Tuberculosis - Coursework Example

Tuberculosis Introduction TB is “a potentially serious infectious disease that mainly affects your lungs”. The TB bacteria are normally spread from one individual to another via the tiny droplets that are released into the air through sneezes and coughs1. It was rare in the developing countries but increased partly with increases in HIV cases in 1985. The TB disease spread is linked to air pollution and enhanced through overcrowding. “Emphasis on ambient air pollution have tended to overshadow the resurgence of TB, especially in developing countries and among poor in developed nations”2 MDR- TB is featured with resistance to rifampicin and isoniazid, without or with first- line drugs resistance. XDR- TB is TB resistance to any flouroquinolone and atleast rifampicin and any of the 3 second- line injectibles (Kanamycin, capreomycin, and amikacin). They are caused by the TB causing organism resistance to TB drugs. They are spread through the air just the same way like the strains that are fully susceptible to drugs3. The Problem: TB Resistance The 2007 World Tuberculosis Day had the theme ‘TB anywhere is TB everywhere’. The idea behind this theme was to show that the fight against TB needed a worldwide collaboration. TB is a preventable disease but kills almost two million people every year, especially in the developing nations. The attempts to control TB has faced threats; these threats are: i) spread of drug resistance TB, ii) difficulty to institute a successful diagnosis and treatment to TB patients that are HIV- infected, and iii) lack of sufficient funds to control TB4. The resistance of TB can be grouped into several types: primary resistance, natural resistance, combined resistance, acquired resistance, new patient’s resistance, resistance in patients that were under treatment, poly, resistance, mono resistance, total resistance (TDR), multidrug resistance (MDR) and extensive resistance (XDR)5. The agent that causes TB (Mycobacterium tuberculosis) has developed to rest many antibiotic drugs like parazinamide and Ethambutol6. This is due to its exceptional cell wall that is highly hydrophobic. See the figure below (Fig 1)7 The global TB statistics estimated that there were 2.9 million TB cases in 2012. The deaths among women was estimated to be 410, 000 (women who are HIV- positive were estimated to be 160, 000 while those negative were 250,000). An estimation of 530,000 TB cases was among children and approximately 74,000 people died that year due to TB. The year 2009 was characterized by approximately 10 million children being left orphans due to TB taking one of the parents. In the year 2012, it was estimated that 170,000 deaths occurred due to MDR while there were 450,000 new MDR-TB cases8. Table Graph: TB Global Statistics9 Region TB Mortality HIV Positive TB Mortality Prevalence Incidence Population Africa 230,000 250,000 2,700,000 2,300,000 892,529,000 Americas 19,000 6,400 390,000 280,000 961,103,000 Eastern Mediterranean 100,000 4,200 1,100,000 670,000 616,591,000 Europe 36,000 3,900 510,000 360,000 904,540,000 South-East Asia 450,000 51,000 4,800,000 3,400,000 1,833,359,000 Western Pacific 110,000 4,800 2,400,000 1,600,000 1,845,562,000 Global Total 940,000 320,000 12,000,000 8,600,000 7,053,684,000 Main Solution: TB treatment and Vaccination TB should be treated with at least four different drugs so as to see that further development of resistance is prevented as per the WHO recommendation. The figure below (Fig. 2) shows the distribution of the drugs to avoid further TB resistance10. Use of Different Drugs to Treat TB Figure 3: It shows how the different drugs affect the life cycle of the bacteria. The use of these different drugs has proven to be effective, even though, the abuse of the drugs is becoming a challenge. Timely diagnosis, the length of treatment that is long, socio- economic factors in the areas that TB is prevalent has made it a challenge to end TB. This has made the TB global treatment by use of antibiotics to fail11. In addition to these external challenges, there are challenges that are related to drug use. Treatment by use of drugs only a metabolically active TB causing organism (M. Tuberculosis) thus leaving the dormant organism unharmed. There are suspicions that active organism eradication leaves space for the latent to become active thus continuing the infection cycle. To tackle this