Tuberculosis: Threat to pregnancy among women at risk of diseases, more advocacies, screening needed – experts

Jomavid Pharmaceuticals Ltd, Surulere, Lagos celebrated this year’s World Tuberculosis (TB) Day, playing host to her community particularly pregnant women in a series of presentations by medical experts on the burden of tuberculosis in pregnant women at risk of the disease. In all, four health experts from different disciplines in relation to TB, who have made tremendous impacts in the prevention of TB in Nigeria, took turn to give their presentations at the occasion. These were Dr Olubunmi Ogbodu, a pharmacist and Consultant public health; Dr Kehinde Adesokan, a Consultant public health veterinarian; Dr Adebayo Awoniyi, a Consultant obstetrician and gynaecologist and Dr Oluwafemi Morawo, a Primary healthcare physician.

In her opening remarks, the CEO of Jomavid Pharmaceuticals Ltd, Dr Olubunmi Ogbodu said her company decided to celebrate this year’s World TB Day with a focus on the burden of TB among pregnant women who are at the risk of the disease maintaining that the burden of TB during pregnancy are grossly under-reported and constitute significantly to maternal mortality in developing countries. She maintained that clinical experience and data from the WHO show that TB remains a threat to conception and pregnancy. In her presentation, Dr Ogbodu reiterated her contributions to the fight against TB inclusive of sustained advocacies, the development of Private Sector Workplace TB Policy, saying that a number of private companies had signed the policy, and are currently using it. She listed the impacts of the policy to include the prevention of stigmatisation against TB patients in the workplace, increased access to screening and treatment for TB patients and greater commitment by employers in the private sector to support staff diagnosed with TB in addition to creating enabling environment for the prevention of the disease among occupational groups at risk of the TB disease. Dr Ogbodu stressed that there was the need to evaluate the methodologies used by field researchers on TB, saying that experience has taught her that carrying out surveys and advocacies among different occupational groups at risk of TB requires different approaches for it to be successful.

She explained further that TB advocacies would only produce the desired results when approached based on the principles of the WHO’s One Health initiatives. Citing the WHO, Dr Ogbodu said “One Health’ is an integrated, unifying approach to balance and optimize the health of people, animals and the environment. It is particularly important to prevent, predict, detect, and respond to global health threats such as the COVID-19 pandemic. The approach mobilizes multiple sectors, disciplines and communities at varying levels of society to work together. This way, new and better ideas are developed that address root causes and create long-term, sustainable solutions. One Health involves the public health, veterinary, public health and environmental sectors. The One Health approach is particularly relevant for food and water safety, nutrition, the control of zoonoses”.

Presenting on the zoonotic aspect of TB, Dr Kehinde Adesokan, Consultant veterinary public health, from the Department of Veterinary Public Health, University of Ibadan, corroborated Dr Ogbodu presentation saying there is the more need for researchers and clinicians working on TB to fully embrace One Health approach in tackling the burden of TB.

“Bovine tuberculosis (bTB) is a zoonotic infectious disease of great public health implication, the developing countries including Nigeria being the worst hit. The disease is more common among livestock workers through occupational exposure”. Referring to the research of his team, Dr Adesokan said “we documented a 2.86% prevalence of zoonotic TB among livestock workers in southwestern Nigeria. Consumption of unpasteurized cow milk, cohabitation with animals, overcrowding, high incidence of human immunodeficiency virus, malnutrition and poverty, all of which characterize most developing nations, including Nigeria, enhanced the prevalence of zoonotic TB in humans”. According to Dr Adesokan, drug addiction, smoking and alcoholism which are prevalent among livestock workers predispose to zoonotic TB. Worse still, most of these occupationally exposed individuals are unawares of their health status, resulting in delayed health-seeking behaviour. Dr Adesokan decried that the lack of bTB control measures in most developing countries facilitates transmission of zoonotic TB.

“Currently, the level of awareness of the zoonotic nature of bTB especially among livestock workers is still poor. This is evidenced by the continued cultural practices, such as consumption of unpasteurized milk and cohabitation with animals which are still prevalent among these individuals. While the Road Map for Zoonotic TB launched by WHO/OIE/FAO/IUATLD resonates that every TB case counts towards 2030 End-TB Strategy, factors enhancing zoonotic TB transmission, including poor knowledge and practices are still prevalent”.

In conclusion, Dr Adesokan said increased enlightenment campaigns especially among the occupationally exposed groups have become urgently imperative. He stressed the need for all-inclusive grassroots sensitization programmes against such practices that could enhance transmission of zoonotic TB in human population.

Dr Adebayo Awoniyi, a United Kingdom based Consultant obstetrician and gynaecologist, educated the audience why TB during pregnancy should be avoided at all costs. “According to the WHO recommendations (2022) on antenatal care for a positive pregnancy experience: screening, diagnosis and treatment of tuberculosis disease in pregnant women, TB poses a serious threat to the lives and health of pregnant women and their infants but is often not recognized during pregnancy and the postpartum period. It is crucial that TB disease and risk for TB progression are recognized and treated, to protect the health of the mother and infant,” said Dr Awoniyi.

