tuberculosis and Leprosy Programme (NTLP) in Tanzania. It was one of the first such national programmes in the world to pilot the current global TB control strategy, pre-dating even global WHO initiatives in this area.

National Public Health systems, unfortunately, in Tanzania and globally, cannot afford to undertake regular population-level TB screening programmes on a national scale. A costly but effective initiative was undertaken in many European countries 50 years ago for identifying TB cases early: doing regular chest x-rays of the whole national population.

In the absence of such a costly national initiative, health services are reliant on the more passive approach of waiting for patients themselves to report to them. Programmes such as NTLP in Tanzania, are beginning to engage in “social marketing” - public education initiatives aiming to motivate more people to seek health care for TB symptoms. Some of these include using previous TB cases as peer educators and highlighting other TB symptoms. (For example, coughing as a symptom is regarded as being very common, especially among smokers, although smoking is not especially prevalent in Tanzania. People, generally, may not be aware that coughing may indicate more serious health problems.)

Personal economy is another factor that perhaps limits people from seeking health care. In Tanzania, TB health care services are provided free of charge after a patient has been categorised as having presumptive TB, or is actually diagnosed with TB. However, the initial costs of first seeking health care, both direct and indirect (food, transport, loss of income etc.) are not covered.

Valuable starting point

This study provides a valuable summary of the current situation in Tanzania with regards to people seeking health care for possible TB. The results document the need for further efforts to encourage more of the population having suspicious TB symptoms (i.e. a persistent cough) to seek care so that the prevalence of TB in the country can be reduced.

Read the article

Health care-seeking behaviour among people with cough in Tanzania: findings from a tuberculosis prevalence survey.
Int J Tuberc Lung Dis.            2015 June
Senkoro M, Hinderaker SG, Mfinanga SG, Range N, Kamara DV, Egwaga S, van Leth F.