challenge, the main solution offers a 6-month prolonged period of treatment. This is to ensure the coexistence of the latent and active organism is well addressed thus complete elimination of M. Tuberculosis12. In the year 2010, it is approximated that 13% (of TB patients) were infected with HIV. 82% of this population were from Africa- 8.8 million was the total number of individuals infected at that time. There is a synergy interaction between HIV and TB making their effect greater than when they are at the individual level. This has seen to it that the common combination of resistant M. Tuberculosis and co- infection of HIV draw global attention thus making it a global issue13. To make matters worse, rifampicin, an anti- TB drug is said to react with the ARVs that are used to treat HIV- positive people. This combination of anti- TB drugs and ARVs can lead to an immune reconstitution syndrome that is fatal. This has made TB control to become a global priority in a quicker pace.14Developed countries stopped the TB research after the invention of the combination therapy over 40 years ago. This therapy led to the formation of TB cure in the next 6 months. Stopping the development of TB drugs has led to few drugs that can be used to treat TB. This is despite the fact that the disease has grown to be complicated and now needs a combination of 4 drugs. Of all the drugs that exist, rifampicin can be termed as the most effective, capable of killing both the active and dormant M. Tuberculosis. Use of vaccination has been a common trend in many countries, making it compulsory and free for children as a maternal service. The vaccination has been partially successful despite the fact that the only current vaccine is BCG (Bacillus Chalmette- Guerin). This is the most used vaccine in the world and its benefits have been witnessed. The BCG vaccine prevents young children and newborns from developing miliary TB. The vaccine cannot prevent the pulmonary TB, a TB found in adults15. The vaccine has no transmission impact at all thus can’t prevent the spread16. The vaccination only protects for a defined lifespan of a number of years in the regions that are TB endemic. The BCG protection timeframe that ranges from childhood to adult life relates to the drastic increase in the incidence of TB. A good example is the situation of the sub- Saharan Africa. The TB cases in this region go as high as above 500 per 100,000 persons of the age of 23 to 35 years. Research shows that BCG is not effective for the individuals that are mycobacterium pre- sensitized. For example, exposure to mycobacterium to the environment prior to BCG vaccination makes the BCG ineffective17. Bacillus Chalmette- Guerin is a vaccine that is alive, and it works through replication in the vaccinated host. The presence of pre- existing response in the immune causes reaction to the BCG thus rendering it ineffective. Implication of Vaccination and Treatment of TB The burden that is associated with vaccination and treatment of TB is normally measured in terms of direct costs associated with prevention and treatment. In this case, emphasis will be laid on the treatment since vaccination is free in most of the countries and is done once in a lifetime of a person. The costs of treatment can be in the form of personnel, medicines, and the used facilities. The economic impacts are far more compared to the social impacts. More often than not, the patients normally go through several medication trials before getting to accurate diagnosis. These treatment sectors normally include private sectors and traditional healers that are costly. The public sector is normally the last option and the fact that it is prone to malpractices people normally sees it as the last option. Additional costs are the food taken while one is in the hospital, travelling costs to and from the clinic or hospital18. In addition to the direct costs, TB imposes additional costs in terms of suffering, pain, grief and discrimination. The table below shows the costs in quantifiable amounts. Table 1. Costs of TB treatment- Uganda and South Africa19 Cost Rural Uganda Rural South Africa Cost to health service (US$) 95 2,570 Cost to Patient (US$) 299 371 Total cost (US$) 324 2, 941 The cost normally varies from region to region, country to country. The costs are normally underestimated since only the only health system costs are usually considered. As per the