Daily News Online
   

Tuesday, 10 April 2012

Home

 | SHARE MARKET  | EXCHANGE RATE  | TRADING  | OTHER PUBLICATIONS   | ARCHIVES | 

dailynews
 ONLINE


OTHER PUBLICATIONS


OTHER LINKS

Marriage Proposals
Classified
Government Gazette

Tuberculosis detection, treatment and control:

TB toll: two million lives annually


Some facts about Tuberculosis

* TB is the leading infectious killer of adults worldwide.

* TB is responsible for 26 percent (more than a quarter of avoidable adult deaths in the developing world).

* Left untreated, one person with active TB will infect 10-15 other people in the space of a year.

* 1.7 billion people, one third of the world's population, are now infected with the TB bacillus.

* An estimated two million people die from TB annually

* TB kills more adults each year than AIDS, malaria and tropical disease combined.

* New outbreaks of Tuberculosis are now occurring in Eastern Europe, where it had been on the decline for 40 years.

* Asian countries, with their large cities, high rates of TB bacillus infection and growing spread of HIV currently account for two thirds of all TB cases. In the industrialized nations, migration, international travel and tourism are allowing TB to cross borders with ease (TB doesn't need a visa)

* Of the 14 million people globally who were HIV positive in 1994, 5.6 million were believed to be infected with TB as well.

* TB is the leading killer of HIV – positive people, accounting for almost one third of mortality worldwide and 40 percent in Africa. It seems to be the leading opportunistic disease in 50-70 percent of AIDS patients in Asia.

* As many as two-thirds of all HIV - positive people who seek treatment is non-compliance where, drugs are not directly observed, to be swallowed.

* Researchers estimate that almost 50 million people worldwide are infected with resistant strains of TB.

* TB treatment can cost as little as $13 per person in some parts of the world.


Tuberculosis is probably the most ancient and vicious foe the world has ever had the misfortune to encounter. The disease has afflicted mankind from the time man first evolved from the simian species (i.e; the ape), proven by evidence of the disease in mummified remains of Neanderthal man and Egyptian mummies. The disease has killed more people than all the world wars combined, and depressingly, more people die of the disease in the 21st century, despite astronomical advances in medicare and therapeutics, than during any of the preceding millenia, when no treatment at all was available.

Approximately 8-10 million people are infected by the causative organism, mycobacterium tuberculosis, every year, worldwide. About four million people actually develop the disease (not all people infected develop the clinical disease, only about one third), and approximately two million people die of the disease every year, more than the total number of deaths caused by Malaria and AIDS combined.

Industrialized countries

Why do so many people contract the infection, develop the disease and die? In a world - lethargy. Lethargy on the part of governments to spend money for the detection, treatment and control of an unfashionable disease they would prefer to ignore and sweep under the carpet, lethargy on the part of medical students, doctors and their teachers to grasp the fundamentals of the disease and its treatment, lethargy on the part of patients to adhere to the correct number of drugs and prescribed length of treatment and lethargy on the part of the pharmaceutical industry in producing more effective drugs for what, to them, is a non-profitable disease, because mostly poor people in poor countries (which cannot afford to pay for the drugs), contract the disease.

The industrialized countries, having endured their own epidemics of Tuberculosis in the 19th and previous centuries, apparently conquered. The disease in the 20th century, mainly due to improved living standards, nutrition and relatively effective treatment of infectious cases. These countries then came to regard tuberculosis (somewhat justifiably) as a disease confined to poor and undeveloped or developing countries, and of no concern of theirs. Western pharmaceutical companies followed suit, abandoning research on newer treatment modalities for the disease.

Their victory, however, was short lived. Widespread emigration (illegal and legal) from developing and less developed countries to the West, and extensive, global air travel resulted in the disease becoming global, with no one immune from contracting the infection. Emigrants, harbouring the tuberculosis bacillus in their bodies, but not actually suffering from the disease (therefore apparently completely healthy) flooded industrialized countries in the latter path of the 20th century.

Western drug companies

As a result of extensive emigration - the stresses and strains of living in a strange country and culture, sometimes on a hand - to - mouth existence, caused many of these people to develop the actual disease, which, when it affects the lung, is transmissible to other people (though not all cases of pulmonary tuberculosis are infectious). This is now happening in many industrialized countries, especially the United States, United Kingdom and the Soviet Union, whose indigenous, relatively defenceless (immunologically speaking), population is contracting the disease with alarming frequency.

