Introduction
The recent
tuberculosis (TB) epidemic has been a major topic in global infectious diseases
being consistently recognized as one of the worlds deadliest communicable
diseases (1,2). In the 2014 Global Tuberculosis Report, the World Health
Organization estimates over 9 million new cases of tuberculosis and 1.5 million
casualties resulting from TB complication in the year 2013 alone(2). Even with
the numerous intervention programs, this number has been continuing to rise at
a steady rate.
Caused by the
pathogenic bacteria mycobacterium tuberculosis, TB is very adaptive and infectious pathogen. With the
rising overuse of antibiotics along with inadequate treatment management of
medical staff, the prevalence of drug-resistant tuberculosis has increased
tremendously ever since the first introduction of TB antibiotic treatment
almost 60 year ago (3). Multidrug resistant (MDR) and
extensively drug resistant (XDR) tuberculosis are the result of mutations in
the bacteria that make it resistant to certain antibiotic medications.
Specifically, MDR tuberculosis is when the organism is resistant to one or more
drugs while XDR TB, a much more serious type, is when the organism is resistant to
most major first-line TB drugs such as isoniazid, rifampin, fluoroquinoline,
and at least one of three second-line drugs such as amikacin, kanamycin, or
capreomycin (4).
After first
declaring tuberculosis as a global emergency in 1993, the World Health
Organization (WHO) started implementing the Stop TB Strategy to reduce
worldwide TB prevalence along with reducing the emerging problems of drug
resistant TB (5,6). DOTS, standing for Directly Observed Treatment Short
course, is one of WHO’s main strategies for controlling tuberculosis. It
contains five elements which are further explained below: government
commitment, early detection, standardized drug treatment, consistent delivery
of drugs, and monitoring results. These guidelines were made to provide clear
objectives for its global intervention program against TB with the major hope
to minimize case re-occurrence and reduce likelihood of future outbreaks of MDR
and XDR tuberculosis (6).
The Directly Observed Treatment Short Course
(DOTS)
The Five Components of DOTS*
1. “Political
commitment with increased and sustained financing”
-
Government support in following through interventions and policies
2. “Case detection through quality-assured bacteriology”
- Increased use of diagnostic techniques to
promote early detection of TB
3. “Standardized
treatment with supervision and patient support”
- Drugs are
implemented according to standards to achieve maximum effectiveness and to
prevent re-occurrence.
4. “An effective
drug supply and management system”
-
Consistent resources to increase recovery
5. Monitoring and evaluation system and impact measurement
- Making sure health intervention are regulated
correctly
*Obtained from the World Health Organization on 12/10/2014
Critique of
Current Public Health Interventions
Different Sources of Drug
Resistant TB
The
efficient management of an epidemic of any disease requires proper knowledge of
the source of infection. This has frequently stemmed the question: “How does
the majority of patients become infected with drug-resistant TB”. An infection
of drug resistant TB can come from either transmission where drug resistant TB
is obtained from another individual or self-acquisition where it is developed
within an individual’s own body. Recently, self-acquisition has been the major
focus among intervention programs. Since drug resistant TB can be “created”
from poor adherence to treatment and long ineffective use of medication, it has
been a significant concern of health officials whether or not new MDR or XDR TB
cases will emerge from improper distribution and control of antibiotic
medication.
In a
2005 research study conducted by Neel R. Gandhi, researchers surveyed rural
South African hospitals to measure the impact of HIV on TB prognosis (7).
During their observation, they found that a majority of XDR TB patients that
were surveyed have never been previously treated for TB. This meant that most
incidences of XDR TB were not likely self-acquired but obtained through
transmission from another patient infected with XDR TB. Major concerns then
came onto the possible outbreak of XDR TB through primary transmission
especially in a susceptible population with a high prevalence of
immunodeficient people where drug resistant TB is more likely to develop.
In
the DOTS intervention program, WHO focuses a significant amount of resources
toward treatment management and follow-through to prevent the occurrence of
self-acquired drug resistant TB. Two out of the five major components
(Components 3-4) of DOTS’s intervention focuses on treatment management while
there were no specifically designated component for preventing and controlling
transmission of TB between patients (6). Although previous interventions that
focused on self-acquired drug resistant TB had a significant role in reducing
the occurrence of drug resistant tuberculosis, the result of Gandhi’s study in
rural South Africa shows that most of the current drug resistant TB are from
transmission and not through self-acquisition. Therefore, it would be
resourceful to redirect much needed focus towards preventing TB transmission
and to not focus entirely on TB treatment follow-through.
Problems with Follow Through
of Antibiotic Treatment
The current
treatment plan for TB provides a significant challenge to proper public health
intervention. As recommended by the CDC and WHO, the standard treatment regimen
for tuberculosis is an initial two month treatment of isoniazid, rifampicin,
ethambutol, and pyrazinamide followed by a second stage of treatment using
isoniazid and rifampicin for another 4 months. The entire treatment procedure
would often require six to nine months of commitment with numerous potential
side-effects. This is not only difficult for the patient but also poses many
financial limitation to public health intervention.
