Today is World Tuberculosis Day: THE GLOBAL BURDEN OF TB

The disease kills nearly 5000 people everyday and 98% of these deaths are in the developing world Global incidence of new tuberculosis cases fell by 1.5% every year since 2000 TB remains one of the most dangerous infectious killers Multi Drug Resistant

Twenty-five years ago, the World Health Organization (WHO) declared tuberculosis a pandemic and a global emergency and recommended revolutionary methods to control the disease, which was threatening to engulf the world. Those efforts appear to have paid off. Happily, the incidence (i.e; the number of new cases each year) of new tuberculosis cases has fallen by 1.5% every year since the year 2000 and is 18% lower now than it was in the year 2000, (though this does not apply to some African countries where the incidence is still rising). It is estimated that effective diagnosis and treatment of new tuberculosis cases saved 43 million lives between the years 2000 and 2014. Deaths from tuberculosis (TB mortality) have fallen by 47% since the year 2000

There is no room for complacency, however. Tuberculosis still remains one of the most dangerous infectious killers in the world. Two billion people (one third of the total population of the world) are infected by the tuberculosis bacillus. In other words, they harbour the tubercle bacillus in their body but the organism is kept at bay by their efficient immune systems and is unable to multiply and give rise to the disease. However, these persons though currently healthy, have the potential to develop tuberculosis later in life if their immune systems are weakened - and there are many things in the world that can do so.the most powerful destroyer of the human immune system is HIV/AIDS (Tuberculosis is the leading killer among Hiv-infected people with weakened or destroyed immune systems) but no less threatening are famines, malnutrition, alcohol addiction, recreational drug use, diabetes, the steroid class of drugs and anti-cancer drugs which also weaken immune systems significantly. Famine and malnutrition are invariable accompaniments of war and it is not difficult to predict that many lraqi, Syrian, Somalian and Libyan refugees will develop tuberculosis, even after they reach safe havens like Scandinavia.

6 million people die every year due to HIV/AIDS, Malaria and tuberculosis. Of these, nearly 2 million deaths are due to tuberculosis. Though it is an eminently curable disease, tuberculosis kills nearly 5000 people everyday and 98% of these deaths are in the developing world, affecting mostly young adults in their most productive years (age range 15 - 54 years). Tuberculosis is a leading killer of young women in their childbearing years, especially in Africa. Some of these countries have shown a drop in demographic indices due to a falling birth rate, because would-be mothers are dying of tuberculosis and a drop in the GDP, due to the loss of a significant proportion of the workforce to tuberculosis.

Tuberculosis especially affects the most vulnerable- the poor and malnourished. Tragically, most of these people live in third-world countries and are least able to afford effective anti-tuberculosis treatment and efficient tuberculosis control programmes. One of the biggest problems in the treatment of tuberculosis is the relatively long period (minimum 6 months) of treatment and the multiple drugs used to treat the disease (a combination of 3 or 4 drugs are used in the initial treatment of tuberculosis). It is essential that these drugs are used in the correct dosage and frequency for the prescribed period, and are of high quality if a cure is to be achieved. Though cure rates of nearly 95% are achievable with the current regimens, in practice the cure rates are far lower and the reasons are many. Patient default of treatment, ignorant doctors, irregular treatment, lack of supervision of treatment, poor-quality drugs, hospitals and clinics running out of drugs, patients having to purchase drugs instead of receiving them free, pilferage and anti-tuberculosis drugs (which are actually antibiotics) being used to treat other infectious diseases.

If the poor cure rates were only because of the above reasons, that may have been manageable with better patient and doctor education and better treatment supervision, better quality drugs, tighter hospital security and tighter controls of sales of antituberculosis drugs in the private sector. However, the most frightening aspect of inadequate treatment of tuberculosis is the emergence of Multi Drug Resistant Tuberculosis (MDRTB) and Extensively Drug Resistant Tuberculosis (XDRTB). This is the emergence of resistance to at least Rifampicin and Isoniazid, the two most powerful and most effective anti-tuberculosis drugs used to treat newly-diagnosed patients with tuberculosis. In other words, these two crucially important drugs become totally ineffective due to the development of resistance by the tubercie bacillus. This phenomenon is seen with the abuse of antibiotic, and all anti-tuberculosis drugs which are antibiotics. However, unlike in the case of other antibiotics, where alternatives may be available in the case of antibiotic resistance, the alternative second A doctor examines the x-ray of a patient diagnosed with TB line drugs available in the case of multidrug resistant tuberculosis are very few, more toxic than first line anti tuberculosis drugs (i.e; anti-tuberculosis drugs used on all new tuberculosis patients with no past history of treatment for tuberculosis), unavailable except in specialized treatment centres and are exorbitantly expensive. In the United States, the average hospitalization cost is approximately USD.285,000 (Rs.42 million approx.) per patient with extensively drug-resistant TB (XDR Tb-the most virulent type of multi drugresistant tuberculosis) and approximately USD 81,000 (Rs.12 million approx.) per patient with Multi Drug-resistant TB (MDRTB), in 2010 U.S. dollars.