report, in the Uganda case, the health system costs are normally a small portion of the total costs. In India, the private sector is more developed with the perception that they are more productive when it comes to efficiency and effectiveness. The private sectors are more convenient, effective, and sympathetic compared to public- providers. TB treatment per person normally increases with an increase in resistance. By using the 2010 currency value, the direct costs are estimated to be $ 17,000 for the susceptible TB while for XDR is estimated to be as high $430, 000. This is minus the productivity losses that are associated with the incapability of the patients to work during treatment. The period of the treating resistant TB can take as more as two years, thus making the process more expensive20. Evaluation of Main Solution: Risks and Benefits a) Risks There are risks associated with further increase of resistance due to mutation. The M. tuberculosis organism may mutate if the administration of drugs is not practices well. The professionals, doctors and pharmacologists, normally administer drugs but those who end up using are the ones that control the drug intake. Due to ignorance and other factors, the TB patients are normally attempted to take the drugs in excess. An overdose might lead to mutation of the M. tuberculosis thus forming a more resistant and complex TB organism in the future. To prevent this there should be a close monitoring of the patients. The interaction between the TB drugs and ARVs; if this is not taken into consideration, the HIV- positive patients might die. The treatment could also cause complexity when it comes to child treatment. A mere negligence can make a child lose his or her life. The children are more at risk since there is no comprehensive research done in relation to TB among children. The fatality level is high when it comes to treating pregnant women who are drug- resistant patients. The strength of the drugs can tamper with the foetus if appropriate attention is not taken.21 b) Benefits There is a need for TB resistant prevention and treatment since it is ethically, politically and technically right. If the drug resistant TB is not treated, prevented or controlled, it will mean that the patient has to succumb to death. For example, involuntary detention cases that are witnessed in many parts of the world has led to the importance of balancing the human liberty and rights against public health protection. With the issuance of drugs, the patients are allowed to interact with the public thus practicing their rights and reducing political tension22. In ethical considerations, TB treatment enables the government to practice their mandate by offering adequate TB treatment. This is a benefit to the public at large since it prevents the spread of the disease. The treatment also capacity builds the public as the patients are counselled and given information in relation to the disease23. Alternative Solution 1: Development of a TB Program to address Resistance Additional funds should be placed in the invention and innovation sector to see that several programs are developed to address the TB resistance. The laboratories should be developed in a way that allows for practice of appropriate bio- safety measures. The staff should be comprehensively trained to ensure that they are competent enough when it comes to TB treatment. The infrastructures should be fully developed so as to ensure so as to allow cultures or smear performance. There should be a DST for at least rifampicin (R) and isoniazid (H) or other rapid diagnosis methods (e.g. Xpert RIF or MTB). National laboratories that are normally used for referral should be used to train personnel and provide quality control and technical assistance to the intermediate labs24. The table below shows the tests done in laboratories25. The table is called “Commercial tests for the direct detection of Mycobacterium tuberculosis in processed sputum specimens”26 Direct NAA assay Company Method % sensitivity (range) Smear-positive samples Smear-negative samples All samples Amplicor PCR Roche Molecular Systems PCR 90–100 50–95.9 91.3–100 (overall) Amplified MTD Gen-Probe Inc Transcription-mediated amplification 91.7–100 65.5–92.9 92.1–100 (overall) BD ProbeTec Becton Dickinson Strand displacement amplification 98.5–100 33.3–85.7 98.9–100 (overall) GenoType Mycobacteria Direct Hain Lifescience Strand