Biggest danger high number of patient drop-outs

TB - the good and the bad

By Tharuka Dissanaike

Appuhamy (not his real name) travels daily from his Ekala home to the Welisara Chest Hospital. Here, a nurse gives him a handful of pills, capsules and a glass of water. She watches sternly as he swallows the medicine and makes appropriate indications on the chart that records the history of the disease. Appuhamy prepares to go. The nurse instructs him to be back the next day for his drugs.

Appuhamy suffers from tuberculosis. He has been a victim of this debilitating disease for the past year. The clinic doctor blamed his slow recovery to irregular medication. Appuhamy has therefore, been asked to report daily to the clinic, where a nurse would administer the drugs. Without continuous treatment for six months a TB patient cannot be cured.

"The biggest danger is the high number of drop-outs," said Dr. (Mrs.) V. R. Weerarathne, Director, Respiratory Diseases Control Programme. "Patients take the drugs for two or three weeks, but as soon as they start feeling better the inclination is to stop medication."

In Sri Lanka, TB treatment involves hospitalisation for the first two months. This is possible due to the wide network of chest clinics and government hospitals in the country. The two main chest hospitals, in Ragama and Chavakachcheri, coordinate 20 district clinics, 12 of them with ward facilities.

"The first two months are crucial. That is the infectious period where the patient can spread the disease. After the first two months, the patient has to take daily medication for the next four months," the Director said

To make sure that patients actually take these drugs a system called DOTS (Directly Observed Treatment Short course) has evolved as the accepted norm for TB treatment. This means that a doctor, nurse or trained health worker observes the patient actually swallowing the daily dose of medicine.

In Sri Lanka the DOTS strategy is being implemented in chest clinics in six districts — Galle, Matara, Anuradhapura, Colombo, Gampaha and Kalutara. Diagnosed patients are generally hospitalisd for two months. The medicines are despatched to the clinics and patients have to report to clinics daily for treatment for the next four months. The law entitles TB patients to six months' leave from work and the state offers a Rs. 500 allowance for additional nutrition during treatment.

The public generally regards TB as a controlled disease- one which requires little attention. But statistics point to a disconcerting pattern where numbers have remained static despite a widespread control programme. For the past decade, around 6,000-6,500 new cases have been reported every year. Deaths are relatively low- 5 per 100,000 population.

"Tuberculosis is a compulsorily notifiable disease. We maintain a central registry here with details from all districts. But I feel that all TB cases are not reported and the real incidence could be much higher than our figures," Dr. Weerarathne said.

Although the disease is notified by all state hospitals, information coming in from the private sector is negligible, Dr. Weerarathne said. She said that many urban and middle-class patients prefer to take private treatment due to the stigma that is still attached to the disease.

TB medicines are distributed free in the government chest clinics, but can be bought from certain pharmacies and drug stores.

Worldwide there has been a virtual explosion of TB in the last decade. A few years ago the World Health Organisation declared the spread of TB a global emergency. It is estimated that one third of the world's population is infected with TB, which is caused by a bacillus, a form of bacteria. As a region, South Asia has the highest incidence of TB. Countries with high poverty, over-crowded cities and little access to health care are the worst affected. Undernourished populations are more susceptible to the disease due to poor resistance to infection. TB is the leading killer disease among women of child-bearing age in developing countries.

The age-old disease is gaining more attention even in countries like the USA due to its link with HIV/AIDS. Nearly half of all AIDS patients die of TB. Here also low immunity causes a ready onset of the disease. Recently Bill Gates, Head of Microsoft, pledged $25 million to research new TB drugs. His charitable gesture was aimed at curbing a new wave of the disease, caused by strains of the bacteria resistant to the old drugs, now sweeping across the world, affecting developed countries just as readily.

"Our biggest task is to de-stigmatise the disease and encourage more patients to seek proper treatment," said Dr. Weerarathne. "TB is completely curable. But the regimen of treatment is very specific. Patients, who stop treatment in a few weeks or months, run the risk of developing drug-resistant TB. This is very difficult to cure and drugs are extremely expensive and toxic."

This is the danger in treating patients in the private sector, said Dr. Weerarathne. "Private practitioners would find it difficult to implement the DOTS strategy, leading to irregular medication and patients could develop drug-resistant TB."

DOTS, now the standard treatment course for TB in 110 countries, needs close supervision. When patients don't turn up for the medication, health workers send them telegrams. Patients are regularly tested to see if their sputum contains traces of the bacteria. Private practitioners have neither the time nor resources to implement such an exhaustive medication course for six months for each patient.

"We are gradually training health workers and staff at clinics to monitor patients. It will take awhile before DOTS can cover the entire country," Dr. Weerarathne said. "We are also experimenting with community-based DOTS. We hope to use the widespread community health worker network to implement DOTS in very remote areas. Already family health workers have expressed their consent to monitoring TB patients."

In Sri Lanka, TB incidence is high among the 45-70 age group. The disease appears to be linked to nutrition and poverty. Twenty-five percent of the patients are in the Colombo district, where overcrowding and population pressure have caused increased susceptibility. Of the younger patients, many are drug addicts or prisoners. Patients at the chest hospital are tested for HIV by the AIDS/HIV control programme.

How you get it?

TB is a bacterial infection that commonly affects the lungs, called pulmonary. But other forms of TB are not uncommon. The most dangerous types are those that affect the blood stream and the brain. Any patient with a cough for over three weeks is expected to do a simple sputum test for TB.

First indications : A bad cough, pain in the chest, blood coughed up with sputum (phlegm from deep inside the lungs)

In addition the patient will also experience weight loss, fatigue, loss of appetite, fever in the evenings and sweating at night.

TB is spread through the air. Droplets that are coughed out can transmit the disease to another by inhalation.

The bacteria can then settle in the lungs for many years- even for life.

Weakening of the immune system due to disease, under-nutrition, drug abuse or AIDS can bring on the disease where the organism multiplies and affects the lungs or spreads through the blood stream to affect the lymph nodes, kidneys, spine or brain.

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