Dr Samuel Akingbesote, the Oyo State Manager for the Institute of Human Virology Nigeria (IHVN), in this interview with SADE OGUNTOLA, explains the role of nutrition in the prevention and treatment of tuberculosis (TB) and why children have a higher chance of contracting TB, among other issues. Excerpts:
WHAT role does nutrition play in preventing tuberculosis generally?
Nutrition and tuberculosis (TB) are situations of public health importance and impart on each other. Malnutrition, particularly undernutrition, increases the risk of people coming down with TB; likewise, tuberculosis will also worsen malnutrition. So, taking care of one and leaving the other will not allow for better outcomes in TB treatment and prevention.
The World Health Organisation (WHO), in its 2023 global report on TB, mentioned undernutrition as a leading risk factor for people coming down with tuberculosis. Adequate intake of both macronutrients and micronutrients is important for good immune function. Once the immune system is affected, it gives room to infections, giving them access to the body. That is why this is significant and both should be addressed.
A quarter of the global population is estimated to be infected with Mycobacterium tuberculosis bacilli, the organism responsible for tuberculosis in their bodies. They don’t have the active form of the disease. However, they need their immune system to be optimal so that there is no progression from TB infection to active TB, which is the diseased stage of tuberculosis. One of the ways to ensure this is through the intake of an adequate diet that consists of various classes of food in the right amounts to boost the body’s immunity and guard against infections, including TB.
Based on WHO recommendations, there are no prescribed specific nutrients or dietary supplements to prevent individuals from coming down with a TB infection. But the obvious thing is that, with an adequate diet, there is no need for nutritional supplements or multivitamins. However, on rare occasions, when an individual, not just someone with TB alone, requires a nutritional supplement, it might be considered.
How does poor nutrition impart the effectiveness of the TB treatment?
It is common knowledge that a TB patient on treatment requires adequate nutrition to aid recovery. Without an adequate diet, the disease condition may worsen, resulting in either death or the disease relapsing into active TB again. That is why, from the start of TB treatment, they are counselled on the need for balanced meals to build worn-out tissues, give energy and check wasting.
However, there is no dietary restriction for TB patients; what is important is to eat a balanced meal based on the available food items in their locality. But it is advised that they avoid highly refined or processed foods, smoking and alcohol. Those who consume a lot of alcohol stand a higher risk of coming down with TB because alcohol lacks micronutrients essential for building the body’s immunity. It can also worsen the treatment outcome for individuals receiving TB treatment. Avoiding the intake of sugary foods, including carbonated drinks, is important.
Coffee is a stimulant; usually, TB patients are restrained from taking any addictive substances. If care is not taken, there is a tendency for them to forget to take their TB drugs. Also, there is the possibility of drug-drug interaction affecting the efficiency of their medication, as smoking can put them at risk of relapsing back into acute TB or worsening the outcome of the TB treatment. Regardless, they also need to maintain good cough etiquette and ensure that they don’t dispose of their sputum just anywhere after coughing.
Are there any medications they must avoid to prevent drug-drug interactions?
Before treatment, the medical history of the patient is taken. It is important to rule out possible drug-drug interactions. There are no medications that they are warned against taking. But it is important that if someone has TB, the medications be modified to take into consideration their other health conditions, like diabetes or even HIV. So, people with TB must be open to their care provider about the other drugs they are taking so that their prescription can be modified if the need be, to avoid them interacting with the TB treatment.
How can nutrition interventions be integrated into TB control programmes, given the importance of nutrition in ensuring a cure?
I will paint the scenario of a multidrug-resistant TB patient; the reason is because of the possible effect of nutrition on the treatment outcome, knowing the nature of drug-resistant TB. What the national TB programme and the TB partners advocated for was that people be supported with an adequate diet to complement their TB treatment. However, with the dwindling of donor support, nutritional support for TB patients has decreased. This needs to be incorporated into the food security policy of the government. In conjunction with the TB programme, the nutrition unit of the Ministry of Health and the primary healthcare development board can identify these individuals and link them with the nutrition programme that supports those who are undernourished. This is because a TB patient, until proven otherwise, is also malnourished. Nutrition is one leading factor in TB infection and the progression of TB disease. A TB patient is a potential individual with undernutrition.
