Essay on tuberculosis

Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia)

In Pakistan, there is a huge gap between Public Health system and Private. A large population including rural people relies on private health system and doctors. Private health service providers are not the part of DOTS. It has been observed that their knowledge and training often lack in TB. They often under-diagnose or over-diagnose cases of TB. Frequently they prescribe the wrong treatment or inadequate treatment. Often the private practitioners themselves lack enough knowledge about DOTS and specific anti-TB treatment. Many people visit the private practitioners at first hand in Pakistan. Their exclusion from the NTP or DOTS could well hamper the condition. It is rather needed to understand the roles of private practitioners in prevention of TB. They should be included in NTP, should be trained for diagnosing, treating and referring the patients properly.

All these factors above have made TB an urgent public health condition. The lack of enough diagnosis, poor adherence to the treatment, injudicious use of drugs by private practitioners, and so forth have made the condition of TB even worse. The emergence of multiple drug resistance is the most worrisome picture. The study in 1989 carried out by Aziz et al in Lahore described that out of 256 people, in the study, having been on treatment for TB, one third showed resistance to isoniazid and pyrazinamide; and the resistance was rising for rifampicin. In past decade the condition of multiple drug resistance have increased. Multiple drug resistance (MDR) is not only difficult to treat as it results into severe form of TB, but it is also an expensive business.

Multiple drug resistance is now defined as having resistance to isoniazid and rifampicin, which requires the need of second line drug treatment for treating TB (Mukherjee et al, 2004). While treating TB costs less than 10 US$, treating MDR TB costs between 500 and 6000 US$ (Brown, 2004). Frequent interruption in the treatment, lack of supply of drugs, poor infra-structure, diagnostic delays, pandemic of HIV and AIDS etc are the main reasons of MDR TB. Developed countries themselves find the MDR TB very expensive to treat spending millions of dollars. Pakistan, on the other hand can not afford to do so, neither can its people. This might well lead to MDR TB endemic. To deal with MDR TB in Pakistan, NTP and government should conduct a survey of the affected areas and identify them as “hot-spots”. Many European countries have declared such hot spots according to the endemic of MDR TB, so that they can concentrate their DOTS program in these areas (Brown, 2004).

DOTS is undoubtedly the best available tool all over the world to prevent TB or to keep it under control. But it hasn’t reached up to the mark and there is a long way to reach the goal in Pakistan. A randomized control trial carried out in Pakistan among 497 people resulted in almost same cure rate in DOTS and in self administered treatment group people (Walley et al, 2001). Although, the study said that the results differed in other countries where DOTS was superior to self administered treatment, the efficacy of DOTS has some issues to be addressed. The DOTS program is too universal to be applied to people worldwide. It has to reach to local involvement rather than sticking to global or national. DOTS, under which people or health workers have to attend each other on daily bases is not very practical attitude. Many people can not afford the travel costs, mainly women who have to be escorted by some family members in Pakistan increase the travel costs. The need is to decentralize NTP and reach to each province, each district, and every corner of Pakistan. Monitoring the health workers is also important thing to do in Pakistan as the corruption and fraud are very common in most parts.

The treatment of TB is a long process involving months of treatment at a stretch. Moreover, BCG vaccine hasn’t shown satisfactory prevention especially in adults due to its lack of sensitivity and specificity. More funding is required in the research of new drugs and vaccines. Very short course drugs, which are affordable and accessible to everyone, should be developed; the same with research of new vaccine. Pakistan, of course, can not afford to fund such research; however, the developed countries, which are not out of the dangers of TB, have taken the initiatives to do proper research to invent new drugs or vaccines. According to BBC World (2004) the first TB vaccine which was invented 80 years ago has now passed safety trials United Kingdom. The study suggests that this could be a useful find for those countries where TB is endemic and numbers of cases are on rise. It is also said by oxford university reasearchers that this vaccine can enhance the potency of already existing vaccine as well. Researcher are still not sure about efficacy of vaccine, some says that it can protect only 66% people, where as in other cases it might protect only 30 percent people.

In the end, Directly Observed Treatment strategy (DOTS) and NTP (National Tuberculosis Program) have done reasonably effective job in controlling TB, but there are some factors which are yet to be addressed and considered to achieve the desired outcome in curbing TB. Pakistan’s population growth and distribution, the socio-cultural and religious hindrance, condition of Afghan refugees, rapidly spreading HIV, influence of private practitioners and poor surveillance system are affecting the efficacy of DOTS. The outbreak of multiple drug resistance is very rapid and this condition is a huge burden on Pakistan economy if not considered promptly.

References:

Aziz, A., Siddiqi, S., Aziz, K. and Ishaq, M. (1989). Drug resistance of mycobacterium tuberculosis isolated from treated patients in Pakistan. Tubercle, 70: 45-51.

BBC World (2004). New TB Vaccine Shown To Be Safe. Retrieved on 24-10-2004 from: http://news.bbc.co.uk/1/hi/health/3944437.stm

Brown, H. (2004). WHO identifies drug-resistant tuberculosis "hotspots". The Lancet, 363 (9413): 951.

Dye, C., Watt, C., Bleed, D. and Williams, B. (2003). What is the limit to case detection under the DOTS strategy for tuberculosis control? Tuberculosis, 83 (1-3): 35-43.

Ferrari, M. (2004). Eleven million adults co-infected with AIDS, TB. The Canadian Medical Association, 171 (5): 437.

Hampton, T. (2004). Funding, Advances Invigorate TB Fight. JAMA, 291 (21): 2529-2530.

Ibrahim, K. and Laaser, U. (2002). Resistance and refugees in Pakistan: Challenges ahead in tuberculosis control. The Lancet Infectious Diseases, 2 (5): 270-272.

Liefooghe, R., Michiels, N., Habib, S., Moran, M. and Muynck, A. (1995). Perception and social consequences of tuberculosis: A focus group study of tuberculosis patients in Sialkot, Pakistan.  Social Science and Medicine, 41 (12) 1685-1692.

Maher, D., Chaulet, P., Spinaci, S. and Harries, A. (1997). Treatment of Tuberculosis: Guidelines for National Programmes (2^nd Ed). Geneva: World Health Organization.

Mukherjee, J., Rich, M., Socci, A., Joseph, J. et al (2004). Programmes and principles in treatment of multidrug-resistant tuberculosis. The Lancet, 363 (9407): 474-481.

Spinaci, S., De Virgilio, G., Bugiani, M., Linari, D., Bertolaso, G. and Elo, O. (1989). Tuberculin survey among Afghan refugee children. Tuberculosis control programme among Afghan refugees in North West Frontier Province (NWFP) Pakistan. Tubercle, 70 (2): 83-92.

Walley, J., Khan, M., Newell, J. and Khan, M. (2001). Effectiveness of the direct observation component of DOTS for tuberculosis: A randomized controlled trial in Pakistan. The Lancet, 357 (9257): 664-669.