Problems
with TB treatment follow up is seen the most in low resource environments.
These locations have a high rate treatment defaulting due mainly to
insufficient resources for physicians to contact and monitor patients.
Therefore, patients often stop or reduce treatment for long duration of time
which is often a precursor to developing drug resistant TB. It is important to
strengthen treatment monitoring programs to follow patients and successfully
treat more TB patients to reduce spread and chances of MDR and XDR TB.
WHO’s
DOT program tries to improve follow up of its treatments through its belief of
rigorous surveillance as stated below:
“with
rigorous monitoring of and accountability for ensuring cure... We believe that
evidence and experience show that the only way to achieve these high cure rates
on a programme basis is through direct observation of treatment given by a
person accountable to the health system and accessible to the patient.”(WHO)(8)
However,
this method of intervention can be a potential problem as it creates reactance in patients. Reactance is behavior
theory where individuals will have the desire to do the opposite choice of what
is given or demanded of them as an assurance of personal freedom (9). If
patients are constantly watched and demanded to follow rigorous treatment
procedure, they might feel that their freedom of choice is being taken away.
Even though the treatment is benefiting the patient’s own well-being,
discomforting treatment side-effects and the lack of understanding the dangers
of TB can reduce willingness for patients to participate to the full extent
necessary. Therefore, it would be better use an intervention that would be able
to provide access to freedom and have them use their own free will to follow
through treatment.
Early Detection Techniques
Treatment
of infectious disease is highly dependent on early detection. One important
early detection method is contact tracing is the act of tracking and
investigating previous contacts of an infected individual during their
infectious period. It is relevant to tuberculosis surveillance because it is
one of the most efficient methods of detecting early spreads of TB infection
which improves treatment success rate. Current diagnostic tests for TB and drug
resistance relies on mycobacterial cultures which can be expensive especially
costly for low income and resource areas of the developing world. It is of
great importance to find newer, faster, and cheaper ways of successfully
diagnosing patients with the correct form of TB.
As
shown through its perseverance in history, tuberculosis is not an easy disease
to control in a population. Due to it contagious and dormant qualities along
with its already global spread, it takes a significant international effort to
keep incidence rate manageable. In the current targets of the Stop TB Strategy,
the WHO predicted that it would take at least 40 year to eliminate TB as a public
health problem. Therefore, it is essential to implement not only short term
interventions but also interventions with long term effects that will provide a
much more powerful overall investment.
WHO’s
current tuberculosis program focuses significantly on direct intervention
methods such through expensive antibiotic drug treatments and sometimes
unreliable follow up procedures. With a significant investment of direct
treatment, early detection techniques such as contact tracing as discussed
would be a valuable intervention tool. Although very powerful when implemented,
many of these intervention are very costly and only result in short term
effects with no significant long term use.A common concept in both medicine and
in public health is “An ounce of prevention is worth a pound of cure” (13). As
a long term investment, prevention through social intervention could prove to
be more efficient and far less costly when compared to direct intervention.
Potential
Public Health Intervention Methods
Infection Control and
Isolation in Health Care
Since
many of the current drug resistant TB are transmitted and not acquired through
incomplete treatment as shown by the Gandhi’s study, it is important to invest
resources into infectious disease control and prevention. TB is a highly
contagious disease being able to become airborne simply through coughing or
even speaking (5). There a number of effective methods to deal with airborne
infectious diseases such as by implementing the wearing of surgical masks or
reducing accessibility to crowded community structures. However, it is
important consider that many TB patients are located in rural undeveloped
countries were there already are wide spacing between individuals. Therefore to
deal with TB transmission, it is important to intervene at its source,
hospitals.
Since
the turn of the century, hospital environments has been a major source of TB
outbreaks especially in developing countries. Heavy TB patient crowding, lack
of proper ventilation, and poorly-sanitized operating conditions of some rural
hospitals create an incredibly dangerous breading ground for TB. Following with
the often poor drug adherence in these areas, many TB outbreaks in hospitals or
clinics such as the MDR and XDR outbreak incidence in South Africa during March
2008 are drug resistant TB (10).
To
combat hospital TB transmissions, one of the most suggested interventions is to
promote immunological and infection control education to first-line health care
provides such as doctors and nurses along with medical administrative staff.
Doctors and nurses have the quickest and most frequent access to patients.
Therefore, well-organized educational seminars can provide long term investment
to reduce not only TB infection but other hospital-related infections. Along with
doctors and nurses, medical administrative staff should be especially
encouraged to be involved in infection control. Since many administrator
control over funding and construction projects, getting the knowledge of proper
disease control in a hospital setting could be long term benefit to the proper
management of hospitals.
Continued
education interventions has has numerous successes. In the US,
hospital-acquired infections are an ongoing problem tackled by surgeons and the
post-surgical staff with over a 10 billion dollar financial burden each year to
the US health care system (11). This burden has been tackled through workshops
and seminars that teaches physicians the various methods of infections and
develop new techniques to prevent them.
