TB or not TB

What did King Tutankhamen, John Keats, Eleanor Roosevelt and Emily Brontë have in common? Their deaths were all allegedly caused by Tuberculosis.

Tuberculosis (TB) is an infection caused by a mycobacteria. It mainly affects the respira­tory system, and in active infections can cause chest pain, chronic cough with bloody sputum, fatigue and extreme weight loss. It is this last symptom that gave TB its former name, “con­sumption”.

When a person is diagnosed with TB, the simplest treatment is to give the patient a full course of antibiotics. However, in some cases this is easier said than done. Many people live too far from medical clinics, are too poor to afford medication or do not understand the importance of finishing a course of antibiotics. The under-use of antibiotics has resulted in the strengthening of the TB mycobacteria through what is considered natural selection in its most basic form. Bacteria that are particularly resist­ant to the antibiotics are able to thrive when a course of medication is stopped too soon.

Along with other factors, including the over-use of antibiotics, multi-drug resistant tuberculosis (MDR-TB) and even extensively drug resistant tuberculosis (XDR-TB) evolved. The World Health Organisation (WHO) developed a Stop TB Strategy which aims to virtually eradicate the world of TB by 2015. However, the increasing number of patients with these drug-resistant strains or “superbugs” has extensively slowed the progress of this program.

MDR-TB is resistant to isoniazid and rifampicin, which are the two drugs used mostly commonly in the treatment of regular TB. Treatment therefore involves a variety of second-line drugs, including a several other injectable antibiotics. Treatment for XDR-TB is even more complicated as this strain is also resistant to some second line drugs. Treatment is costly, can result in serious side effects and is not always effective. In fact, we are almost no better placed to treat XDR-TB than we were to treat regular TB in the pre-antibiotic era. The cure rate is believed to be somewhere between 40 and 60%.

TB was once a disease feared by all: rich, poor, adults and children – no one was safe from the highly contagious disease. But nowa­days, in the developed world, TB is considered a thing of the past. We have long since devel­oped effective treatments for regular TB, and the disease became less prevalent in scientific research – and, we all presumed, less prevalent in the population.

This is not totally accurate, however, as the ‘simple cure’ for TB is anything but these days – particularly with the rise of antibiotic re­sistant strains. In 2011, nearly 9 million people were infected with TB, and 1.4 million people died as a result.

This is approximately equal to the num­ber of deaths caused by HIV every year, yet the world wide publicity for HIV is ten-fold that of TB. Death by severe illness is always tragic. But is death by an entirely treatable disease more so? People are dying from regular TB when there is a cure that costs a mere $15 to $25. By contrast, medicine taken for HIV is much more expensive and is taken to manage symptoms and stave off the effects of the disease for as long as possible. The cyclic relationship be­tween HIV and TB also cannot be overlooked when considering the two diseases. Because HIV weakens the immune system, patients suffering from this disease are more susceptible to developing TB. This is why TB is one of the biggest killers in patients with HIV in the third world. Current medical research is so caught up with curing HIV that it is repeatedly over­looked that eliminating TB would be a strong step towards minimising deaths of HIV patients in the third world.

There are an enormous number of ethical issues being raised in the treatment of TB and in public health, particularly when it comes to pandemic planning. Questions regarding the ethics of third-party notification, the limit to health workers supposed ‘duty to treat’ and how medical resources should be allocated are crucial considerations.

Similarly in the quarantine debate, committees and policy makers worldwide have to strike a balance between a person’s right to freedom of movement and protecting public health. In 2007 a precedent was set by the Centre for Disease Control (CDC) in America when Andrew Speaker was the first person to be forcibly quarantined since 1963 after he was suspected of having XDR-TB.

Although TB seems as though it is only a problem for the third world, it would be very short sighted of us to think this true. As an airborne disease it has every potential to travel and infect worldwide, particularly MDR-TB and XDR-TB.

For more information about TB and public visit the World Health Organisation (WHO) website.

Madelynne White

The author Madelynne White

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