World TB Day: Can You Snitch?

2017-03-14 10:29

Picture: Rollsettravel

Harmony

As you go about your perfect life, in your perfect home, with your perfect family, let me come in and invade your space. We all understand how relative perfection is and most of us strive for a comfortable and acceptable life given conditions and circumstances of daily living. We live in a country that is not at war. I am referring to army-led kind of war. It is however a country at war for service delivery, political freedom and inter-racial stability. Let us go back to the perfect family I described. You are safe, you have food, water and shelter. You still have the support of friends and loved ones. What could disturb your peace? Allow me to introduce you to a problem that will directly and indirectly affect you and your family. A problem on the rise and often ignored by the general public as they don't think they have a role to play. I am talking about drug resistance. In simple terms, medication meant for a specific condition are no longer effective.

Drug Resistance

When people think of ineffective medication being taken for a medical condition, some think of drug tolerance. Tolerance is when one's body adapts to the medication they have been taking and at times a higher dose will be needed to produce the required effect. Drug resistance is more specific to microorganisms (sometimes cancer cells). Drug resistance occurs when microorganisms continue multiplying despite good medication dosage, strength, frequency and duration. We will look at drug resistance as it pertains to antibiotics, TB medication and anti-retroviral (ARV) treatment.

Poor Adherence

One of the biggest challenges we still get everywhere in the world is patients not taking their medication well, not finishing their course of antibiotics or not being able to continue with lifelong therapy. People struggle with medications for various reasons.

The young and novice usually complain about bad medication taste, difficulty swallowing pills or fear of needles.

Side effects are in no doubt always a huge stumbling block. If one is not made aware of mild side effects nor reassured of them, one tends to decide on stopping treatment. Some medication may unfortunately have severe side effects that may not be predicted for a specific individual yet can be managed timeously.

There has always been a myth that all medication should be taken on a full stomach. As a result, people who skipped breakfast because they had an early start at work or simply did not have food may not take their morning dose. Please note that not all pills or tablets are affected by food and some can be taken on an empty stomach. First line South African ARVs can be taken without food.

We all expect to get well or better if we gather enough courage to take medication. With antibiotics, ARVs or TB medication, improvement may not be immediate. That alone may discourage some patients from continuing with treatment.

Sexually transmitted infections like gonorrhoea may have a bad stigma linked to them. Some people may miss antibiotic doses to avoid family judgement and interrogation. Same applies to HIV and TB. Some people believe that only HIV positive people get TB, which is not true.

Failure to disclose one's illness will negatively affect one's lifelong treatment adherence. This is very difficult to address and people have their own reasons for non-disclosure. However, how long will HIV positive persons continue to infect others in secret? When is that TB cough too much in the hands of a poor cough hygiene person?

Those are some of the problems related to poor adherence to medication. Microorganisms have developed a strategy that allows them to mutate or change their genetic material. At low levels of medication in the blood, microorganisms are given an opportunity to "study" how the drugs work. With low drug concentrations, microorganisms are not all killed and the survivors will eventually develop "thick skin". The end result is drug resistance despite resuming regular drug dose routine.

Low Drug or Medication Level Concentration in the blood

Adherence can be easily improved with patient co-operation; unlike other causes. These causes are related to the pharmacology of medication and include:

Altered stomach pH balance that hinders medication breakdown

Poor absorption in the digestive track

Decreased drug distribution in the blood

Metabolic interaction with other medication, drugs, traditional, herbal, complementary or alternative therapies

Incorrect Dosage and Drug Interactions

There is a growing trend for self-medication amongst our people to cut down on consultation fees. Although that might work well for some, special population groups like children, pregnant women, the elderly and people with kidney or liver failure should ideally request assistance with dosage adjustment. With children, the weight change may render a previous effective dose sub-therapeutic. Pregnant women may put their unborn babies at risk because some medication may be harmful (teratogenic). Dose adjustment may also be needed in other special groups as well.

People are very adamant that herbal or traditional remedies are safe and natural. Sorry to disappoint but some prescription medication may interact with these seemingly natural remedies. These interactions may either lead to ineffectiveness of prescription medication or high side effect profile, both leading to potential adherence problems. In cases of drug ineffectiveness, low drug concentrations will lead to drug resistance in the long run.

Decreased drug excretion may lead to side effects and discourage adherence. Kidney and liver failure are the usual suspects. These organ failures usually result in high and toxic drug concentrations in the blood. It is worth mentioning as some herbal or traditional medications may cause kidney and liver damage, besides the interaction problems.

Antibiotic Resistance

Besides the growing antibiotic resistance secondary to antibiotics use for livestock, we are also seeing challenges in and out of the hospital. As described above, incomplete antibiotic courses are pre-cursors to growing resistance strains of common respiratory, wound and sexually transmitted infections to list a few. Some of these infections are then spread and "shared" with loved ones increasing the burden of resistant strains. These strains can either be lethal or persistent increasing our demand for new, stronger and more expensive treatment modalities.

Drug-resistant HIV

If you knew that your partner was on a 2nd or 3rd line ARV regimen but isn't taking their medication well, what would you do about it? Remember that if you were planning on having children, they are more likely to get infected because of a high HIV viral load as a result of poor adherence to treatment. If your partner were to stop taking their ARVs today, who will you tell? Will you sacrifice yourself for their sake or are you that scared of them? If you knew that this drug-resistant HIV strain will be introduced to the community, and eventually the whole country, can you make the difficult decision and inform healthcare professionals?

Drug-Resistant TB

Unlike HIV, TB is airborne and people around the affected individual are at risk. Children under 5 and immuno-suppressed individuals are at a higher risk of contracting TB. With poor treatment completion rates, sometimes linked to unavailable TB medication, the cases of Multi-Drug Resistant (MDR) and Extensively-Drug Resistant (XDR) TB have increased with more virulent strains described as well. Another issue that led to development of resistance was, most likely, the provision of temporary grants for sick TB patients, which were terminated when these individuals got better. This was a means to temporarily alleviate poverty for some and they could not afford to get better. Patients would deliberately stop treatment to avoid grant termination. The lowest of lows was "sputum sales" where TB patients would put a price on a sputum jar/container to "assist" others to get TB grant benefits as well.

Picture: Management of drug-resistant tuberculosis policy guidelines 2013

Ticking Time-bomb

March is TB awareness month, and 24 March 2017 is World TB day. We are struggling with controlling and preventing drug-resistant TB. Resistant strains are circulating around us; in schools, in the bus, in the taxi, in the shopping centres, in the malls, in the hospital corridors and maybe in your house. Can you "snitch" on your treatment non-adherent family member, friend, neighbour, relative or stranger to save us all?

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