Challenges and perspective in the fight against tuberculosis in the Democratic Republic of Congo

The Democratic Republic of Congo (DR Congo), as an African country, has been classified as one of the poorest countries in the world with a weakened and paralyzed healthcare system with various outbreaks of infectious diseases such as tuberculosis (TB) and Corona Virus Disease 2019 (COVID-19)1. We realized that the healthcare system of DR Congo being fragile, poor, lacks major sophisticated medical materials, and equipment for surveillance, control, diagnosis, and management of certain infectious diseases, for example, TB, Ebola2,3. As the case maybe, TB, being a deadly infectious disease like COVID-19, Meningitis, Ebola, Bubonic, have been shown to kill millions of people in the world including the DR Congo3,4. This is a public health challenge in the DR Congo that needs serious attention. We found that the DR Congo’s healthcare system, being confronted with TB, needs an urgent eradication especially through the One Health approach at all costs within its national territory, because TB is a preventable and treatable disease despite the fact that the poor recognition in children and adolescents, and its difficulty in terms of diagnosis and treatment by healthcare providers5. The bacterium Mycobacterium tuberculosis, otherwise known as Koch’s bacillus has been implicated as the causative microorganism of TB. TB, as a communicable disease, is transmitted from an infected person to another person especially when the infected person with TB sprays tubercle bacilli into the air after coughing, thereby releasing aerosol droplets to the environment. As a matter of fact, TB largely affects the lungs and represents the usual source of transmission2. TB is a major public health problem in the DR Congo and is still a widespread disease in Africa where measures to curb its spread suffer from weaknesses related to financial constraints, the standard of living of the population, and the healthcare system in place6. As a part of EPI program, BCG vaccine is offered on national level between 0 and 11 months. It is definitely a tool that can help in eradicating TB but several other steps are required to ensure its complete implementation. Studies have shown that the DR Congo is among the 30 countries mostly affected by TB in the world2,7, ranking ninth in the world and second in Africa for susceptible TB, eighth in Africa for TB and HIV co-infection and multidrug-resistant TB7. In the year 2021, despite the occurrence of the COVID-19 pandemic, the DR Congo, through its National Tuberculosis Control Program (NTBCP), notified more than 216 690 cases of TB of all forms within its national territory compared to 2020 (less than 200 000) or even 2019 (178 000), including 120 724 men, 92 498 women, 28 750 children7,8. These statistics are alarming and frightening figures especially in the city-province of Kinshasa, taking the lead, with more than 29 841 cases, followed by Haut-Katanga (15 721 cases), Kwilu (12 757 cases), and South Kivu (12 375 cases)7. Ending TB by the year 2030 is one of the health targets of the United Nations Sustainable Development Goals. The WHO advocates the use of rapid molecular tests for the initial diagnosis of all people with signs and symptoms of TB. These tests are highly reliable and will make significant progress in the early detection of TB cases and drug-resistant TB. Rapid diagnosis and early treatment of TB can save thousands of lives5,7. In population such as a DR of Congo, both TST and IGRA’s use can be debatable. A low resource setting would favor TST more and it can play a role in diagnosis with but their use would be hindered since they can be false positive in people vaccinated with BCG. As for use of IGRAs it too cannot differentiate between active and latent TB. In the DR Congo, the fight against TB should be coordinated by the NTBCP, which should properly integrate a well implemented management protocol in health centers for the detection and treatment of TB, theoretically, with a minimum of equipment to meet the needs of the population. Although, since 2008, this management protocol has integrated systematic screening for HIV infection, but the introduction of new drugs has also been very slow, which is difficult to intensify preventive therapy against TB in the DR Congo9. For more effectiveness to curb TB in Congo, improved infection control measures in all public and private health facilities are needed to prevent the disease because many people contract TB by visiting health facilities for health problems other than TB. In DR Congo, the emergence of multidrug-resistant TB could be prevented by putting in place and implementing appropriate diagnostic and treatment strategies. These also include public health measures indirectly involved in curbing down the disease’s impact such as use of indoor stoves with better ventilation and even general dietary measures to reduce malnutrition and in turn susceptibility to TB. Its treatment is difficult and very expensive due to the poor response to conventional treatment with first-line drugs. In DR Congo, as in the rest of Africa, the cure rate for multidrug-resistant TB is low10. The country needs to step up and accelerate the response and remain committed to ending the suffering and death of people from TB. Health authorities should equally increase the capacity for free active TB screening by mobilizing teams and mobile units in the field and equip laboratories with GeneXpert machines for rapid TB diagnosis. GeneXpert if used as a routine test instead of standard care can be potentially effective. LAM as a tool for screening and diagnosing TB in HIV positive and HIV negative patients has an encouraging sensitivity and specificity (45 and 92%) and can serve as a good screening method but depends on the availability of CD4 cell count. In a resource limited population it can be a major deal breaker since access to CD4 count is limited and inconsistent at best. The country should also implement case-finding strategies using rapid molecular diagnostic tests as initial tests for TB diagnosis and adopt a universal screening and treatment approach. Even though the DR Congo has made progress in the fight against TB in recent years, several obstacles still stand in the way of efforts to end this preventable and curable disease, yet the impact on the disease control efforts has been particularly severe. At this rate, the global goals of eliminating the disease by the year 2030 seem increasingly difficult to achieve because of the disruption that the DR Congo’s healthcare system has suffered. We, therefore, urge the Congolese government to allocate a somewhat larger health budget for TB control. The fight should be multisectoral and health services (the One Health approach), and care should be supported by the government and not borne by the households (families) of people who are victims and vulnerable to the disease7. According to the WHO’s strategy to end TB, no person or family affected by TB should bear the catastrophic costs of treatment5 because of its socioeconomic influence, development determinants, such as undernutrition, diabetes, HIV infection, alcohol use disorders, and tobacco use. Finally, it should be noted that TB is also a social problem. Thus, reducing poverty and improving general living conditions such as housing and employment will go a long way in reducing TB transmission in the DR Congo. Ethical approval Not applicable. Sources of funding Not applicable. Author contribution A.A.: conception; M.O.O.: design; A.A.: administrative support; H.C.: supervision; C.B. and F.K.: literature search; A.A., M.O.O., and C.A.I.: manuscript preparation; A.A., L.S., and H.C.: manuscript editing; A.A., M.K.M., J.O., and M.O.O.: manuscript review. All authors contributed in final approval of manuscript. Registration of research studies Name of the registry: not applicable. Unique identifying number or registration ID: not applicable. Hyperlink to your specific registration (must be publicly accessible and will be checked): not applicable. Guarantor Hugues Cakwira, Faculty of Medicine, Catholic University of Bukavu, Bukavu, Democratic Republic of Congo. E-mail: [email protected]; https://orcid.org/0000-0001-7939-8848 Conflicts of interest disclosures There are no conflicts of interest. Provenance and peer review Not commissioned, externally peer-reviewed.