Moreover, Dr Awoniyi took participants at the event down memory lane, saying active cases of TB during pregnancy was considered as a serious threat and in extreme cases as an indication for termination of pregnancy until the middle of the 20th century. Consequently, pregnant women who survived TB during the period were discouraged from getting pregnant due to high risk involved.

However, with the introduction of effective TB medication the situation improved and after adequate treatment of TB in women of reproductive age, no increased risk of relapse during pregnancy has been observed. He noted that the breakthrough in TB treatment notwithstanding, the burden of TB during pregnancy still continues to date, especially in Africa, hence the need to look into the approaches applied to the prevention and control of the disease.

According to Dr Awoniyi, clinical research reports have demonstrated that active TB disease during pregnancy remains associated with a substantially elevated risk for poor maternal and fetal outcomes, including a threefold increase in maternal morbidity ninefold increase in miscarriage, twofold increase in preterm birth and low birthweight, and sixfold increase in perinatal death among others.

He further corroborated his experience with WHO’s report saying “according to the WHO, each year, it is estimated that there are over 200 000 cases of TB among pregnant women. The global number of TB deaths increased in 2020, most likely as a result of coronavirus disease (COVID-19). Even though TB is a leading cause of death among young women in high-burden countries, it is not known how many pregnant and postpartum (after delivery) women die of TB, as these numbers are often not recorded by national TB programmes. However, it is known that pregnant women are at increased risk of developing TB disease”.

He maintained that apart from COVID-19, HIV remains another clinical condition that could predispose pregnant women to TB. Pregnant women living with HIV need to be critically screened because they are at particular risk from TB. Dr Awoniyi also quoted the WHO saying women living with HIV who develop TB disease in the postpartum period are twice as likely to die during the year following the birth of their infant than similar women who did not develop TB. Also, their infants are three times more likely to die during their first year of life, and are more likely to become infected with HIV. This shows that the burden of TB during pregnancy goes beyond the exposed mother and extends to the next generation, hence there is the need to do all possible to prevent TB among pregnant women. “This progression of the results of a mother having TB during pregnancy has been demonstrated to be a series of undesirable events. For example, there are confirmed reports from the WHO that the babies of women with TB are also at risk of being infected with TB if the mother has untreated TB disease when the baby is born. A baby who is infected with TB has a high chance of quickly developing TB disease” said Dr Awoniyi.

Another presenter at the occasion was a Saudi Arabia based Primary healthcare physician, Dr Oluwafemi Morawo. According to Dr Morawo, Primary healthcare (PHC) plays a vital role in the control of tuberculosis (TB) by providing accessible, affordable, and continuous care at the community level.

“Early Detection and Diagnosis of TB is very paramount in the prevention and control of the disease. Primary healthcare centers are often the first point of contact for individuals with symptoms suggestive of TB; these include persistent cough, weight loss among others. PHC facilities conduct initial screenings, might offer diagnostic tests like sputum microscopy and chest X-rays if the facilities are available or refer patients for further testing. Just like any disease, early detection and treatment forestall complications and offer cure”.

On treatment and medication management for TB, Dr Morawo maintained that PHC plays a key role in managing TB treatment, particularly for drug-sensitive TB. The care provider administers Directly Observed Therapy Short-course (DOTS), ensuring patients adhere to their medication regimen, which is critical for preventing drug resistance and achieving cure. The patients also have the benefits of discussing with the primary care physician issues relevant to their general health like Nutrition, drug’s side effects and managements. He further stressed that PHC promotes TB prevention through health education, vaccination (BCG), and screening of high-risk populations, including those with HIV, who are more vulnerable to TB. Contact tracing and preventive therapy for people exposed to TB are often coordinated at the PHC level.

“Generally, TB treatment is integrated with other primary healthcare services like maternal and child health, HIV care, and diabetes management. However, in our environment there are in addition, some isolated Centres designated for TB treatment. The integration helps address comorbidities and improves overall patient outcomes, especially in vulnerable populations.
Pregnant women diagnosed with TB or at risk should look out for Primary Health Centres in their Local Government Areas, designated as TB Centres. Start the Anti-TB medications and continue their antenatal visits. This way they can have and enjoy the benefit of wholistic care of primary health care” maintained Dr Morawo. Dr Morawo concluded saying “Untreated TB in pregnancy poses a high risk of increasing maternal mortality and infant morbidity and mortality. So pregnant women with the risk of having TB, are encouraged to seek medical help early enough in order to mitigate complications on themselves and their precious babies. This is my message on this occasion today; TB in pregnancy though challenging, is treatable!”

In her closing remarks, Dr Ogbodu thanked the guest speakers for their robust contribution to the prevention and control of TB over the years. According to Dr Ogbodu, the One Health approach is needed in addressing the burden of TB in pregnant women. She said in 2015, the United Nations (UN) Sustainable Development Goals (SDGs),3 which are fully aligned with the WHO End TB Strategy, were adopted. The SDGs have set the target of ending the TB epidemic by 2030 yet the progress made so far in Africa does not suggest that the target is being met. Dr Ogbodu maintained that nurses and midwives, medical doctors, veterinarians, pharmacists, public health workers, and environmental health workers among other health professionals all have to work together to end TB.