How common is TB in children and what are the risk factors for it?
Tuberculosis is a contagious disease caused by Mycobacterium tuberculosis. It is airborne and affects all age groups, social status and gender. TB disease affects virtually all parts of the body, although, in 70 percent of cases, it affects the lungs. WHO estimates that between 12 and 15 percent of all TB cases identified by any nation would be in the paediatric age group. That is quite a lot. So, for a country like Nigeria, the estimated TB burden is about 470,000 cases annually and, at least, 70,000 of them are children.
In children, the age group that is worst affected is from zero to five years old, because their immune system is just developing. Also, the rate of progression from TB infection to TB disease is faster in them than in adults. The risk of the infection progressing very quickly is also dependent on the volume of bacilli received by the child and the age. Whenever you see a child with TB, it means that there is an adult with TB around who has infected that child. So it is a good opportunity to do what is called a reverse contact investigation to look for that adult or older person who possibly must have infected the child.
What are the common risk factors for TB in the case of children?
The commonest risk factor for TB in children is close contact with a person with infectious TB disease. Other reasons include conditions that weaken the immune system, such as HIV, the use of steroids because of medical conditions, undernutrition and juvenile diabetes. Risks for TB exposure include overcrowding, undernutrition and poor household conditions.
What should parents do if their child has been exposed to someone with TB?
Once they have this information or it is obvious that a child has been exposed to an adult or someone around them with TB and they know this person is on treatment, they should approach the nearest facility to complain and possibly also to work with that adult or individual that has tuberculosis who is not on treatment to see if they can seek treatment. Treatment for TB is free. There must be screening to be sure that the child is not already infected with the TB bacteria. However, if the child is not exhibiting any signs or symptoms, they will then also do a further clinical evaluation, and they can now place the child on TB preventive therapy.
What are the symptoms and signs of TB in children?
Unlike in adults, where we have a clear-cut symptom of tuberculosis, for children, most times, we have nonspecific forms of presentation. But once you have a child that has been coughing for two weeks or more, you must investigate; once you have a child that is not gaining weight or has gained weight but is now losing weight, a child that is not thriving or a child that is not growing the way he should, then you should consider TB; a child that has had a fever for two weeks or more and we’ve ruled out various ailments, then you should consider tuberculosis; or if you have a child who is lethargic, not interested in what goes on in the environment with all these other symptoms, you should consider tuberculosis. Other symptoms could be swollen lymph nodes on the neck, swelling on the back, loss of appetite and sweating at night. The older children present with symptoms just like adults. The most common symptoms of active TB in older children include coughs that last for more than two weeks, weakness, loss of appetite, weight loss, fever and sweating at night.
How do you explain the common misconception that children cannot have TB?
Children can come down with TB inasmuch as they are breathing, because the organism responsible for TB is in the air and you just need an individual who is not on TB treatment to spread it. So, healthy individuals, whether young or old, only need to inhale the bacilli and then they may come down with a TB infection. However, children are at risk of progressing from TB infection to active TB within months because their immune system is not fully developed. So, it is a misconception that children, including new babies, cannot have TB.
Importantly, because TB can have long-term effects on a child’s health, prompt and adequate treatment is essential. Very young children are more likely than older children to have TB spread to other parts of the body through their blood stream to cause long-lasting damage. It can also cause infections of the bones, spine, brain covering, spinal cord, lymph nodes, glands and so on. TB is associated with various complications; when the lung is destroyed, it collapses and thus causes difficulty breathing. When TB affects the backbone, it can bring forth a form of deformation that will change the posture of that child, resulting in the child bending over or having a hunchback. It can also affect the child’s neurological functions when TB affects the covering of the brain and the brain tissue. So, if a child is observed not to be doing well or sick, don’t just go over the counter to get drugs for treatment; rather, take the child to the hospital for proper assessment and treatment.
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