Tuberculosis (TB) is a major global challenge. According to the 2023 Global Tuberculosis Report (GTR 2023), TB was the world’s second leading cause of death from a single infectious agent in 2022, after coronavirus disease, and it caused almost twice as many deaths as HIV/AIDS. Currently, it is estimated that more than 10 million people continue to fall ill with TB every year, and urgent action is required to end the global TB epidemic by 2030. The following article offers some general background on TB, before proceeding to highlight Eritrea’s multifaceted efforts to provide quality prevention and care services.
Background
TB, which has existed for thousands of years, is a potentially serious infectious disease that most often affects the lungs. In 1882, Dr. Robert Koch, a German physician who is widely regarded as one of the founders of bacteriology, announced that he had discovered mycobacterium tuberculosis, the bacillus that causes TB. Preventable and usually curable, TB is spread from person to person through the air and a person needs to inhale only a few of these germs to become infected. When someone develops active TB disease, the symptoms, which include prolonged cough, chest pains, fever, night sweats, weakness, and fatigue, or weight loss, may remain mild for many months. As a result, this can lead to long delays in seeking out care and frequently contributes to transmission of the bacteria to others. While all age groups are at risk of TB, the disease tends to predominantly affect adults in their most productive years. Additionally, people with compromised immune systems, such as those living with HIV, malnutrition or diabetes, or people who use tobacco or have alcohol disorders, have a higher risk of falling ill.
According to the GTR 2023, in 2022, the reported number of people newly diagnosed with TB was 7.5 million worldwide, with an estimated 10.6 million people falling ill with the disease. In total, around 1.3 million people died from TB. Although TB occurs in every part of the world and no country has managed to become “TB-free”, the vast majority of deaths and cases continue to occur in developing countries. For 2022, 30 high TB burden countries accounted for nearly 90 percent of the world’s TB cases and two-thirds of the global total was in eight countries: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh, and the Democratic Republic of the Congo.
Putting the spotlight on Eritrea
Since independence, Eritrea has made important strides in combating TB. At present, the country’s TB-related figures and progress are not only among the best in the surrounding region, they also compare quite favorably with continental and global averages.
According to data from the World Health Organization (WHO), while in 2000 Eritrea registered a TB incidence rate of about 177 per 100,000 population, in 2020 there were 2,873 TB cases (including HIV-associated TB) in the country, for an overall incidence rate of 81 per 100,000 population. For further context, in 2020 there were approximately 9,870,000 total cases of TB worldwide, with the estimated TB incidence (per 100,000) for Sub-Saharan Africa (SSA) and the world being approximately 230 and 130 cases, respectively. Moreover, while globally, TB incidence has been falling at about 2 percent per year and between 2015 and 2020 the cumulative reduction was 11 percent, in Eritrea the cumulative reduction between 2015 and 2020 was about 20 percent.
What is more, the national cure rate for TB has increased impressively, reaching approximately 92 percent in recent years. Notably, this is higher than the global recommendation from the WHO.
Eritrea’s success in combating TB is not down to one single factor. Instead, it is the result of several different things. For one, the country’s national health policy aims to maximize the health and well-being of citizens at all ages and seeks to ensure equity and access to essential health services at an affordable cost. All individuals that have TB (or a number of other diseases and disorders) are provided with free continuous care and quality treatments by the Ministry of Health (MoH). In addition to serving as a powerful reflection of Eritrea’s longstanding commitment to social justice and equality, this is critical to ensuring that TB patients (and their families) are not burdened by catastrophic financial costs as a result of the disease – something which is all too common in many countries across the globe. (Empirical work and international organizations suggest that due to TB, people face costs or suffer income loss equivalent on average to more than 50 percent of their income.)
Eritrea has also maintained a firm focus on prevention, diagnosis, and treatment. Prevention helps to stop people with TB infection from becoming sick, averts suffering, and saves lives. Through TB preventive treatment, not only are Eritreans protected from becoming sick, the risk of transmission in the community is significantly reduced. (Globally, it is estimated that people with active TB can infect 5-15 other people through close contact over the course of a year.) Furthermore, public campaigns and community awareness initiatives, which are conducted in all parts of the country, raise general understanding and reduce misconceptions, ultimately helping ensure that people with TB symptoms know to seek help. Meanwhile, efforts to improve early detection of TB have also been intensified, including through the training of village health workers nationwide. Ensuring that people are quickly and correctly diagnosed can allow them to get started on the most effective treatment regimen as early as possible.
Another important factor underlying Eritrea’s progress against TB has been the country’s efforts against some of the main risk factors or conditions that can impair the immune system, such as HIV, malnutrition, and undernutrition. Efforts against HIV go closely hand in hand with the fight against TB since HIV and TB form a lethal combination, each speeding the other’s progress. Worldwide, people living with HIV are approximately 18 times more likely to develop active TB disease than people without HIV. In Eritrea, as a result of the sustained implementation of high-impact interventions and a well-coordinated, comprehensive multisectoral approach, notable success has been achieved in halting the spread of HIV and sustaining a steady decline in prevalence and incidence. Based on recent estimates from UNAIDS, HIV prevalence among adults (aged 15-49 years) in Eritrea was approximately 0.4 percent in 2022, down from 1.1 percent at independence in 1991. Additionally, in terms of incidence, it has declined from about 1.37 per 1,000 uninfected population (across all ages) in 1991 to 0.06 in 2022.
In terms of nutrition, Eritrea’s Health and Nutrition program, led by the MoH, in partnership with international organizations and partners (such as UNICEF), works to prevent and treat malnutrition and micronutrient deficiencies across different population groups and within various parts of the country.
Alongside all of the above, Eritrea has a high Bacillius Calmette-Guerin (BCG) vaccination coverage rate. Developed and introduced in the early decades of the 1900s by French bacteriologists Albert Calmette and Camille Guérin, BCG is considered the world’s most widely used vaccine. Although it offers limited protection against TB in adults, it helps to protect young children against severe forms of TB. (It is sometimes offered to adults who are at risk of TB, such as some healthcare workers.)
Today, BCG is primarily administered in low- and middle-income countries as a simple, cost-effective intervention against TB. In Eritrea, at birth (or within a few days of being born), almost all newborn children receive a dose of the BCG vaccine. Since 1998, the country’s BCG vaccination coverage, defined as the percentage of one-year-olds who have received one dose of BCG vaccine in a given year, has been extremely high, averaging about 97 percent – a figure that is much higher than both the global and SSA averages.