This phenomenon alarmed the West to such an extent that tuberculosis was declared a global emergency by the WHO in 1995. Matters were made worse because Western drug companies, usually the most active and innovative of researchers, had ignored, for decades, developing more effective drugs for the disease, which for them was a non-profitable entity. Some of the drugs (like Streptomycin and Isoniazid), that are still used for the treatment of the disease, originated as far back as the 1950s.

Immune systems

Matters were made infinitely worse when the HIV epidemic exploded in the latter part of the 20th century, almost totally wiping out the immune systems in millions of people, worldwide. It is the immune system that keeps the tuberculosis bacillus at bay, so that even if people are infected by the organism, most of them do not actually develop the disease, because of their intact immune systems.

They remain free of the disease for the rest of their lifespan, though they harbour the bacillus in their bodies, as one third of the world's population - 1,700 million people - do. In other words, 1,700 million people the world over are reservoirs for the disease, with the potential of actually developing the disease and spreading it.

When some of these people contract HIV, their immune systems are destroyed, and the tubercle bacillus explodes, causing severe, widespread tuberculous disease affecting almost all the organs, including the lungs, making the patient highly infectious. The HIV/Tuberculosis duo is very appropriately labelled the 'cursed duet' (or devilish pair), because each helps the other to destroy the patient, and consequently, nations. This is actually happening now, as evidenced by some countries in Sub - Saharan Africa, where million of productive, young people have been wiped out by the dual epidemic, simultaneously wiping out the economies of those countries.

Infectious disease

In a world where most diseases are becoming incurable (diabetes, hypertension, Chronic kidney failure, Asthma, Ischemic heart disease, cerebrovascular disease, cancer), tuberculosis remains eminently curable. After all, it is merely an infectious disease, and infectious diseases, in most instances, can be cured or controlled with antibiotics or prevented by immunization.

The disease, when widespread in the community, profoundly damages the economies in poor countries, because it is predominantly their young (15-54 years age spectrum), productive workforce that is struck down by the disease. Being young is the greatest plus point for these patients, because other than the lung, all their other organs are mostly healthy, young, and functioning normally. All they need is effective, appropriate treatment to eradicate the eminently curable disease afflicting their lungs, and, when they recover, they are as good as new.

Accurate diagnosis

So why are more people dying of the disease than ever before? To cure a disease, one first has to diagnose it, and herein lies the first stumbling block. X-rays are relatively useless in the accurate diagnosis of tuberculosis, because many other diseases (lung cancer, sarcoidosis, fungal diseases, viral pneumonias, bacterial pneumonias, industrial lung diseases) can mimic tuberculosis almost exactly on the chest x-ray. A doctor may treat lung cancer as tuberculosis (this happens with alarming frequency, in this country and other countries) or vice versa.

Tuberculosis may be suspected on the chest x-ray, but not confirmed. Confirmation is by demonstrating the causative organism, myco tuberculosis, in the patient's sputum, other body fluids, or biopsy specimens, which confirms the diagnosis with nearly 100 percent accuracy. Other, more sophisticated and expensive investigations, like PCR (Polymerase Chain Reaction) and gamma interferon tests do exist, but they are reserved for doubtful cases and are irrelevant in the day-to-day detection and diagnosis of the tuberculosis disease. Actual demonstration of the bacillus in the patient remains the mainstay and gold standard of diagnosis, and the most reliable.

Demonstrating the bacillus in the patient's sputum is the foundation of diagnosis, treatment and control of tuberculosis. If the organism is shown to be present in the patient's sputum or other secretions, the diagnosis is confirmed. It is also the patients excreting the bacillus in their sputum (smear positive patients) who are the most infectious.

Not all patients with pulmonary (lung) tuberculosis are infectious, only those excreting the organism in their sputum. Patients with tuberculosis of other organs are almost never infectious. Therefore, infectious patients can be detected and diagnosed with certainly by examining their sputum under the microscope. As luck would have it, the investigation is so simple that it can be done in the most primitive of hospitals, clinics, dispensaries, huts or even under a tree. All it requires is the patient, a sample of correctly collected sputum, a few simple, inexpensive stains, a microscope and an experienced, dedicated microscopist. This is how pulmonary tuberculosis is diagnosed, treated and controlled in resource poor countries, like those in sub - Saharan Africa, with remarkable success. X-rays and other more sophisticated investigations are redundant and irrelevant.