In a country like Sri Lanka, such treatment regimens would be unthinkable and impossible and such patients would be condemned to a miserable, lingering death. Worse, they may infect family members and other contacts with the same drug-resistant disease before they die. In contrast, the cost of treating a NON-MDRTB (non-resistant) patient in the United states is just USD.17,000 but the cost is significantly lower in countries like Sri Lanka, because purchase of high quality anti-tuberculosis drugs by the government is subsidized by the Global Drug Facility (GDF), a subsidiary of the World Health Organization. The cost of treating one tuberculosis patient in Sri Lanka is just Rs.5000 (USD.34 approx.) for the full six month course of treatment, which makes anti-tuberculosis treatment one of the most cost-effective forms of health interventions in this country.

The tragic fact about the emergence of Multi Drug-resistant Tuberculosis is that it is entirely man-made. It would be safe to say that if there were no doctors, no anti-tuberculosis drugs and no drug companies in this world, there would be no Multi Drug-resistant Tuberculosis. Certainly, millions of people would die of tuberculosis -like in the century when no anti-tuberculosis drugs were available - but they would not die of multi-drug resistant tuberculosis. Doctors create MDRTB by prescribing the wrong drugs, wrong dosages and wrong combinations of drugs for the wrong period, because of ignorance and/ or poor training. Patients create MDRTB by prematurely stopping treatment when they feel better, taking lower dosages than prescribed and by taking some of the drugs but not all the drugs that are prescribed (especially when they have to purchase the medication), because naturally, they cannot understand the principles of antibiotic therapy and emergence of drug resistance. Drug companies create MDRTB by manufacturing poor-quality anti-tuberculosis drugs with poor bioavailability and then charging exorbitant sums from the patient. In reality, all anti- tuberculosis drugs should be provided free, as happens at all the chest clinics and hospitals in Sri Lanka. As a matter of fact, some of the best-quality antituberculosis medication in the world (certified by the WHO), with 3 or 4 drugs conveniently combined in a single tablet (fixed dose combinations, so that the patient does not miss taking a particular drug) are available only in government health institutions in Sri Lanka .In other words, the safest and best place to obtain treatment for a newly-diagnosed tuberculosis patient would be a government chest clinic or other health institution in this country. Equally important, chest clinics and other affiliated health institutions in Sri Lanka are the only places where the patient is actually observed to be swallowing the drugs by a health worker (Directly Observed Treatment Short Course - DOTS), so that there is no doubt that the patient has actually ingested the medication and not thrown it away or secreted it inside his/her mouth to be spat out later. DOTS is possibly the single-most important treatment modality that prevents the emergence of MDRTB, because it ensures compliance with the prescribed treatment. it is also probably one of the major reasons for the declining worldwide incidence of tuberculosis and the dramatic fall in mortality rates by 47% between 2000 and 2014.

Almost five hundred thousand (half a million) cases of Multi-drug Resistant tuberculosis are diagnosed every year throughout the world. The majority of these cases are to be found in Eastern Europe, Africa and Asia. The countries with the largest numbers of patients with MDRTB are also some of the poorest, least able to afford the stunningly expensive treatment of nearly 81,000 USD per patient with MDRTB. Even then, cure is not certain because second line drugs used for the treatment of MDRTB are not as effective as first line drugs, are extremely toxic, possess extremely unpleasant sideeffects and are unbelievably expensive. It would seem that most of these patients would be condemned to a miserable death but infecting others with the same resistant organism before they die.

The answer is not the actual treatment of patients with MDRTB but the prevention of the emergence of MDRTB. And how do you do that? Easy- just ensure that your newly-diagnosed patient (family member, relative, friend or domestic) with tuberculosis is given free, high-quality anti- tuberculosis drugs in the correct dosage and correct combination for at least six months, preferably in fixed dose combinations and directly observe him/her swallowing the medication daily. There is a 95% chance that he or she will be completely cured, with an extremely remote chance of a relapse of the disease or of developing MDRTB, at a fraction of the cost of treating a single case of MDRTB.