Change needed in TB discourse
New response strategies are necessary to help cope with evolving strains of the tuberculosis epidemic
NEVER could we have imagined that incurable tuberculosis (TB) would become a reality. For decades, health professionals have given TB patients a ray of hope in the effective six-month treatment plan that liberates patients from TB. Drug-resistant TB has eclipsed those hopes as more patients are now diagnosed with potentially incurable TB strains (untreatable by drugs currently available in the country).
TB kills more people each year than any other infectious disease, including HIV/Aids. Globally it is estimated that 1.4 million people lost their lives to TB and 500 000 people were diagnosed with multidrug-resistant TB (MDR-TB) in 2014.
South Africa had 20 000 MDRTB cases detected in the same year (there were many more undetected), 8% of which were thought to be extensively drug resistant or totally drug resistant.
MDR-TB may occur when patients inappropriately or incorrectly use antimicrobial drugs or prematurely interrupt treatment, though several other factors, including inherently low drug levels in the body in some, may be important, too.
Further resistance to the drugs used to treat MDR-TB results in extensively drug resistant TB (XDRTB), which occurs when the patient is resistant to at least four of the antibiotics used to treat TB in the first-line regimen.
There has been an unfortunate growing burden of near-totally drug-resistant cases, with patients having to come to terms with an incurable disease. Until recently, it was thought that drug-resistant strains of TB were less transmissible, and that MDR- and XDR-TB were only acquired by individuals as a result of poor compliance to treatment.
Recent molecular and epidemiological studies have challenged this belief, suggesting that in most regions of the world, drug-resistant TB is now predominantly caused by transmission, with an estimated 95.9% of new cases infected with MDR-TB strains due to the drug-resistant bacteria spreading from one person to the next.
TB is a highly infectious disease that is commonly spread through the air from one person to another. TB germs enter the air when a person with active TB disease of the lungs or throat coughs, sneezes or speaks. People nearby may breathe in these germs and become infected, and subsequently develop active disease. This ease of transmission applies to XDR-TB as well as incurable TB when people infected with XDRTB or incurable TB spread that particular strain, and not a normal TB strain that is treatable.
As drug-resistant TB continues to rise, so does the need for rapid diagnosis, new treatment and community-based containment strategies for MDR-TB and XDR-TB patients. At present, patients with either XDR-TB or incurable TB who have failed treatment, when discharged back into their communities pose a risk of infecting fellow community members, inevitably increasing the number of infections.
Studies have shown that patients are more likely to suffer psychologically, abandon treatment and generally show very poor treatment outcomes as a result of being isolated in XDR-TB treatment hospitals, or at home, for a long time.
The same studies have also asserted that decentralising treatment may yield equivalent results to keeping them in hospital.
Taking into consideration both the patient’s well-being as well as that of the communities in which they live force South Africa’s public health specialists to develop ingenious interventions that will be beneficial for all.
These strategies include new detection and intervention technologies for infectiousness, and voluntary long-term community-based facilities and palliative care so that discharged patients can spend their last days with their families.
Strategies that will develop new rapid diagnostic tools are just as important in the fight against drug-resistant TB. Although the government has made some efforts in containing the spread of DR-TB by means of rolling out new-generation diagnostic technology (GenXpert), more needs to be done regarding development and deployment of more comprehensive diagnostic tools and better TB drug development and education.
Tackling the problem requires a multipronged approach, including reduction in poverty and overcrowding and other drivers of TB like HIV and smoking, roll-out and development of improved diagnostic technologies, actively finding cases, better drug dosing and administration strategies, improving the health care system, providing infection control solutions to health care workers and making more effective treatment and newer drugs more widely available to the entire population.
The emergence of MDR-TB has resulted in a more aggressive and urgent approach to TB research and development.
Public Health officials have found that, despite drug-resistant TB comprising less than 5% of the total TB case load in South Africa, it is already consuming 40% of the total TB budget.
The very heart of the health system is further affected as TB continues to claim the lives of a large number of health care workers.
World TB Day is about a dynamic change in discourse. We need to focus on response strategies to the emerging complexities that TB presents to our country and the world.
Although South Africa has made some noticeable headway in managing TB, with an estimated 49 million lives saved through TB diagnosis and treatment between 2000 and 2015, the rise of drug-resistant TB poses a peril to these significant efforts.
Professor Dheda is the head of the Division of Pulmonology at UCT and president-elect of the SA Thoracic Society.
HOW will future historians assess these dark days of early 2017, with the world still reeling from what US and UK voters did at the polls the year before? In years hence, scholars of the early 21st century may credit a certain tonic for keeping depression at bay for millions of people all over the world.
I refer to a 43-second video clip of the live Skype interview of a political science professor in South Korea who was interrupted by his toddlers bursting into his home office. Their gatecrashing crashed the internet as millions of people watched it live and many more shared the video.
If it doesn’t make you chuckle they will test your funny bone for Osteoporotic Humour Deficiency.
Now I know you’ve already seen countless post-mortems on that top YouTube video. These include complaints about Professor Robert Kelly’s alleged patriarchy. This charge was for staying seated in front of his webcam instead of jumping up to help his wife eject his four-year-old daughter and eight-month-old son.
South Africa’s own Trevor Noah offered an explanation as to why the prof couldn’t come to his wife’s aid. Like all Talking Heads on TV and computer screens, he wasn’t wearing pants – a theory that Noah proceeded to prove true on The Daily Show by jumping up to reveal that he was wearing only boxer shorts.
There has been a relentless onslaught of parodies of Prof Kelly getting flustered as the BBC interviewer laughingly tells him: “I think one of your children has just wandered in.”
In a Star Wars parody the interviewer tells Darth Vader: “I think one of your droids has just wandered in.”
Unnerved
There’s a Mom version showing a woman who is totally unfazed by her kids bursting in mid-interview. She distracts them, makes supper and even detonates a bomb while continuing her commentary without missing a beat.
Aside from welcome comic relief, there are some lessons herein – especially for older people. Let us rewind to the point right after the wife and mother (not nanny, as per another internet controversy) finally removed the toddlers. When the interview ended, the producer asked Kelly for permission to rebroadcast the video.The understandably unnerved professor replied with a question: “Is this the kinda thing that goes ‘viral’ and gets weird?” Now that’s the kinda question I would have expected from someone much older than that father. The answer is definitely yes. It is the kinda thing that can go viral and get weird. And often does, as the Kelly family learned when those brief moments of family interaction caught on video began to be shared on Facebook and WhatsApp, Tweeted, e-mailed and broadcast world-wide.
Prof Kelly lamented that a recap of this “family blooper”, as he quaintly termed it, would be the first sentence of his obituary one day, instead of his professional reputation as a political scientist. That is the price one pays for internet celebrity. A second lesson, also especially salutary for older people, is a warning: be vigilant and guard your personal data.
Think carefully before giving permission for anyone to spread information or images on your personal life. Prof Kelly has since told interviewers that he wishes he had refused the request to disseminate that video clip.There is yet another aspect of this story that has relevance for older people.
This home office incident is a reminder of the increasing numbers of people all over the world who operate from home, for reasons ranging from self-employment to unemployment.
It’s not only those who have permanently left the workplace who are hanging around the house for much of the day.
Visit the blog, My New Old Self: What to do next for the rest of my life, www.mynewoldself. com and on Facebook, and follow @mynewoldself on Twitter.