Multi-drug resistant TB: Treatment today, hope for tomorrow.

I would like to introduce Smaranda Fillip, a colleague of mine who is studying towards her MD at my old alma mater, the University of Queensland, in addition to studying in New Orleans as part of a joint medical school program. She wrote the bulk of this succinct informative introduction to multi-drug resistant tuberculosis along with myself (in a mostly editorial context).

Tuberculosis (TB) is the second most common cause of death related to an infectious disease agent. It is caused by the bacterial pathogen, Mycobacterium tuberculosis. Progress has been made, and the rates of TB are declining; however the numbers are still staggering. In 2013, 9 million people became ill with TB and of those, 1.5 million died from the disease. In addition, 480,000 people became infected with either acquired or primary multi-drug resistant TB (MDR-TB). Most cases occur in underdeveloped regions including African and Asian nations, India and Eastern Europe. MDR-TB affects not only the countries that have to carry the burden of disease, but it impacts the global community, as we strive to meet the 2015 millennium developmental goals.

During the initial diagnosis of TB, the patient is placed on a 6-month regimen of chemotherapeutic drugs. If taken correctly, the treatment allows for a greater than 95% cure rate. If the patient is not compliant with the medication and does not follow treatment protocol, or if the medication is prescribed incorrectly, TB can mutate into MDR-TB. MDR-TB is defined as tuberculosis that is resistant to at least rifampicin and isoniniazide; the primary drugs used in the first line treatment of TB. Thus, resistance to these drugs develops as a consequence of improper treatment regiments and failure, on behalf of the physician, to ensure that patients complete treatment. The reasons are varied, including lack of access to hospitals, little money to afford the medication, lack of community support for the sick patient, and the inability to take time off work; all of which contribute to the high levels of non-compliance in developing countries. Once an individual develops MDR-TB, transmission of the disease can occur through respiratory droplets, which is also known as acquired MDR-TB. The people most susceptible to acquiring MDR-TB are HIV/AIDS patients, and individuals in the prime of their lives, usually between the ages of 15-44. Diagnosing MDR-TB is inherently difficult due to the high cost of the equipment required to make the diagnosis, and the time it takes to obtain test results. Once MDR-TB develops, medication costs 200 times more than drugs used for TB, and treatment can take up to two years, resulting in social isolation, loss of jobs, and long-term psychological and socioeconomic effects.

It is estimated that developing nations will have to spend between $1-3 trillion dollars over the next 10 years on MDR-TB. This is especially concerning in developing countries because it places a financial burden on fragile and unstable economies. These countries have limited resources, and are currently struggling with problems such as famine, failing infrastructures, and overpopulation. Placing an additional stressor, such as MDR-TB, which is inherently difficult and very expensive to treat, results in a situation where many people will not get the drugs they require. Many will not even have the opportunity to be diagnosed. Therefore if nothing is done, more people will continue to get sick. They will be forced to stop working, either due to debilitating disease, or because of the social stigma associated with TB and their family members will have to take time away from work to help care for them. This will have a negative impact on the GDP of these countries as fewer goods are produced and bought. If the economy struggles, it will exacerbate the problem of MDR-TB because less money will be available for drugs, diagnostic equipment, and expansion of hospitals into areas that carry the burden of disease. As we approach 2015, the world is trying to meet certain goals, the United Nations Millennium Development Goals (UNMDGs) of 2015, in order to eradicate disease, promote education, stop hunger and promote well-being. To achieve this, countries need to be as stable as possible in order to have available resources, which are required to undertake some of our world’s most significant problems that threaten millions of lives. While MDR-TB is a growing concern, it is not yet one of endemic proportions, and we have the capability of quelling MDR-TB as a problem before it becomes costlier, and takes away from human productivity and resources which are needed to meet the millennium developmental goals.

So far, strategies such as DOTS or Directly Observed Treatment have successfully decreased the number of people with TB. In addition to that, other strategies and agents can be utilized. Doctors must be aware of how MDR-TB develops, and work towards prescribing medication correctly, never treating TB or MDR-TB with just one drug, and strict follow up with patients which are diagnosed with MDR-TB. Health care workers and hospitals can improve ventilation systems in hospitals to decrease the chances of transmission between patients and hospital staff. Media in developing countries can work towards promoting public awareness of MDR-TB to decrease the social stigma associated with disease. Lastly, because of the concomitant risk of AIDS patients developing MDR-TB, a continued effort must be made via organizations such as the World Health Organization and Doctors Without Boarders, to decrease the number of people becoming infected with HIV/AIDS as this will reduce the cases of MDR-TB.

Doctors have a fiduciary responsibility with their patients and providing them with the best care possible, regardless of their background. This involves educating patients, making the right diagnosis and choosing the appropriate medication which would best treat the disease. Technology and globalization has made extensive travel possible, therefore, physicians will continue to be exposed to an increasingly diverse patient population. It is therefore necessary to continue onwards with improving medical training with a focus on the science of disease, and to also garner increased awareness of global events and their wider effects. What is required are people which enjoy teaching, and bringing attention to these global issues so that the doctors of tomorrow can strive towards universal health and well being for their patients.