Monthly Archive for September, 2010

Grania: A Day with the CATTS (Part Two)

After my eventful day with Rose we headed out again to see a patient who had recently been started on TB treatment. Emmanuel was HIV-positive and had recently suffered from night-sweats, had a cough, and had lost 10kgs in a short period of time. He was referred to the TB service from Touch Namuwongo and had been so sick when he was seen by Dr Edith that he was immediately admitted into Hope Ward.

From what I understood, Emmanuel’s CD4 count (his level of immunity – an indicator of the severity of his HIV) was very low. He had abnormal liver test results and had become so weak that he was unable to walk. On the ward he was found to have TB in his sputum and had been started on TB treatment two weeks previously. As soon as things began to improve he was sent home.

On the way to Emmanuel’s house, Rose explained some of the misconceptions around TB that were held within the community, many of which she had believed herself before she attended Dr Richard’s training sessions.

TB is a considerably more severe illness in people with HIV-AIDS, and can cause someone to become very unwell very quickly (like Emmanuel). Before she became a CATT, Rose had only encountered TB when it was acquired by patients already infected with severe HIV. Many of these patients had died within weeks of being diagnosed with TB, often just after starting TB treatment. Because of this, she had believed that if you acquired TB you would die almost immediately.

On our community education visit earlier in the week, some of the people we talked to thought that TB was more dangerous and more fatal than HIV-AIDS. They were surprised to hear from Rose that TB is in fact completely curable if caught early and if treatment is taken correctly. Educating the community in this way has been one of the most important aims of the TB project. Ensuring that people realise that TB can be cured, and that free medical services are available, will hopefully help to save lives in this area of Kampala.

On arriving at Emmanuel’s house it was obvious that he is still very unwell. He was lying in bed and his daughter explained that he is still too weak to stand. I would estimate that he is at least five foot nine in height, but he only weighs 45kgs. I understand why the community fear TB so much, as his story was depressingly familiar.

Emmanuel had become sick quite quickly (over a period of two months) and had only just presented to Touch Namuwongo and the TB project in time. He had newly-diagnosed HIV (with a very low CD4 count) as well as TB and would probably have died if he had not received immediate treatment. Due to his weakness and liver problems he had only been started on the TB treatment, as the TB was the illness that would kill him first.

As his strength improves and his liver begins to tolerate the TB medication, Emmanuel will be started on the ARVs. (Both HIV and TB medication can cause problems with the liver so if possible you try not to start them at the same time). Although Emmanuel was a sorry sight, his family had already noticed a change in the two weeks that he had been on treatment. His appetite had returned and he looked slightly less gaunt.

Rose went through the usual checks on clean water and malaria prevention, as well as ensuring that his room (again, he shared a room with his family of five) was well ventilated and that he knew to cough covering his mouth, with any sputum produced disposed of in a safe way.

Another problem with treating TB is that it is a long course of treatment requiring eight months of tablets. Patients usually improve after three or four months of treatment and often don’t see the point of taking the large tablets for another five months when they feel and look better. We are aiming for the CATTS to reinforce the importance of completing treatment from the start to try and improve the high rate of treatment defaulters. Rose was showing her training as she patiently explained why the treatment is so long and how she will be supervising Emmanuel throughout this period.

These vulnerable patients live in small, crowded rooms, and the risk of infecting other family members is extremely high. This is something the TB project has yet to address, but as the service develops and systems strengthen it is definitely something that Dr Edith is keen to look at in more detail.