Tuberculosis: policies to contain MDR-TB

Tuberculosis, one of the deadliest diseases in human history, is a leading cause of death worldwide. The cause of tuberculosis is infection with the rod-shaped bacteria Mycobacterium tuberculosis (MTB). This obligate aerobe dates back to 4000 BC in Egypt, though it wasn’t until the 17th century where epidemics of TB became a serious problem. Currently, it remains a problem in both developing and developed countries. Transmission of this disease is carried in airborne particles and those that are sick with TB are highly contagious. This disease is treated with antibiotics. Antibiotics, though a blessing for bacterial infections, are also a curse because of the so-called antibiotic resistant bacteria; an issue that is on the rise with TB.

An extreme issue that poses ethical questions in the field of medicine is the multi-drug resistant tuberculosis (MDR-TB) and the extensively drug-resistant forms of tuberculosis (XDR-TB). Multi-drug resistant tuberculosis is where the bacteria are resistant to at least two of the first-line TB antibiotics. Extensively drug-resistant tuberculosis is where the bacteria are resistant to almost all of the drugs that are used to treat TB. It is a more extreme case of the MDR-TB.

When presented with a tuberculosis patient, one must look at all of the social factors and demographic characteristics of the patient, along with the medical condition(s). These characteristics play a big role in how compliant the patient will be with the curative antibiotic therapy. Some factors to consider include: the patient’s lifestyle, employment status, income, housing status, or other medical conditions (e.g. alcoholism or drug addiction).

When a curative agent is not taken to completion, there are consequences to not only the patient but also to society. Primarily, when the curative agent is an antibiotic or a set of antibiotics, then not completing the regimen completely leads to more antibiotic resistance. The bacteria are more likely to evolve resistance to the antibiotics. Given that there are only 5 first-line antibiotics that are generally used, and 5 second-line antibiotics that can be used, this would be detrimental. The patient could get to the point where they are not able to take any of the drugs used as curative agents. This perspective would be viewing the patient as a victim. However, we must also view the patient as a vector of the disease as well. The antibiotic resistant bacteria on the patient could also lead to the bacteria on the people around the patient to also become resistant to these agents (and so on and so forth, eventually spreading to an entire population).

Antibiotic resistance is not the only issue here. If the curative agent is not taken to completion, then the patient is not cured of the disease. When the general public is exposed to this patient, his/her bacteria will spread – therefore, spreading tuberculosis. Tuberculosis is not the most difficult bacteria to transmit, and so anyone who might come in to contact with this patient is likely to get exposed to the bacteria.

Directly Observed Treatment, also known as DOT, is a disease control strategy in which a qualified medical health professional or an approved designated individual observes the patient taking the prescribed drugs for treatment of a disease. This guarantees that the patient is actually taking the medication(s) and following the treatment regimen correctly which in turn secures better compliance. Whether this program is ethically justified or not is a question that many people ponder. In the interest of the health of the patient and the general public, this strategy can be considered ethical. A patient is not being detained for reasons other than that they pose medical harm for themselves and others around them; it is in their best interest to comply with it. However, this might be strictly viewing the patient as a vector. In viewing the patient as a victim, some might argue against it saying that DOT takes away the patient’s liberty. Some healthcare facilities use DOT as a threat to the patients; if the patient is not going to be compliant with the therapy, then he/she will be lawfully detained. Once DOT started making an appearance in the healthcare field, patient activists argued that this detainment program would be stripping the patient(s) of their respect and autonomy. The fact that the patients are being forced to into taking medications, aggressive screenings, therapy, etc. was deterring them away from seeking medical attention in such cases.

In a perfect world, a ‘volunteerism’ approach to this program would be ideal because then all of the sick patients would not only worry about themselves but also about the public health, and eventually comply to such therapy.  However, since we do not live in a perfect world, this is not the case (I know, I sound really cynical here – but it is the truth).

With such scary diseases, we think – why is there not a vaccine for this? Well, there is and its called the BCG vaccine. Woohoo, GO SCIENCE! BUT, it is a controversial topic because the vaccine consists of weakened live tubercle bacilli (bacteria) and the protection that it gives has a rate of only being 80% successful in children and less than 50% successful in adults. BOO! *inserts thumbs down emoji* This vaccine is not generally recommended in the USA because of its efficacy and its interference with the PPD tuberculin skin test reactivity.

I could go on and on about Tuberculosis. I find it so interesting and there is just SO much to say. I guess the main point of this piece is to not only get you to think about health policies that are being implemented in our community but to also encourage you to do some light reading about the health issues in today’s society.  We often take our advancements in medicine for granted and forget to think about some of the recurring issues that could detrimentally affect our society. I am completely guilty of this, unfortunately. I tend to think that there’s a solution for everything with how far scientific research has gotten – but that is not the case. Even if we did think we had cures for bacterial infections like TB, we run in to issues like antibiotic resistance.

Where do we go from here? Well, I am not sure. But, if I am sure of anything, it’s that we need to continue to educate ourselves about everything going around us.

I hope you enjoyed reading a little (or a lot, sorry if the post was a tad bit longer than usual) about Tuberculosis. Feel free to message with me any questions, comments or concerns. Sending love and peace your way.

xoxo

♥ FH

 

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