Tuberculosis Infections and Healthcare in Brunei

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Introduction

Tuberculosis is a respiratory killer disease and it poses a health risk to the lives of many people in different parts of the world. Cases of tuberculosis are higher in the South East Asian countries. This assertion implies that Brunei, being one of southeast Asian countries, tuberculosis is a great health problem to her population and has been listed as one of the leading causes of mortality and morbidity. However, Brunei does not have advanced medical facilities and schools and hence refers to the healthcare systems of both Malaysia and China and seeks to improve its systems to reach such advanced standards.¹

The largest human population in Brunei has been suffering from the infections of tuberculosis for a long time. The history of TB cases in Brunei date back to 1958 when the government introduced the TB services in the old hospital, and since then the notifications and relevant TB statistics are frequently sent to the World Health Organisation (WHO).^2.The country remained with a single health unit for TB cases where for referral, admission, and treatment of all TB infection cases, until 1984 when the government, through the help of WHO, introduced the same services in Ripas hospital. However, the services have currently extended to all major health facilities such as SSBH, KB, and Tutong hospital. In addition, voluntary community health service is being offered at homes and combined with volunteers who fight against malaria in the rural though greater population lives in the urban areas.

Current Measures for Containing TB in Brunei

All cases of pulmonary TB found to be smear-positive or culture-positive and less infectious are considered highly infectious^3. However, infected patients are isolated for an unspecified period until when found not infectious and hence discharged. There are special wards in every district chest-clinic health facility preserved for the isolation of TB infected patients. For instance, Tutong hospital has been having a TB isolation unit since July 2009 where infectious cases such as SARS, Influenza, and TB cases are referred until they aretreated^4.

However, going by the history of tuberculosis infections and health policies, it is evident that tuberculosis is not only a killer disease but also an economically hazardous disease that has been a matter of concern for the government and other international health organizations. In October 1995, an awareness campaign on TB stagnation and the increasing trend of new infections was launched in Tutong hospital. The public campaign aimed at the creation of public awareness in the increasing health risks resulting from TB infections and educating the public on how to prevent themselves from being infected. Another historical event on matters of TB infections took place from 1^st to 20^th July 1999 with the visitation of the WHO consultants to Brunei and recommended the formation of the National Tuberculosis program that was launched later on 29^th March 2000.⁵

The formation of the National Tuberculosis Program (NTP) was driven by the ideology that the integration of various disciplines would greatly help in containing TB infections with regard to prevention and control of TB in the country. NTP guidelines were prepared based on the WHO guidelines in an effort to ensure that health personnel practice uniform and standardized measures of data control for the TB at all levels of healthcare across the world^6.This aspect implies that NTP operates under the guidelines of the WHO, which standardise all sorts of measures taken for the TB prevention and control across the world. However, not all world countries apply the WHO guidelines in the prevention and control of TB as developed countries have adopted their own unique way of dealing with the problem due to their advanced modern technology and knowledge in the healthcare.

According to the NTP, the available chest clinics in different hospitals are responsible for diagnosing and in some cases giving initial chemotherapy for about two months and in extreme cases that demand maintenance of at least four months, decentralisation of patients has to be done at specific health centres and MCH clinics^7. In addition, the chest clinic facilities are mandated with a crucial role of recording the data and periodic reporting of TB cases to the NTP for further consultations and decision making at the national level.⁸

NTP, being an integration of different healthcare units and profession, is headed by the countrys director general of health services and the rest of the committee members consist of directors of health care services at the national level. They include environmental health services, hospital services, medical pharmaceutical services, radiology department, disease control unit, epidemiologist, national principal nurse, senior scientific microbiology research officer, and senior supervisor of health education.⁹

However, the above NTP committee has various responsibilities that are of great importance in the fight against tuberculosis in Brunei. These responsibilities include the definition of national strategies for diagnosis and treatment policies in an effort to ensure uniformity in prevention and control of the disease in all health facilities. In addition, the committee is responsible for planning, implementing, and evaluating NTP projects and preparing their budgets and execution plans. The committee also ensures that the government of Brunei and other stakeholders give high priority to the NTP in the allocation of financial, human, and other relevant resources in an effort to ensure smooth running of the program independently of the other national factors such as economic growth and development^10.Moreover, the NTP committee is responsible for ensuring that laboratory equipment and facilities are up to date in ensuring sputum smear-microscopy services and culture services for TB detections are in good conditions. Additionally, the NTP committee ensures that there is regular and independent supply of anti-TB drugs and other relevant medical equipment from the government and other stakeholders. This aspect ensures that the trend of TB cases is always under check and it is in a position to launch a quick action against slight detection of the rise of the vice. The NTP committee is also responsible for the supervision of health facilities/DOTS centres and ensuring quality training of health workers by the health training institutes in the country. Lastly, the NTP committee consolidates and evaluates submitted reports on the notified cases and results of treatments from the health workers at chest clinics across the country.¹¹