Redirect treatment emphasis
and
An
integrative intervention method to combat the current problem of follow up
requires two steps . First, it is important to implement the right ratio of
funding for treatment and follow up. Following from the discussion of “all or
nothing”, lets consider two intervention methods. The first method places more
emphasis on TB treatment and attempts to treat 100 people. The second method
places more following through each TB treatment and attempts to treat only 20
people. If we assume that 10% of people follow through in intervention one and
50% followed through in intervention two, the resulting number of recovered TB
patients would be the same. However considering how many people Therefore, the point of this illustration is
that it would be more resourceful to treat fewer people with higher success
rate than to treat more people with a lower success rate even if the end is the
same number of recovered people.
From
our first intervention, there would be an decrease in the number of available
treatment. The second intervention is complement of the first intervention by
creating an application pool. It is important to visualize the association of
treatment and results for TB to determine the method of intervention. In a
broad view, treatment of TB is an “all or nothing” situation. It is necessary
for patients to follow the duration of treatment plan for the patient to fully
recover. If dropped out of treatment, the patient is likely to redevelop TB and
be infectious. Therefore, any form of service or treatment provided to
individuals that do not follow through will potential be wasted. In actuality,
the “all or nothing” statement is not entirely true since patients who took TB
medication and did not follow through are likely to develop drug resistant TB
which is more difficult to treat in the future and can cause further
transmission of MDR and XDR TB to others.
Marketing and Focusing on
Immunodeficient Groups
A
potential social intervention to prevent cases of tuberculosis is to expose young
children and school programs to the proper techniques in preventing disease
transmission. As social cognitive theory suggests, individuals often learn
through social context and observation (15). Young children are often the most
susceptible to this theory and will most likely provide more effective results.
In this intervention, school student would be taught at an early age to wash
hands, cover up coughs, or wear surgical masks when sick. Marketing campaigns
such as posters and basic sanitary equipment are potentially important tools to
introduce proper prevention of disease transmission.
The
practicality of this social theory can be seen in the recent cultural changes
of certain Asian countries. In Japan, wearing surgical masks has become a
standard for people who are sick or have symptoms of coughing or sneezing. The
habit which is often learned at an early age has become so deeply embedded in
Japanese culture that it is constantly enforced through pressures of social
conformity (15).
Additional
benefits to the early exposure of daily sanitation techniques, children can
become more knowledgeable about the role of health care providers. In many
developing countries of Africa, many TB patients refuse treatment from doctors
and hospital due to fear and misrepresented images of health care workers. This
has been seen significantly in the recent Ebola epidemic where individuals
infected with the deadly Ebola virus would hide and prevent themselves from
being quarantined and treated by health care professionals. By introducing
children consistently to the positive image of the hospital environment and
health care workers, it would likely improve the general image of health care
to the population at risk for TB potentially increasing future participation in
TB treatment and supporting earlier diagnosis.
Conclusion
Using Complementing Long-Term
Social/Behavior Interventions
The DOTS
program has had many accomplishments since its initiation in 2006 having
treated millions of tuberculosis patients world-wide(6). Although the DOTS
program provided an essential springboard towards the management of TB
treatment in developing countries, many direct intervention
methods such as importing antibiotics and implementing expensive testing
methods creates significant self-limitation to its own intervention’s
availability and applicability.
Considering the staggering
costs of Stop TB Strategy and DOTS program, the current TB management is very
time consuming and resource draining to WHO and many supporting organizations
and countries. The solution is to direct portion of the funds towards long term
investment. Many of the potential interventions discussed in this article such
as infectious control education and health awareness in youth provide a much
longer lasting effect than direct intervention. Direct interventions are
necessary and has been an important effort in stopping the immediate spread of
TB, but it is important to think about the long run and properly invest in
long-term invention methods to complement ongoing direct interventions.
References
1. New Jersey Medical
School: Global Tuberculosis Institute. A History of Tuberculosis Treatment.
http://globaltb.njms.rutgers.edu/tbhistory.htm
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Organization. Global Tuberculosis Report 2014. xii
3. Mayo Clinic.
Tuberculosis Causes. http://www.mayoclinic.org/diseases-conditions/t
uberculosis/basics/causes/con-20021761
4. Centers for
Disease Control and Prevention. Multidrug-Resistant Tuberculosis (MDRTB).
Tuberculosis Fact Sheet http://www.cdc.gov/tb/publications/factsheets/
drtb/mdrtb.htm
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of Allergy and Infectious Diseases, Tuberculosis
http://www.niaid.nih.gov/topics/tuberculosis/Understanding/history/pages/historical_killer.aspx
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http://www.who.int/tb/strategy/stop_tb_strategy/en/
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http://www.goodreads.com/quotes/247269-an-ounce-of-prevention-is-worth-a-pound-of-cure
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