A few weeks ago, we talked about the effects of
globalization, one of which is an increase in traveling and ultimately, the
spread of infectious disease worldwide.
TB has recently been in the news and is the second leading cause of infectious
diseases after HIV/AIDS, claiming 1.3 million deaths in 2012 (1). TB is caused by the bacterium Mycobacterium tuberculosis (2); however,
one of the major challenges with TB today is the rise of Multidrug-Resistant strains
(MDR-TB) (2) due to the overuse of antibiotics, improper dosage, not following
the prescribed regimen, and the slow progress of antibiotic discovery compared
to the rate of adaptation of the bacterium to our current drugs (3). Another cause for alarm with TB is that
it exists in active and latent forms, where individuals with either form are
still able to spread the disease (2).
I stumbled upon this interview of Dr. Mario Raviglione, the
Director of the World Health Organization’s Global Tuberculosis Programme where
he talks about the much higher prevalence of TB in India (4). India currently has a quarter of all TB
cases worldwide (4) and has not really made progress towards reaching the 2015
Millenium Development Goal #6 (5) due to a high number of missing reported
cases and lack of political will and commitment (4). India’s neighbor, China, on the other hand, has been able to
make progress because of a national effort in tackling TB, whereas India, as
Dr. Raviglione is quoted, “has yet to initiate survey at the national level to
document drug resistance and TB disease prevalence. A drug resistant TB survey
is about to start in early 2014. India has conducted surveys in some states but
not on a national base” (4).
Incomplete reports of cases have led to inaccurate numbers as far as
estimating need as well as the unknowing spread of disease since individuals
are unaware that they themselves are infected. Related to the drug resistance issue, Dr. Raviglione
mentions the lack of regulation of TB drugs in India as chemists sell medication
without a doctor’s prescription (4).
He recommends Brazil’s example, where TB drugs are unavailable in
pharmacies and instead, individuals with TB are referred to public TB clinic
where drugs are administered and free (4). I view this as drug quality are ensured (no counterfeiting)
and patients will participate in Direct Observation Therapy (DOT) where they
are ensured they are taking the right dose at the right time (6) as well as
providing staff support and encouragement to return for the next dose. As Dr. Raviglione admits, every culture
is different, and with India being that much more different than Brazil, the
Brazilian model may not work elsewhere in the world (4). It is up to us, the next generation of
public/international health advocates to spread knowledge as well as address
concerns in terms of how the culture views TB in order to design and implement
an intervention that will hopefully eventually eradicate tuberculosis once and
for all. But similarly to what we
see with polio today, these efforts cannot and should not stop as soon as the disease
is under control for fear of outbreak.
There needs to be constant checks and balances for a few years after eradication
to ensure the disease is gone (as in smallpox).
The following are components of the WHO Stop TB Strategy (1):
ReplyDelete1. Pursue high-quality DOTS expansion and enhancement
2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations
3. Contribute to health system strengthening based on primary health care
4. Engage all care providers
5. Empower people with TB, and communities through partnership
6. Enable and promote research
The WHO stop TB strategy has the vision of a TB free world. Goals include dramatically reducing the global burden of TB by 2015 in line with the Millennium Development Goals, and by 2050, eliminating TB as a public health problem (1). This strategy while only composed of 6 points will not be so simple to implement. Point 2 involving populations with TB-HIV coinfections and populations with MDR-TB, will certainly pose numerous problems to public health practitioners. Unfortunately there are more cases of resistant cases of TB being detected every day. One way to slow this incidence would be careful implementation of the DOTS method to assure adherence to drug schedules. However, this alone will not reduce the new resistant strains. One beneficial research development is a new diagnostic test called the XPERT MTB/RIF which is a cost effective, fully automated test that will rapidly detect TB and detect resistance to rifampin. This will help health workers to more easily detect cases and provide information about treatment strategies(2).
1. World Health Organization. The Stop TB Strategy. Tuberculosis. (2013) http://www.who.int/tb/strategy/stop_tb_strategy/en/
2. http://www.cepheidinternational.com/tests-and-reagents/ce-ivd-test/xpert-mtbrif