World TB Day


It’s World TB Day. One day on the calendar to remind us of the world’s highest prevalence infectious agent and the impact it has on numerous lives, especially in the developing world.

I’ve seen too much tuberculosis in my life. And I haven’t seen that much at all. In my month in Papua New Guinea, I spent much of my time wondering, with every little cough, if I would come home with MDR-TB (multi-drug-resistant tuberculosis; resistant to at least isoniazid and rifampin) or XDR-TB (extensively-drug-resistant tuberculosis; resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs). Now, I hear that there’s TDR-TB (totally-drug-resistant tuberculosis) emerging in India. For an infection that’s almost as easy to catch as influenza, that’s pretty darn scary.  I’ve put too many chest drains in tuberculosis-infected chests, only to watch three litres of pleural effusions (fluid in the chest) drain out in ten minutes or less. I saw the relief in the faces of the patients as they could suddenly breathe again – but I knew that the drain only treated their symptoms and did nothing to cure them. I’ve seen a frail young man coughing and spluttering from the miliary tuberculosis spread throughout his chest, eating away all of his energy. And, when asked to wear a facemask to protect the other patients in our over-crowded emergency room, he looked puzzled. He had no idea how deadly this infection was, despite how much it had ravaged his own body. I looked at his mother with sadness – her son was not to last much longer, and chances were that she would be infected. I saw a baby who was only months old cough with such an exhausted chest that, had I not known the noise was from our tiny charge, I would have guessed it was from an elderly person with a long history of smoking.

Tuberculosis isn’t, however, just an infection of the developing world. It’s a disease of over-crowded environments. It’s an infection that has largely been forgotten in the past thirty years of panic, and ensuing effective treatment control, of HIV/AIDS. Tuberculosis was once a huge killer on our own soil. It orphaned my own grandfather almost a century ago, and killed many more on battlefields, and in hospitals. It still rears its ugly head in many parts of this country. And, despite being a focus of the Global Fund for HIV/AIDS, TB and Malaria, many of our treatments are in excess of fifty years old.
We’re running out of ways to treat tuberculosis. We’re running out of drugs that are effective against an increasingly mutating infection. And it hasn’t gotten any less infectious. It’s particularly dangerous to the young, the elderly, and to the immunocompromised (which doesn’t just mean those with HIV, it also means those with cancers, those who have received organ transplants and many who are treated for auto-immune conditions). The treatment regime for “normal,” sensitive tuberculosis is DOTS – directly observed therapy, short-course – of four-drug therapy for eight weeks (isoniazid, rifampicin, pyrazinamide, ethambutol) followed by double therapy for four months (isoniazid and rifampicin) [BMJ Best Practice]. According to the Centenary Institute, based next to Sydney’s Royal Prince Alfred Hospital, our current treatments are more than 50 years old. We haven’t found anything more effective in half a century. And we need something better. Treatment of MDR-TB and XDR-TB involves long-term (it can exceed 24 months) treatment with a range of drugs that are measured to be effective against the infection. Sometimes, we don’t know if anything will work. The drug treatments are arduous, often requiring isolation to prevent further infection, and exceedingly expensive. For a disease that places its highest burden on the developing world, these treatment regimes are not feasible in already strained local and aid-based health facilities. Last year, a young Papua New Guinean woman made headlines in Australia due to her XDR-TB treated in Cairns. Despite the $0.5-1 million price tag of her drug treatments, no cure could be guaranteed.  Sadly, hers is not an isolated case. PNG is Australia’s nearest neighbour and one of the highest per-capita tuberculosis-infected nations in the world. This is a social disease and one of poverty – and we’re running out of ways to defeat it.

Prevention, of course, is always better than cure. Drug-resistant strains of TB came into existence because treatment regimes were not continued for long enough – whether this was because of lack of access or misunderstanding of health professionals’ explanations. The problem with infectious diseases is that an infected individual will feel much better before the infection is completely eradicated, leaving them exposed to re-activation of latent infection down the track. A latent infection that is likely to be resistant to the previous line of treatment. And, on the re-activation, the disease is still infectious, spreading to close relatives. Early symptoms of TB don’t seem much different to a cold or flu – fever, chills and coughing.  Once infection is present, it can be hard to treat. So how do we prevent it from happening in the first place? Can we come up with an effective vaccine? Our current vaccination is only even mildly effective if given in childhood but may do little to protect adults.  Can we do to TB what has been done to smallpox and (very nearly) polio?

There is still so much to be done in our fight against this infectious disease. It’s time to stop tuberculosis. It’s time to develop better prevention and control strategies. It’s time to invest in drug research. It’s time to find a vaccination and acure.
Are you going to stop TB with us?

This piece was originally posted on hiavenir.com

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