Some tuberculous thoughts


Doctor , how long I have to take these medicines ? Should I continue it even if I am completely all right?

I hear this question very frequently, mostly from patients diagnosed with tuberculosis. TB medicines usually make most patients all right in 4-6 weeks. But science has estimated that at least 6 months of treatment is needed for complete eradication of the pathogen from the body. The sad fact is most people stop therapy early and there by help in development and propagation of drug resistant TB

 

Fortunately I do not see much drug resistant TB in my clinical practice. But in last 10 years,  I have not seen a visible reduction in incidence of TB. It’s true that we do not see the TB meningitis and spinal TB as much as before, but the pleural effusions, lymph node TBs and the most dangerous variety to the community, the sputum positive TBs are not declining much. In my experience TB is not confined to poor people. The middle and high income population are also very much affected.

Today, March 24, is the World Tuberculosis Day. It was on this day in 1882 that Robert Koch, the German bacteriologist, announced to the Berlin Physiological Society that he had discovered the cause of tuberculosis.

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Tuberculosis is an ancient disease. It is said that modern strains of mycobacterium tuberculosis originated around 15-20 thousand years ago.  But still it kills around 4400 people every day. In 2014, TB killed 890 000 men, 480 000 women and 140 000 children.  Every year 9 million people get sick with TB. Of this 3 million or 1/3rd do not get the correct and complete treatment. If correctly treated with first line combination of  3-4 drugs most of the tuberculosis patients are cured. 3 million do not get treatment because of lack of facilities, poverty , lack of awareness etc.

Huge shortage of funds is also a cause for this missing 3 million. It is said that there is an annual short fall of 1.4 billion US $ in treatment programs and 1.3 billion US$ in research.

Due to lack of timely, correct and complete treatment multi drug resistant TB has emerged as a big threat to the health of humankind. It is estimated that globally in 2014, 480 000 people got infected with multi drug resistant TB ( MDR TB).

Indian Scenario

India has the dubious position of number one country in the world, both in incidence of TB and mortality due to it. It is estimated that in 2014, 2 million Indians got sick with TB and around 222 000 died due to the disease.  But there is some reassuring news. India has met the World Health Organisation targets set for 2015. The targets were a falling number of new cases of TB  and 50% reduction in prevalence and deaths due to TB compared to 1990.

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This World TB day came with some good news for India. A new drug,  Bedaquiline has been introduced into the national tuberculosis (TB) programme.. Bedaquiline, which is a drug for Multi-Drug Resistant TB, is being introduced at six identified tertiary care centres across India.
The government has  also inducted more than 500 Cartridge Based Nucleic Acid Amplification Test (CBNAAT) machines into the Revised National TB Control Programme. This is a fully automated rapid molecular test which detects mycobacterium tuberculosis and rifampicin drug resistance simultaneously.

Tuberculosis is only a surrogate marker of poor living conditions in the society. Containing and eradicating of tuberculosis from the world is closely linked to eradicating poverty and hunger. It is also very much related to availability of affordable good quality health care for all human beings. A humanist world view and great political will are a must for eliminating this captain of death.

References:

http://www.who.int/mediacentre/news/statements/2016/tb-day/en/

http://www.who.int/mediacentre/factsheets/fs104/en/

http://www.who.int/tb/publications/global_report/en/

 

 

 

 

 

Comments

  1. lorn says

    I suspect that in the not too distant future (alternate reality?) there will be a residential hospitals where anyone taking antibiotics, will live. A place where the staff makes sure you get take the appropriate doses in a timely manner for the duration, and where all the antibiotics excreted in biological wastes are destroyed by high-temperature incineration to help keep antibiotic resistance at bay.

    Antibiotics are too valuable to use in a careless manner simply because patients like the convenience of being able to take them as they see fit at home. Limiting antibiotics to in-patient facilities with specialized room sterilization and sewage treatment systems would go a long way to limiting bacterial resistance to a minimum.

  2. Surly Misanthrope says

    India is unfortunately a veritable lab experiment in developing antibiotic resistant bacteria. In my experience here (~18 months) and from various discussions I have had with locals (across economic classes, but mostly from the laborer class), it appears to be common practice to prescribe an antibiotic for anything and everything, even when the doctor explicitly identifies (often without actual testing) that the cause is viral. Add to that the fact that any person with the money can buy antibiotics without a prescription and many do. I’ve spoken to several people that self medicate with two days of antibiotics any time they get a tickle in their throat or feel a little nauseous.

    Before coming here, I worked with several physicians and many residents that received their MBBS in India before being accepted into an American program. They were all highly intelligent and conscientious care providers. Since I’ve been here, most of my experience (direct and with friends and family) have been mortifying. A friend saw an experienced ENT doctor at Apollo (a well regarded hospital that attracts a lot of medical tourists) due to allergies. The doctor told them that the symptoms were psychosomatic, because “there is no pollen or dust in India”.

    I think (correct me if I’m wrong) that this kind of thing stems from an educational system built on rote memorization and arguments from authority. Many (definitely not all!) doctors here basically diagnose off of memorized flowcharts like you’d find on WebMD or similar sites. Like I said, I’ve met a lot of doctors that received their MBBS in India that were competent and savvy, but I can only assume they studied extensively independently or at some particularly exclusive and high-end universities.

    Unfortunately, this lapse in basic education also creates uninformed and uncritical consumers of information, particularly scientific or medical information. It’s this problem (as I see it, PRIVILEGE FLAG) that underlies a lot of problems and perpetuates things like the federal Ayush program, chit schemes, and the continued incumbency of majoritarian/populist politicians that haven’t fulfilled a campaign promise in decades.

    I’m not even sure how one would begin to tackle reforming the education system or expanding accessibility to that education for all Indians but I think that’s going to be the key to improving the standard of living here for all.

    I want to apologize if I said anything offensive (if I did, please let me know so I can learn), I’m new to having these kinds of conversations and I’m not really sure how to approach this kind of discussion from a position of privilege.

    • Arun says

      No need to apologise for anything. Most of your observations are correct. May be there many reasons for the sorry state of affairs in medical education in India.Too big a subject for a comment. Will try to post more about it, with my views on how to make it better.

Comments welcome