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FRESH APPROACH FOR TUBERCULOSIS & CONTROLLING MDR TB
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Dr. Rajesh Chauhan, Consultant Family Medicine & Communicable Diseases CHAUHAN MEDICAL & RESEARCH CENTRE, 309/9 A.V. Colony, Sikandra, AGRA -282007. INDIA.
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drchauhanrajesh{at}yahoo.com Dr. Rajesh Chauhan
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Dear Editor, Tuberculosis has beleaguered humankind since time immemorial. Many unsuccessful attempts have been made to get rid of this disease, but it has stood steadfast against all measures that have been undertaken to eliminate it, becoming more resolute and resilient in the process [1]. Multi-drug resistant tuberculosis (MDR TB) is the latest ongoing problem associated with this infection, and is usually a result of irregular and incomplete therapy. It is considered as “the return of the white plague” [2]. Poor compliance is one of the important factors related to MDR TB [2,3]. Maybe it is the time to have a "re-look" at the cause of failure of compliance to scheduled therapy. The problem perhaps starts with a person being labeled as suffering from tuberculosis. Being thus labeled represents a stigma of sorts, despite numerous efforts and means to overcome it. For instance, anyone even visiting a TB clinic/outpatient department (OPD) or a TB hospital starts feeling stigmatized, notwithstanding the fact that special efforts have already been taken for the cause. One possible solution is to stop using the terms TB or tuberculosis forthwith. A patient, his/her relatives/caregivers and acquaintances should not be allowed even the faintest chance to even remotely consider TB or tuberculosis or any of its related nomenclature in local dialects as the cause of the problem. A TB/tuberculosis hospital or clinic can be renamed, for example, as "Respiratory Diseases" or "Tropical Diseases" hospital/ clinic/OPD and it should also start dealing simultaneously with all other respiratory diseases/tropical diseases with certain additional resources to supplement the efforts in the form of an upgraded laboratory and pharmacy. The staff can be motivated and trained to start dealing with all other respiratory diseases/tropical diseases. These changes, besides helping to contain and remove stigma, will also lead to increased utilization of resources that have been otherwise catered for only one disease entity. It is all the more essential, perhaps, for this changeover to take place when considering the context of HIV/AIDS patients. Patients with HIV infection may also have concurrent infections with tuberculosis as well as other pathogens, and therefore they will start having better management under a single roof. To reduce stigma, a patient can be told that s/he is suffering from Koch’s Disease instead of using the term TB/tuberculosis or a relative term in local dialect. Some other appropriate name can also be considered, which helps in "de-linking" the terms that are so stigmatized. Likewise, the specialization may be given another name. All of this will have no adverse consequences on the management and yet the course of management would continue to remain unaltered. The aetio-pathogenesis, course of illness, and the associated and anticipated problems can be told to a patient, and to her/his relatives/caregivers and acquaintances in a manner that should not raise the doubt of the disease being TB, while ensuring that the other facts are put across just as straight as possible. Every effort must thereafter be made to initiate the treatment as rapidly as possible so as to bring down the infectivity and the risks of secondary spread. Probably when a patient or her/his relatives/caregivers and acquaintances are told of a disease without raising hackles or undue alarm and thereby curbing the stigma, compliance can be improved considerably. As a consequence, occurrence of cases of MDR TB can also be curtailed. Another aspect of tuberculosis which needs a "re-look" is the system of follow-up, which needs to be strengthened and rejuvenated. We are into an era of computers, "intranets" and internets. Computerization of all such hospitals/clinics can help in proper follow-up. Once the patient data and clinical details are fed in a computer, generations of reminders can be ensured with requisite software. This can thereafter be easily followed up by social workers and/or health workers, who can visit the patient. Once computerization is accomplished, the departments of radiology, pathology and pharmacy can also be interconnected. This would remove unnecessary paperwork and the need for patients to carry hefty files and medical documents during each visit. Chances of their loss would also be eliminated. Time spent in a hospital/clinic can also be cut down drastically as the need of queuing up for collection of reports would be done away with as all the reports can be made available online, thereby limiting chances of transmitting infections. Moreover, there would be less chance of reports being missed inadvertently or interchanged with other patients. Since pharmacies can also be online in a similar fashion, prescriptions can be easily generated and transmitted directly to a pharmacy and the chances of misunderstanding a scribbled prescription and ensuing wrong drugs and dosages can be minimized. The system can have the facility of generating alternatives if the prescribed alternative is not available. “The ticking TB time bomb” is already primed and needs urgent action for it to be defused [1]. The incidence of MDR TB is expected to only worsen further and the honeymoon of tuberculosis with HIV/AIDS has the potential to create a havoc of sorts as is already being witnessed [4-8]. Therefore, the need of the hour is to consider effective ways and means to control the further incidences of failed compliance and improve upon the existing policies framed for the control of TB. There may be a need to re-examine and re-explore the continued reliance and effectiveness of the DOTS modality of treatment of TB. Warm regards. Dr. Rajesh Chauhan References: 1. Rusen ID, Enarson DA. FIDELIS--innovative approaches to increasing global case detection of tuberculosis. Am J Public Health 2006; 96 (1):14-6. 2. Mitchell D. The Return of the White Plague: Global Poverty and the New Tuberculosis. BMJ 2004;328:1206. 3. Olle-Goig JE. Control of multidrug resistant tuberculosis. DOTS- plus strategy will be hard to implement. BMJ 1999; 318 (7185): 736. 4. Gavin Yamey. Multidrug resistant tuberculosis. BMJ 2003;326:606 5. Sidley P. South Africa acts to curb spread of lethal strain of TB. BMJ 2006; 333: 825-a. 6. Moszynski P. UK parliament creates all party group for tuberculosis. BMJ 2006 333: 938. 7. Lawn SD, Wilkinson R. Extensively drug resistant tuberculosis. BMJ 2006;333:559-560. 8. Faustini A, Hall AJ, Perucci CA. Risk factors for multidrug resistant tuberculosis in Europe: a systematic review. Thorax 2006;61:158 -163 |
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