Regular treatment

Probably the greatest advantage in demonstrating the presence of the bacillus in the patients sputum is that we know who is infectious and who is not. Priority is given to detection of patients with infectious forms of pulmonary tuberculosis - one infectious patient (ie; a patient excreting the bacilli in his sputum) can infect 15-20 healthy, uninfected people during the course of an year, if not detected and treated. So, more the number of infectious patients detected (by sputum examination), effectively treated and cured, lesser the number of healthy people infected and lesser the number of new cases of tuberculosis.

This is the basic foundation of tuberculosis control. In almost all infectious diseases, the theme is, 'prevention is better than cure'. In the case of tuberculosis however, cure (with adequate treatment) is prevention - more the number of infectious cases detected and treated adequately with high quality medication until they are cured, lesser the number of healthy people infected. High quality, regular treatment renders the infectious patient non-infectious remarkably quickly, within the space of a few weeks.

Treatment of Tuberculosis is relatively lengthy, and entails the use of a combination of antibiotics to prevent the emergence of drug resistance. It is essential that the patient takes the correct combination of drugs for the prescribed period, never skipping a single dose. Herein lies the crunch-patients almost never do that, because they forget (they are human, after all). Present day anti tuberculosis medication is so effective that even very ill, moribund patients begin to feel well within a few weeks.

When they feel well, they forget to adhere to their treatment regimen. It has been demonstrated repeatedly that doling out drugs for patients to take home is one of the least efficient ways of treating tuberculosis.

So emerged Directly Observed Treatment Short Course (DOTS), where the patient is actually observed to be swallowing his medication by a health worker, on a daily basis. This mode of treatment has dramatically improved cure rates, and dramatically reduced the emergence of the dreaded, almost incurable, Multidrug Resistant Tuberculosis (MDRTB).

Health workers

For DOTS to be effective, all drugs should be free of charge, the patient should not have to travel far to the health institution for his daily treatment, there should be minimal delay in administering treatment, the health staff should be courteous and helpful, and all drugs should be freely available. These are difficult conditions to fulfill in resource poor countries, but countries like Zambia and other Sub-Saharan African countries (some of the poorest countries in the world) have demonstrated remarkable success with this mode of treatment, with dedicated, well trained health workers and enthusiastic governments.

Tuberculosis does not require doctors for its treatment and prevention. All it needs are well trained dedicated health workers who have been taught the basic principles of treatment of the disease and the basic mechanism of emergence of drug resistance. The health workers may be nurses, public health midwives or well trained volunteers.

In many cases, these categories have proven to be better than doctors in the management of the disease. Doctors sometimes tend to be impatient, irritable or possess the I - know - it - all complex. A health worker who asks for advice when he/she is unsure is a far better treatment administrator than an over confident but ignorant doctor.

In fact, doctors are responsible for many of the woes tuberculosis creates, such as multidrug resistant tuberculosis. This distressing phenomenon starts in medical school, where medical students are inadequately and/or inaccurately taught the basic principles of tuberculosis diagnosis, treatment and control, and they carry this burden of ignorance with them for the rest of their careers.

As doctors, they may treat anything they cannot diagnose as tuberculosis (a convenient escape diagnosis), or they may treat tuberculosis itself with the wrong combination of drugs, wrong dosage of drugs, wrong type of drugs for the wrong period of time, or fail to detect life threatening adverse affects of the treatment (such as hepatitis), or create multidrug resistant tuberculosis (MDRTB), a virtual death sentence, because patients with multidrug resistant tuberculosis are virtually resistant to all (or almost all) first line anti-tuberculosis drugs.

Can tuberculosis be totally eradicated, like smallpox? Probably not, as history dating back to the origin of mankind has demonstrated. But certainly, it can be controlled, with better living conditions, nutrition and socio-economic parameters, efficient detection of infectious cases and adequately treating them until cure is achieved. This is how industrialized countries controlled the disease in the 20th century and there is no reason why other countries cannot, in the 21st century.

EMAIL |   PRINTABLE VIEW | FEEDBACK

ANCL TENDER for CTP PLATES
Sri Lankan Wedding Magazine online
www.defence.lk
Donate Now | defence.lk
www.apiwenuwenapi.co.uk
LANKAPUVATH - National News Agency of Sri Lanka
www.army.lk
Telecommunications Regulatory Commission of Sri Lanka (TRCSL)
www.news.lk

| News | Editorial | Business | Features | Political | Security | Sport | World | Letters | Obituaries |

Produced by Lake House Copyright © 2012 The Associated Newspapers of Ceylon Ltd.

Comments and suggestions to : Web Editor