Looking into the mission statement for the National Tuberculosis Control Programme for Brunei, one gets the image of an active organisation whose vision is to zero-rate the tuberculosis cases in the nation. The most attractive statement in the mission says that NTP will ensure that good quality services are made available and accessible to those in need. The objectives of NTP are first, to reduce the annual infections by at least 7% per year^12.Second, to reduce the prevalence of sputum cases by at least 7% per year and finally reducing the mortality rate to as low as at least one person per 100,000 people in a population^13.The government and other health stakeholders are hopeful of achieving the goals of NTP, but there are factors that would greatly contribute to the realisation of the goals.¹⁴

Identification and Diagnosis of TB Cases in Brunei

Under the current measures of containing TB cases in Brunei, the first component to the service delivery of NTP is the case finding^15. TB infected individuals are identified through having signs and symptoms of TB. The rationale of identification is through focusing on the examination of sputum smear for patients aged 10 years and above and this rationale is effective due to two great reasons. First, the microscopic test has a higher chance of success in the detection of infectious bacterium like is the case of tuberculosis and other diseases that are caused by a bacterium^16.Second, the majority of infected patients fall into this age group due to lesser heath attention they receive as compared with the children of age less than 10years old. This rationale is essential for the early identification of TB cases because the bacterium cannot withstand the effects of available TB drugs as opposed to when they are identified at later stages of development.¹⁷

In order to ensure uniformity of diagnostics offered to patients, the NTP set policies that must be adhered to by all health workers in Brunei. First, the NTP demands that a health worker, who is working on a TB case, must use the direct sputum microscopic test as the primary diagnostic tool for identification of a case. In addition, in a case where other advanced health facilities such as culture and PCR are available, they too are acceptable for use as primary diagnostic tools^18.

After the identification process, an identified symptomatic case undergoes a smear examination process for initial diagnosis before the initiation of treatment. This process precedes other tests that confirm the validity of initial results. At this stage, the subject is not confirmed to having extra pulmonary tuberculosis regardless of having the results of x-ray.¹⁹ Smear examination is believed to be a near perfect test, but in case of yielding negative results, x-ray together with other tests are applicable. However, x-ray is not a reliable test for tuberculosis due to medical reasons, but rather results of sputum microscopic results are used regularly in the treatment process.

Comparing Brunei with China and Malaysia

Brunei is a small and developed country whose majority of population lives in the urban areas, hence implying that its urban areas are densely populated and hence infectious diseases pose a great health risk to her population^{20, 21.}Although Brunei has a small population of about 400,000 people, it is considered a developed country because of high Gross Domestic Product (GDP) per capital, but its yet to get to the level of the first world countries. Malaysia can be classified as a fast developing country as it has not yet gotten into the economic levels of a developed country, but it could be classified as a second world nation because it is bigger than Brunei and much developed in terms of infrastructure. China is a developed country with sufficient capacity to deal with health cases that affect its citizens.²²

Social Issues arising out of TB diagnosis coupled with how to overcome them

Various social issues arise out of TB diagnosis. Beginning with issues that affect an individual who is diagnosed with TB, they include social stigma, poor productivity, and emotion stress. Beginning with social sigma, according to the majority of people, tuberculosis is closely related to HIV²³ and thus it infects people who have low immunity such as HIV infected persons. That misconception has resulted to the prejudice and discrimination of tuberculosis-infected persons.²⁴ Social stigma leads to poor productivity of a person due to low social confidence that results from the feeling of being hated by other individuals based on ones uncontrolled situation like a disease.²⁵

In addition, just like is the case for all healthcare systems across the world, a TB infected person is isolated from the society to reduce the chances of passive infections. However, due to insufficient public education on how to control and prevent TB in Brunei, people perceive isolation as a case that is only applicable to a dying person, and thus they develop a negative attitude towards anybody who is isolated from the society due to TB infection. This aspect makes TB patients suffer emotion stress due to isolation and the realisation of the negative attitude that people have towards them for being TB victims.²⁶

Secondly, social issues that affect the entire society due to TB diagnosis are poor productivity and emotional stress. Society suffers from low productivity when a reliable individual is diagnosed with TB. For instance, in the case where an employer is diagnosed, employees lack the peace of mind, and thus they perform poorly due to the absence or poor productivity of their employer. This aspect has a direct relationship with an individuals poor performance after being diagnosed, as psychologists argue that when an employer lacks the peace of mind, his or her employees lack the peace of mind too.

