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3 October 2011

Tuberculosis still a threat

Writing articles for a national daily is indeed rewarding in the sense that a large group of people can be reached simultaneously. But while my colleagues feel that we should be writing about the various general patient and clinician related issues, I think this opportunity should be utilised more to highlight major issues of public health. So, in this article I will be talking about tuberculosis, popularly known among doctors as our national disease, and coded as “Teek Bahadur” (TB).

Tuberculosis is a disease of great public health concern and for years, the government has been running a national tuberculosis control programme. What has struck me recently is the increasing number of tuberculosis cases detected in my clinical practice. The disease seems to be increasing in incidence, and I am neither quoting the national data nor data from the World Health Organization—I am relying on my own observations. In a week I see around 200 cases, and not all are related to the respiratory system. What I have noticed in these last few years, more so in the last six months, is that cases of TB are on the rise. With every outpatient stay, I diagnose at an average of 1-2 cases per week, which is much more compared to the   previous rate of 1-2 cases per month. Maybe this has to do with the modern tools of diagnosis such as the sputum PCR (polymerase chain reaction), a genetic tool that detects the Mycobacterium Tuberculosis (microorganism causing tuberculosis) gene in the sputum.

Another interesting trend is that people from elite families, who visit my clinic at an expensive private hospital, who have a history of low-grade fever and generalised aches and pain, are also increasingly diagnosed with tuberculosis. Mind you, all these patients are relatively young. Previously TB was thought to be a disease of the poor and the rich were in constant denial of the fact that they too could be infected. This recent spillover of the disease from the “have-nots” to the “haves” of society is noteworthy. It tells us that the disease is no more contained within the usual group of patients but has spread far and wide. Obviously the next question would be to consider whether the control programme really is efficient. Every year a substantial budget is allocated to the programme, which is spent in various ways. But, after all this time, shouldn’t the incidence of the disease be decreasing? As encouraging as the 2010 annual report of the National TB control Programme might be, my own data contradicts this positive outlook. Again, there is the question of the emergence of multiple drug resistant (MDR) and extended drug resistant TB (XDR). The incidence of such cases is definitely not decreasing in our population. MDR and XDR TB outbreaks usually occur in immune-suppressed patients, like those who are HIV infected. Given the recent report about the depletion of the stock of anti retro-viral drugs in the government         pharmacy, this issue may have to be given more emphasis.

It is clear that this kind of   situation would not have come about if tuberculosis therapy was proper and the treatment was effective. Drug resistance occurs during treatment of fully drug sensitive TB when the course of antibiotics is interrupted and the levels of drugs in the body are insufficient in killing the bacteria completely. This can happen due to a number of reasons: 1. Patients may feel better and halt their treatment, which can be overcome by the DOTS (directly observed therapy), 2. The supply of drugs could have run out, which may happen in countries like ours where people have to walk for days to reach a primary health or DOTS centre, 3.The patient may forget to take medicine frequently. One can arguably say that this can        happen only if the DOTS therapy is not being followed diligently. The usual rate of MDR TB in third world countries like India is around 1.5-3 percent and a      failing national programme can be held responsible.

Considering the fact that TB is no longer limited to a particular group of people like the deprived, malnourished, diabetic or immune-compromised, including the HIV infected, but is in fact spreading further into society, means that we have to think about the efficiency and implementation of our control programme. Up until now, we have been following the protocol set by the WHO. We arrange     programmes to spend money given by the various funds. But have we pondered over the fact that there might be other issues with the disease and the drugs? As I mentioned, I have not gone into the reports submitted by the TB control programme. I might be speaking for a pocket full of people as we have not been regularly informed about the disease and the drug trend. But should we not reevaluate and reorganise our control programme now? It is a good thing that DOTs has abandoned the CAT III regime in 2009, which was indeed useless. Maybe the duration of treatment for the intensive phase should also be prolonged to avoid treatment failure and to restrain the disease. It is already an established fact that Lymphnode TB has high recurrence rate and the inclusion of streptomycin increases the chance of resolution.

In the end, I would like to emphasise that we doctors are responsible for the public’s health and should take their   welfare as our first priority. Let’s hope that the points I have raised will be appreciated and invoke discussions.

Dr Neopane is an Associate Professor of Medicine at the Kathmandu Medical College.

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