Tuberculosis has plagued mankind since the time of the ancient Egyptian civilization. This seemingly innocuous micro-organism, mycobacterium tuberculosis, one of mankind’s most vicious enemies, has survived for millennia; flourishing at times of war, famine and natural disasters; going underground when living conditions and nutrition improve. No country or person is immune from the disease-widespread illegal and legal migration, wars, famines, refugees, the AIDS epidemic and unprecedented air travel have made sure of that. The disease has killed George Orwell, Franz Kafka, Anton Chekov, Simon Bolivar, John Keats and Frederic Chopin. London has become the tuberculosis capital of Western Europe, and cases of Multi- Drug Resistant Tuberculosis (MDRTB) in the United Kingdom have doubled during the previous decade.
"In a world plagued by an epidemic of incurable non-communicable diseases (Diabetes, Hypertension, Hyperlipidaemia, Cancer); tuberculosis remains eminently curable"
About nine million people develop the disease every year, and, of these, about two million die, most in the productive years of their lives. Tuberculosis has killed more people than all the world wars combined. Though tuberculosis has been knocked-off its perch as the world’s number one infectious killer by the Human Immunodeficiency Virus (HIV), it still occupies second place. About half a million people develop the dreaded, virtually incurable MDRTB every year. Tuberculosis is the biggest killer of HIV infected people. About one third of the total population of the world (about 2000,000,000 people) is infected by the tuberculosis bacillus, and each of these individuals has the potential of developing the actual disease.
The diagnosis of pulmonary (lung) tuberculosis still predominantly depends on an archaic, relatively inefficient, microscopy technique nearly 140 years old, dating back from the time of Robert Koch. True, there are new diagnostic techniques like PCR, Xpert MTB/RIF and gene techniques available, but these are expensive and emerged relatively recently, during the past twenty years or so. There are new, experimental drugs like PBTZ 169, but that is exactly what they are-experimental.
"There is no point in expostulating the management and treatment of MDRTB in this article because that is specialized management"
“Mycobacterium tuberculosis is infamous for many reasons, not least as the biggest infectious killer of all time. Dating as far back as ancient Egyptian times, the disease is present in most countries world wide. For some, the spectre of Tuberculosis may seem relegated to the past, enshrined in 19th Century books and plays. For many others however, the disease is all too alive, wreaking havoc in their bodies, their families and their communities. No matter how you view it, Tuberculosis is one of the gravest health threats facing the world today, and is all the more serious as drug resistance takes a grip.” Quote – Medicine Sans Frontiers MDRTB crisis alert. DR TB 2014.
Tuberculosis is an eminently curable disease. Used in the correct dosage and for the prescribed period of time (6-9 months) on a compliant, newly diagnosed tuberculosis patient, the five first-line anti-tuberculosis drugs (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol and Sreptomycin) are capable of curing 90-95% of newly diagnosed patients; provided the patient strictly adheres to the treatment regimen. In a world plagued by an epidemic of incurable non-communicable diseases (Diabetes, Hypertension, Hyperlipidaemia, Cancer); tuberculosis remains eminently curable. Multi-Drug Resistant Tuberculosis –the biggest threat to global health you have never heard of. It is all the more tragic, therefore, that tuberculosis is becoming virtually incurable due to the emergence of Multi-Drug Resistant Tuberculosis (MDRTB). The inappropriate or unnecessary use of antibiotics, the world over has resulted in the emergence of ‘Superbugs’- organisms resistant to all known antibiotics, like Methicillin Resistant Staphylococcus aureus (MRSA) and Multi-Drug Resistant Tuberculosis (MDRTB).
Treatment of MDRTB is horrendously expensive (upwards of USD 10,000 per patient) but cure is not guaranteed (less than 1 in 2 patients are cured). Treatment is with a combination of four or more extremely toxic drugs and painful injections for a minimum of eight months and the total duration of treatment for a minimum period of two years, with about 10,000 tablets to swallow. On the other hand, the five drugs used to treat drug sensitive tuberculosis (i.e; non-MDRTB) are relatively pleasant to use, with most patients experiencing no adverse effects at all. Adverse effects (like hepatitis, visual and hearing problems), when they do occur, are manageable.
Obviously, creating a large number of MDRTB patients is not an option for Sri Lanka - we are too poor to spend upwards of Rs.1000,000 per patient, even then with less than 50% guarantee of cure (with the danger that untreated or inadequately treated patients are free to spread the disease to other healthy people). The priority is to prevent MDRTB emerging. How do you do that? Simply: Ensure that all newly diagnosed patients with Drug Sensitive Pulmonary Tuberculosis (non-MDRTB) are diagnosed early, by scrupulous sputum microscopy by experienced microscopist. If necessary, send sputum samples for culture to confirm/exclude drug resistance.
Ensure that high quality anti-tuberculosis drugs, preferably in fixed dose combinations (three or more drugs combined in one tablet) are freely available in all Respiratory Treatment Units (Chest Clinics) and other major Government Health Institutions, but not in private pharmacies (so that indiscriminate use of these powerful antibiotics is restricted). Ensure that drug shortages do not occur.
Refer all diagnosed and suspected patients with tuberculosis to the closest chest clinic for further evaluation and treatment. Start Directly Observed Treatment Short Course (DOTS), where the patient has to report, on a daily basis, to the nearest chest clinic or health institution, where he is given the daily medication with the least possible delay and observed by a member of the health staff to ensure that he/she is actually swallowing the medication. But the short course, Directly Observed Treatment (DOTS) has been proven to reduce mortality (death) rates, improve cure rates and prevent emergence of MDRTB – the mortality (death) rates from tuberculosis have fallen by 40% from 1999 to 2011 the world over. At the conclusion of treatment, ensure that the patient is actually cured by repeated sputum microscopy, and if necessary, sputum culture and chest radiograph. Review the patient every six months for a period of two years to ensure that he/she remains cured.
There is no point in expostulating the management and treatment of MDRTB in this article because that is specialized management. Fortunately, the number of MDRTB cases in Sri Lanka is still low, compared to Eastern Europe, India and Africa; possibly due to our well established health institutions (there is a health institution within 4 km of every person’s home), literate populace, good personal hygiene, knowledgeable and conscientious doctors and other health staff, a health ministry that provides adequate quantities of high quality anti-tuberculosis drugs and an efficient National Programme for Tuberculosis Control and Chest Diseases (NPTCCD). However, the way things are going in the world, it seems likely that tuberculosis will be with us till the day of the apocalypse. Even more frightening, the disease itself may be the actual cause of the apocalypse .