Self medication, expired drugs aggravate spread of resistant TB

By Agnes Asiimwe

Two deadly strains of TB are quietly and steadily spreading and will claim more victims if deliberate efforts arent put in place to check the spread. The multi-drug resistant tuberculosis or MDR – TB and extensively drug-resistant tuberculosis or XDR TB are both very difficult and very expensive to treat.  The spread of these types of TB could get worse if TB drugs stock-outs arent controlled because the resistance mostly develops out of poor drug adherence.  Government health centres are contributing to the problem by distributing expired drugs, but again many of the cases arise from failure by the patients to consistently swallow their drugs.

The temptation to default is huge. The tablets are big and intimidating and take six months to complete. Many patients feel better after two weeks of taking the medicine, and because they feel strong many drop off treatment. With no pain and no fever, thats when one needs family support and friends to finish the dose, says Dr. Francis Adatu-Engwau, the programme manager, National TB and Leprosy Programme, Uganda.

He says every person with MDR-TB was not treated properly, did not take their drugs properly, or was infected by somebody who was not treated properly or did not take their medicines properly.  Although persons with MDR-TB can usually be treated effectively by relying on second-line drugs (amikacin, kanamycin, or capreomycin), these have more side effects and are more expensive and less effective than first-line drugs and require regimens lasting 18-24 months.

Each patient costs $30 dollars to get cured [of regular TB], an MDR patient needs $2,000 dollars, said Adatu.

This is added stress to an already overwhelmed public health system.  Adatu lists self medication at drug shops, taking expired drugs or wrong combinations, interrupting medication, and poverty as the main drivers of MDR-TB. Because the drugs increase appetite and many patients cannot afford to get enough food, dropping off treatment becomes the easier option. In public hospitals, the Uganda national policy is that TB patients get discharged after two weeks because feeding them would be an extra cost to the health centres.

In 2007, 13% of TB patients defaulted on their drugs. “This is something we want to reduce to 5%,” said Adatu who says that fortunately for Uganda, MDR-TB is still low. A 2008 anti-tuberculosis drugs resistance survey by MSF-France in West Nile, a region with a high movement of people including Congolese and Sudanese and therefore a potentially high MDR-TB zone indicated only 2.6% cases. “I attribute it to the stringent distribution of drugs. We discourage open sale of drugs in drug shops,” said Adatu. Adatu revealed that this year the MOH has plans to conduct a national survey to establish the actual burden of drug resistance in the country.Â

Even deadlier than MDR-TB is XDR-TB. Treatment failures and subsequent death are more common among patients with XDR-TB, and the drugs available to treat XDR-TB are associated with serious adverse effects.  First described in 2006 in KwaZulu Natal, South Africa, XDR-TB killed 52 of the 53 HIV-infected people it affected. According to Centers for Disease Control and Prevention, CDC, because of the limited responsiveness of XDR-TB to available antibiotics, mortality rates among patients with XDR-TB are similar to those of TB patients in the pre-antibiotic era. No XDR cases have officially been reported in Uganda.

Scant knowledge about TB

While many people can fluently talk about HIV, they know very little about tuberculosis. “The public doesn’t know what TB is, people are not able to suspect that the cough they have is TB,” said Adatu, “and they don’t know where to go to seek treatment.” Yet, in Uganda, every health centre II and IV has TB services and that’s about 700 centres across the country (except for the notorious stock-outs).

TB spreads when people with the disease cough tiny droplets containing TB bacteria into the air and other people breathe them in. In overcrowded, poorly ventilated areas like hospital wards, schools, prisons and IDP camps, the germs are more likely to spread easily. The small airborne droplets containing the germs can remain in the air for hours. The majority of persons who become infected remain non-contagious and without a cough or other symptoms. However, vulnerable persons like children, pregnant women and HIV patients can easily catch TB.

Nobody is putting money in awareness campaigns [yet] if we got resources to respond to TB, we would be able to increase our case detection beyond 51%, said Adatu. The recommended TB case detection target by WHO is 85%.

Adatu says people need to be educated on how to recognise the symptoms and how and where to get prompt treatment. He says any cough lasting two weeks should be checked for TB because prevalence of the disease in the country is high. “About 60% of TB patients have HIV,” says Adatu, “it doesn’t make sense to talk about these as two separate diseases. It is a misguided programme which focuses only on HIV programmes.”

In 2007, there were 21,303 infectious cases of which 61% were successfully treated while 4.8% died. Some of the patients arrive for treatment when the disease was so advanced with only a small portion of their lungs left.

 Drug shortage

Uganda needs about $1.5 million (Shs 3 billion) per year to buy TB drugs. In 2007 only Shs 25 million was available to buy and distribute the drugs. This tight-fisted funding has led to shortages of TB drugs, the latest being shortly before Christmas in 2008. The Ministry of Health had to get emergency drugs from Kenya, which lasted two months, as they waited for a fresh supply of drugs by the Global Fund.

We do it all the time, Adatu said of their borrowing of TB drugs. We do it with Rwanda, Tanzania, when each others stocks run out. But even the borrowed emergency drugs got finished in some centres although some remained well-stocked with expired drugs. The Global Fund is the main donor for TB drugs. The drug shortages could exacerbate the problem of multi or extensive drug resistant TB.