World TB Day

Several million deaths per year are caused by tuberculosis - a disease which still remains epidemic in many countries.  World TB Day raises public awareness of the disease and commemorates the day that the cause of tuberculosis was discovered.

World TB Day - 24 March 2009

Background Update

It is considered that a third of the world's population is infected with the bacteria that causes TB. The World Health Organisation estimates that 9.2 million people developed the active disease in 2006 and there were up to 2.5 million deaths.

Anyone can get TB. People at greater risk of developing active disease include:

• Children and the elderly
• Smokers
• Those living in overcrowded conditions
• Those who have a poor diet
• People with HIV
• The homeless
• Those who have a weakened immune system because of other medical conditions, such as diabetes, or because of other medical therapy, such as immuno-suppressant medication

Although significant protection can be obtained through vaccination and long established therapy is effective in patients affected by sensitive strains when used properly for the correct duration, a number of key issues have assumed a higher profile in the treatment of TB.

These include:

• the increasing number of cases of the disease resistant to routine multi-drug therapy (WHO suggests that about 500,000 new cases are infected with resistant strains). As a result patients may need to be treated for extended periods or, in the case of extremely resistant TB, with non standard regimens. The development of resistant strains of Mycobacterium means that there is a higher risk of patients not completing their treatment and obviously a higher cost. Additionally some patients may contract a form for which no effective drug regimen exists.
• efforts to improve laboratory processes so that sensitivity data is obtained in a shorter time. Given the delay in getting sensitivity data it is likely that patients with a resistant form may not be receiving effective treatment in the interim. In addition they may continue to be a possible source of the disease to their close contacts. In some countries with limited laboratory facilities data on sensitivity may not be available at all which may increase the likelihood of resistant strains emerging in these patients.
• improving understanding of the issues where patients have TB and other significant diseases, particularly HIV/AIDS, In 2006 just under 8% of those diagnosed with active TB were also infected with HIV/AIDS.

Pharmacist’s Role in the Prevention & Management of Tuberculosis

Prevention

Raising awareness of TB
Advice on vaccination
Advice on avoiding transmission
Referral to diagnostic services

Care

Advice on nutrition
Advice on maintaining physical health
Provision/referral to psychosocial services
Reducing stigma & promoting equitable access

Treatment

Provision of medicines in appropriate form and dose particularly in the context of DOTS services
Medication information
Management of medication side effects
Management of opportunistic infections
Management of HIV/TB co-infection
Recording/reporting drug resistance
Supporting adherence and continuity of treatment

Recent Studies

In addition to engagement in routine professional roles supporting these activities in their own health systems some recently published material may suggest some other features practitioners might apply in increasing their individual practice effectiveness.

Resistant TB

A study of risk factors for multi-drug resistant TB (MDR-TB) in patients at a tertiary care Hospital in Pakistan showed a high percentage of patients with MDR-TB were uneducated and poor: all had previous history of TB with 1,2 or 3 previous courses of treatment by different clinicians with unsupervised treatment during the initial course.

A study of TB patients treated in a DOTS programme in South India had an 8% failure rate. Significant numbers of failed treatment were in males who had previous TB treatment and were infected with drug resistant strains.

Surveillance of anti-tuberculosis drug resistance in children from Western Cape, South Africa showed doubling of resistance to single or multiple anti-TB drugs over relatively short period. Those who had been previously treated for TB showed a higher incidence although this was attributed to transmission of resistant strains rather than development of resistance within the individual. HIV status was not significantly associated with TB resistance.

A joint South African and US meta analysis on published trials showed MDR-TB patients needed at least 18 months treatment and a DOTS approach.

The CDC in Atlanta (USA) estimated that the cost of treatment for extensively resistant TB is twice that for those with MDR-TB. The response in these patients is such that mortality is at similar levels to those pertaining prior to the availability of antibiotics.

HIV/AIDS and TB

A high co-infection rate (24%) of TB in patients with HIV/AIDS patients was found in a study in Trinidad and Tobago but was 10% patients at Kano teaching Hospital, Nigeria. 75% of the latter group had pulmonary TB but there were also cases of abdominal and spinal TB and TB adenitis.

In an Indian study HIV/AIDS co-infected with TB was associated with

• High pill count
• Challenges to adherence (concordance/compliance)
• Overlapping drug toxicities
• Increased risk of immune reconstitution inflammation syndrome (IRIS)

The authors suggest that there is a need for co-ordination between HIV and TB programmes.

Other Diseases and TB

In a study in Quebec (Canada), the standardized (for age and gender) rate of TB in patients with Rheumatoid Arthritis was 10 times that of the general population. This was related in part to the use of disease modifying anti-rheumatic drugs and steroids.

Society and TB

A study of attitudes and behaviours of community members towards TB in Ghana showed a stigma attached to the disease particularly associated with fear of infection leading to the avoidance of personal contact and desire to exclude TB patients from community activities. The consequence was that TB patients hide their diagnosis or attribute symptoms to another disease and be may default from treatment.

Due to the poorer prognosis, it is suggested by the Nuffield Centre, Leeds (UK) that in countries where TB is epidemic the patients under diagnosis or treatment should be offered co-treatment with anti-tobacco agents.

World TB Day provides an opportunity to review our practices and to update our activities so that we make best use of the time we spend dealing with patients with TB.

To find out about the Commonwealth Pharmacists Association's past activities to mark World TB Day follow the links below:

World Stop TB Day - 2008

World Stop TB Day - 2007

World Stop TB Day - 2006

World Stop TB Day - 2005