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Respiratory infections and tuberculosis

  • Page updated onFebruary 26, 2025
Tuberculosis and other respiratory infections
Photo: Bruno Abarca

Respiratory infections are the leading cause of preventable death in humanitarian and low-resource settings. This group of conditions includes upper respiratory tract infections (affecting the larynx, pharynx, middle ear, nasal passages, and sinuses) like the common cold or pharyngitis, and lower respiratory tract infections (affecting the lungs, trachea, and bronchi) such as pneumonia or bronchitis. Among the infectious diseases affecting the lungs is tuberculosis, a condition that disproportionately impacts the poorest populations.

Acute respiratory infections in humanitarian crises

For many years, respiratory infections have been the leading cause of death among children under 5 worldwide. Among these, the most concerning are lower respiratory tract infections, especially pneumonia, which accounts for 14% of all deaths in this age group. Today, significant tools are available for both the prevention and treatment of acute respiratory infections. However, both prevention and treatment remain challenging in humanitarian settings.

Challenges for pneumonia prevention in complex humanitarian crises

Today, the causes behind the increased risk of respiratory infections in emergencies are well understood. For instance, deaths from pneumonia are closely linked to heightened vulnerability due to malnutrition, including acute and chronic malnutrition, as well as vitamin A deficiency. Additionally, overcrowding, poor shelter and housing conditions (especially in cold climates), and poor indoor air quality further increase the risk. Addressing all these risk factors in contexts of displacement, conflict, and prolonged crises remains a significant challenge.

Additionally, vaccines are available for infections caused by Haemophilus influenzae type B and Streptococcus pneumoniae, the most common causes of pneumonia. These vaccines can also provide immediate (though less lasting) protection against these pathogens when given in reduced schedules, which can be necessary to achieve immunity in broader age groups. However, these vaccines are often unavailable when routine vaccination programs collapse amid humanitarian crises. Furthermore, in many cases, they are not prioritized in mass vaccination campaigns designed to bridge gaps in services.

There is a serious problem with treating these infections in low-resource settings

In these settings, there is often a use of antibiotics that is indiscriminate and inappropriate, despite their high cost, which is frequently covered directly by the affected person. In fact, it is estimated that up to 75% of outpatient antibiotic use is directed at treating acute respiratory infections.

Often, the norm is empirical treatment with antibiotics, without a clear suspicion of bacterial infection, despite the fact that many acute respiratory infections are caused by viruses (which generally lead to milder cases). This is partly due to the lack of diagnostic methods. Other contributing factors include gaps in training and supervision of health workers in rural and remote health posts regarding the rational use of medications. These personnel also tend to attend to people who demand injections or treatments with multiple products, believing them to be more effective.

Tuberculosis in complex humanitarian crises

Tuberculosis is a major public health problem that is not always prioritized

Tuberculosis is one of the leading causes of death in impoverished countries in Africa, Asia, and Latin America, and the primary cause of death in people with HIV. Its prevalence has progressively declined over the years, partly due to the use of the BCG vaccine in children. However, each year, more than a million people, almost all adults (for whom the BCG vaccine is ineffective), die from tuberculosis.

The importance of tuberculosis becomes very evident and visible in complex humanitarian crises where there are large displaced populations. This often leads to poor living conditions in high-density areas, with limited access to health services. These populations are often malnourished and exposed to many other infectious diseases. In fact, most countries with a high burden of tuberculosis are the origin or destination of thousands of refugees. Despite all this, the disease rarely ranks among the key priorities to be addressed in the early moments of humanitarian emergencies.

The challenges in addressing tuberculosis are numerous. These are related to tackling the social determinants of infection and its consequences, its prevention in adults, early diagnosis, and the difficulties in achieving successful treatment.

How to mitigate the risk of tuberculosis and its complications in humanitarian crises?

It is a priority to have systems of social protection and poverty alleviation, adequate preparation for emergency response, and strong health systems. These systems should focus on universal health coverage, proper epidemiological surveillance, and a solid community and social mobilization base. This allows for the provision of information to the population, preventive treatment for individuals with the infection (but without active disease) and their contacts, as well as the implementation of preventive measures to reduce the transmission of respiratory infections.

In the future, it is also expected that there will be vaccines that overcome the current limitations of the BCG vaccine, which only provides protection in children. The new vaccines should offer protection to adolescents and adults, who are at greater risk of severe disease and mortality.

Improving early diagnosis of tuberculosis is also a priority

In displaced populations, it is important to conduct a screening based on clinical signs of the disease at the destination or registration point. The screening should also identify individuals who were already in treatment and need to continue it as soon as possible to minimize the risk of antibiotic resistance. This, of course, must also be done for families relocating to host communities, but their dispersion makes it more difficult. Screening, in all cases, must always be conducted with guarantees of protection and without the risk of repatriation.

Early diagnosis not only allows for earlier treatment initiation and minimizes the risk of severe cases, but also interrupts the transmission of the disease to others. It is also essential to increase access to the most modern diagnostic tests available in these contexts. These include mobile X-rays and molecular diagnostic tests.

Achieving success in tuberculosis treatment: the final major challenge

Achieving success in tuberculosis treatment is a truly complex task. It may require directly observed treatment programs, with the active involvement of community health agents and local organizations. Additionally, protocols for the continuation of treatment in mobile populations across different countries and multiple healthcare points are essential. Finally, it is crucial to ensure access to medications and the most effective therapeutic regimens. Effective treatment of tuberculosis requires the combined and simultaneous use of several antibiotics at fixed doses for about 6 months. This is how the slow growth of the bacteria can be interrupted and the risk of resistance minimized.

However, the treatment of antibiotic-resistant (or extensively resistant) tuberculosis may require specialized care (including surgery) that is rarely available in humanitarian crises. Additionally, many more toxic medications (with severe side effects) are needed, and treatment lasts much longer (up to two years). Even so, these treatments achieve cure in only half of patients, and even fewer in cases of extensively resistant tuberculosis. Palliative care is sometimes also necessary. For all these reasons, not only is access to the best existing medications required, but also research into new, more effective products that can reduce the duration and adverse effects of therapeutic regimens.

Infectious diseases

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