In addition, when an individual is diagnosed with TB, the society suffers emotional stress. In this case, the society refers to the individuals family members and friends. When a family member is isolated from the rest of family members due to an infectious illness, there is sorrow in such a family that results from the feeling of near-loss of a family member and they cannot work effectively until when their person is discharged. Unfortunately, little can be done to rectify that situation as isolation is done to reduce the rate of new infections. However, only public education mechanism can work in such a situation to change the mentality of most people in the society. They above social issues have little impact on the societies living in either China or Malaysia. The main reason for such a conviction hinges on the fact that they are literate, and thus they understand the health procedures taken for infectious diseases such as TB.²⁷

Public Education

Citizens of the republic of Brunei need public education on the issues of TB in relation to prevention, diagnosis, treatment, and control. The NTP committee set policies does not provide for public education on TB. Public awareness is the key determinant of the nature of a social reaction towards a problem. In many countries across the world, there have been numerous public campaigns carried out by the government and other stakeholders in the health matters over the issue of TB. The main aim of public campaign is to reduce the rate of infections through creating awareness to the public and at the same time educating on how to prevent and control the infections.²⁸Public campaigns are most effective when carried out through public media such as televisions, radio, billboards along the highways, and posters in public places.²⁹

Financial Assistance or Self-Employment for Patients

Going back to the social issues that result from TB diagnosis, an individual suffers adverse effects of TB infections, which include poor productivity. Poor productivity is the root of poverty for unhealthy person will always consume more than what is being produced. Worst still, in the case of a sole breadwinner of a family being infected, the effects are worse than for other people as the family would face the risk of extreme poverty.³⁰In addition, the majority of developed countries have policies that look into the welfare of a patient as the treatment process continues. Such welfare includes the dependent parties on the patient and in some cases; loans from financial institutions are exempted from earning interest when the patient is not in an economic activity. However, this social scheme is available to the Brunei citizens through government initiative to give financial assistance to the TB patients as a way of reducing emotional stress.

Self-employment may not work well for patients as they lack the peace of mind, which would then deter them from working effectively. This aspect implies that it may only be possible after the patient is discharged from the hospital, after which, self-employment may work well. However, after a TB patient recovers from an illness, it may not be good to do business because financial and business intelligence are the key factors of self-employment. Surprisingly, developed countries like Brunei do that, although it is normal to offset the hospital bill of a patient if he or she cannot raise the bill in many other world countries regardless of economic status.³¹

Special Rooms for isolation in Clinics

It would be necessary for Brunei to adopt the same mechanisms that are applied in the developed nations in their fight against infectious and viral diseases. Most developed countries as well as some second world countries such as Malaysia have isolation wards in the majority of health clinics, and in majority parts of the country. In most cases, those isolation units are used for other purposes when emergency medical needs arise.³²

However, Brunei has isolation rooms in the majority of health clinic across the country, but according to World Health Organisation (WHO) report, they are still not sufficient to cater for the needs of her population in the urban areas. Hence, in order to reach the level of China and Malaysia, the government of Brunei should increase the number of medical clinics to satisfy the demand so that some special facilities can be added to the clinics for the case of isolation and other emergencies.

Education of Health Care Providers

It is very necessary for the NTP to not only supervise the quality of education and training being offered to the medical practitioners, but also ensure that education is up to date and in line with the education offered in other developed countries. This move will go a long way in ensuring that high quality education is available for medical students and boost the competitiveness of the medical practitioners operating in the country^33.This scenario is prevalent in nations such as China and Malaysia whose education system is in line with the education system of developed countries such as Russia among others^34.In addition, some countries attract investors from developed countries who invest in the health sector and help in the provision of high quality training of medical personnel and medical services to patients^35. This move will bring a remarkable difference in the health sector of Brunei and bring it closer to the level of China and Malaysia in health perspectives. Improved education system does not necessarily imply that economic growth has to reach that of developed countries as some countries carry out exchange programs in the medical sector to improve the sector^{36, 37.}This strategy will be of great benefit to the citizens of Brunei if the government, through the NPT, finds the program appropriate for the development of the health sector.

Conclusion

Tuberculosis infections are a major health concern in Brunei, just like is the case for other South Asian countries. The Brunei government, through the National Tuberculosis Program, has made many achievements in the fight against tuberculosis in the implementation of international standard health policies for containing the increasing rate of infections in the country. However, the government should look into various areas in a bid to reach the status of other countries such as China and Malaysia. Such areas include the improvements of health facilities by installing isolation rooms for accommodating tuberculosis patients in urban health clinics that normally receive numerous new cases of infections. In addition, measures that would improve the creation of public awareness should be implementation in the fight against the spread of tuberculosis.

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