displacement amplification 85.7–94.6 33.3–65.4 99.6–100 LAMP Eiken Chemical Co. Loop-mediated isothermal amplification 97.7 48.8 99 (overall) The bar graph below shows the success rates that have been experienced due to the use of laboratories 27 Evaluation of Alternative Solution 1: Risks and Benefits The benefits of developing such a platform are that addressing the risks associated with the drug resistant- TB. This is seen in the effectiveness and efficiency of the laboratories that conserves the cost related to the infection. Having adequately facilitated labs with competent personnel will save both time and money28. The risk associated with this solution is the costs that it incurs. Capacity building of the human resource can be also affected by the human resource mobilisation. Since private sectors are well paying, the public sectors will be prone to capacity developed personnel lose. This will mean a double fold lose to the government and the public in general29. Alternative Solution 2: Preventing Drug Abuse and Ensuring Patients Finish their Dosage. This solution major aim is normally to reduce the mutation of the TB organisms to more resistant ones. Failure to follow treatment on the part of the patient, normally lead to the formation of drug resistant TB organisms. Selective drug ingestion and wrong timing during ingestion are major causes of organism mutation. Plans should therefore be put in place that minimises or eliminates these practices30. The graph below shows the population in India that are under TB treatment thus in a position to abuse drugs.31 Evaluation of Alternative Solution 2: Risks and Benefits The benefits that are associated with the practice of this solution include the avoidance of TB organism mutation. The direct benefit of this is that many lives will be saved. The indirect benefit is that the costs associated with investing in stronger antibiotics are eliminated through the process32. The table below shows factors that can lead to TB drug abuse or misuse; and the primary drug resistance in India respectively33. Table: Primary drug resistance, India (1999-2002) District (Zone) Intake period Number of patients Primary isoniazid resistance % Primary multi-drug resistance %  North Arcot (South) 1999 282 23.4 2.8 f  Raichur (South) 1999-2000 278 18.7 2.5  Wardha (West) 2000-2001 197 15 0.5  Jabalpur (West) 2001-2002 273 17 1.0  Hoogly (East) 2000-2001 350 10.3 3.0  Mayurbanj (East) 2000-2002 343 2.5 0.7 The risk that is associated with this kind of intervention is that the outcome cannot be determined. People will react differently to the idea or awareness creation created. This would mean that a large sum of money can be invested in it yet the impacts can be so little. The intervention also is so much costly because it will have to capacity build the general public. Another cost of this intervention is the cost in reference to time34. Conclusion MDR and XDR forms of TB organisms are a major threat to life as per now. There is a need to address these organisms and see to it that their impacts become insignificant and eliminated completely in the long term. The three solutions that are issued are all important and should be practiced by the governments and the public in general. Since the main solution: Treatment and Prevention, is already being implemented, emphasis should be laid on the alternative solution 2. This is because it is the only intervention that deals specifically with the major problem: drug resistance. Though costing so much, this intervention will ensure that the mutation of the TB causing organism is stopped. This is the only way that TB can be eliminated completely. Annotated Bibliography Caminero, J., Guidelines for clinical and operational management of drug resistance tuberculosis, ed. IUATLD, Paris, IUATLD, 2013, p. 56. In this report, Caminero elaborates on how screening can be used to efficiently and effectively determine the XDR and MDR- TB. This report shows how effective the lab can be used to control TB resistance. The report will be used in the issuance of laboratory investment as a method to address TB dynamics. In contrary to the other two references, this report emphasis on the use of laboratory processes to control TB effects. Hoek, P. Et al., ‘Resistance to pyrazinamide and ethambutol comprises MDR/XDR- TB treatment’, SAMJ, Vol. 99, No. 11, 2009, p. 785. In this article, Hoek et al. shows the resistance level of MDR and XDR using South Africa as a case study. The article explains to us the anti-biotic drugs that MDR and XDR- TB have rendered ineffective. This article will be used to show an example of anti- biotic drugs that are no longer effective on resistance TB- organisms. In contrary to the other two references, this article addresses the antibiotic drugs used in resistant TB treatment. Marisa, K. et al., ‘Emergence and Spread of extensively and totally drug resistant tuberculosis, South Africa’, Emerging Infectious Diseases, Vol. 9, No. 3, 2013, p. 449. In the article, Marisa et al. gives the statistic in relation to TB drug resistance from MDR- TB in South Africa. This article helps us understand the extent to which MDR- TB has grown to be in terms of TB drug resistance. In contrary to the first reference by Caminero, this article specifically shows the data in relation to the South African situation. This work will help in the explanation of the drug resistant TB organisms. Bibliography Asres, B., Yifru, B. and Desalegn, Y., ‘A Meta- Analysis of Drug Resistant Tuberculosis in Sub- Saharan Africa: How Strongly Associated with Previous Treatment and HIV Co- infection?’, Ethiopian Journal of Health Science, Vol. 23, no. 3, 2009, p. 271 Caminero, J., Guidelines for clinical and operational management of drug resistance tuberculosis, ed. IUATLD, Paris, IUATLD, 2013. CDC, ‘Fact Sheet: Treatment for Drug- Resistant Tuberculosis’, http://www.cdc.gov/tb/publications/factsheets/treatment/drugresistanttreatment.htm , 2012, (accessed 23rd March, 2013) Corbett, E. et al., ‘The growing burden of tuberculosis: Global trends and interaction with the HIV epidemic’, Arch Intern Med, Vol. 163, 2003, p. 1010. Denis, A., The stop TB Initiative: The economic impacts of tuberculosis, Amsterdam, WHO publishers, 2000. Dietrich J. and Doherty T., ‘Interaction of Mycobacterium tuberculosis with the host: Consequences for vaccine development’, Journal for Immunology Research, Vol. 117, No. 6, 2009, p. 441 Gelmanova I. et al., ‘Barriers to Successful Tuberculosis Treatment in Tomsk, Russia Federation: non adherence, default and acquisition of multi- drug resistance,’ Bulletin of WHO, Vol. 85, No. 9, http://www.scielosp.org/scielo.php?pid=S0042-96862007000900016&script=sci_arttext Global Alliance for TB Drug Development, ‘MDR- TB/ XDR- TB’ , http://www.tballiance.org/why/mdr-xdr.php#sthash.7GATvDJG.dpuf , 2015, (accessed 23rd March 2015) Hoek, P. Et al., ‘Resistance to pyrazinamide and ethambutol comprises MDR/XDR- TB treatment’, SAMJ, Vol. 99, No. 11, 2009. Kaufmann, A. et al., ‘Airborne Spread of Brucellosis’, http://onlinelibrary.wiley.com/doi/10.1111/j.1749-6632.1980.tb18912.x/abstract ,2006, (accessed 24th March 2015) Lancet, ‘Stopping Tuberculosis proves hard to do’, The Lancet, Vol. 369, 2007, p. 965 Linda P. et al. ‘Laboratory diagnosis of tuberculosis in resource poor countries: challenges and opportunities’, Clinical Microbiology Review, Vol. 24, No. 2, 2011, p. 318. Marisa, K. et al., ‘Emergence and Spread of extensively and totally drug resistant tuberculosis, South Africa’, Emerging Infectious Diseases, Vol. 9, No. 3, 2013, p. 449. Phamchem, ‘Mycobacterium’, http://www.microbiologyinpictures.com/bacteria%20photos/mycobacterium%20tuberculosis%20photos/mycobacterium%20tuberculosis%20030.jpg, 2002, (accessed 20th February 2015) Saunderson R. ‘An economic evaluation of alternative programme designs for tuberculosis control in rural Uganda’, Social Science and Medicine, Vol. 40, 1995, p. 1204. Stefan, K. and Shreemanta P., Tuberculosis in Africa: Learning Pathogenesis for Biomarker Identification, Berlin, Plank Institute of Infection Biology, 2008. TBC India, ‘About RNTCP’, http://www.tbcindia.nic.in/rntcp.html , 2010, (Accessed 27 March 2013) WHO, ‘Ethical Issues in Tuberculosis Prevention, Care and Control’, http://www.who.int/tb/publications/ethics_in_tb_factsheet_28jan11rev.pdf , 2014, (accessed 23rd March 2015) WHO, ‘Global Tuberculosis report 2014’, www.who.int/tb/publications/global_report/, 2014 , (accessed 24th March, 2015) A. Listorti A., M. Doumani & IBRD, Environmental Health: Bridging the Gaps, Washington DC, World Bank, 2001, p. 107 B. Olsen S. et al, Facing the reality of drug- resistant tuberculosis in India: Challenges and potential solutions: Summary of a joint Washington workshop, Washington DC, National Academic Press, 2012, p. 5- 9. Read More