When standard treatment of tuberculosis does not work, it might indicate that you have drug-resistant tuberculosis.
According to the World Health Organization WHO when the most efficient anti-TB drugs, isoniazid as well as rifampicin are no longer effective against TB in other words the TB that shows resistance against these drugs is called multidrug-resistant TB (MDR-TB). For the treatment of TB drug resistance is the major hurdle. The duration for treatment of MDR-TB is quite long about 2 years and treated with a combination of second-line drugs. These drugs are more costly, less efficient, and more toxic than first-line drugs so the success rate of treatment is low approximately 54%.
EPIDEMIOLOGY OF TUBERCULOSIS
Tuberculosis (TB) is the tenth major cause of death globally and a major public health concern.10.6 million suffered from TB and 1.3 million people died in 2022 reported by WHO. Around lives of 75 million people were saved by worldwide efforts in 2000 to eliminate TB. 1.6 million patients lost their lives to TB and 10.4 million patients suffered from TB in 2017 globally reported by the World Health Organization (WHO).
DRUG RESISTANCE TB STRAINS
It can be defined as the strains of bacteria causing which are resistant to one or more anti-TB antibiotics which means these antibiotics can't produce it's good results against TB. There are two main types of drug resistance TB which are:
Multi drug resistant tuberculosis (MDR-TB)
When TB is resistant to a minimum of two most effective and powerful anti-TB drugs which are isoniazid and rifampicin, it is called multidrug-resistant TB.
Extensively drug-resistant tuberculosis (XDR-TB)
When TB is resistant to drugs like isoniazid, and rifampicin, in addition to Fluoroquinolones and resistant to a minimum one of the three (amikacin, kanamycin, or capreomycin), the injectable second-line drugs.
DIFFERENCE BETWEEN MULTIDRUG RESISTANCE TUBERCULOSIS (MDR-TB) AND DRUG-SUSCEPTIBLE TUBERCULOSIS
When the bacteria that causes tuberculosis is resistant to at least two of the most efficient first-line anti-TB drugs, isoniazid, and rifampicin are called Multidrug-resistant tuberculosis (MDR-TB). MDR-TB is difficult to treat and needs longer, more complicated treatment regimens, often with second-line drugs that are less efficient, more expensive, and more toxic.
When the bacteria that can be efficiently treated with standard first-line TB drugs is called drug-susceptible TB. Treatment for drug-susceptible TB is easy to treat and usually shorter and more straightforward compared to MDR-TB.
PREVENTION TO SPREAD
1) MDR-TB EXPOSURE PRECAUTIONS IN HIGH-RISK ENVIRONMENT
You should avoid sitting in those places where you are seeing another MDR-TB patient, especially in crowded or closed places. If your job is in the hospital where TB patients are most probably to be seen then consult infection control or occupational health experts.
2) ENSURING EFFECTIVE TREATMENT
It should be monitored that patients are receiving effective treatment promptly. The preventions that can prevent MDR-TB from spreading is to take all medications and not to skip any and the same dosage as prescribed by healthcare professionals. The treatment should not be stopped early. If the patient is facing difficulty in taking medications he or she should concern with his or her doctor.
3) IMPLEMENTING INFECTION CONTROL MEASURES
Isolation of infectious patients, taking care of personal protective equipment, and proper ventilation all these precautions to take is necessary to minimize the risk of infection.
4) UPGRADED DIAGNOSTIC TOOLS
It is necessary to diagnose early and drug susceptibility tests so there is a need for improved diagnostic tools so the treatment could start early.
5) HEALTH AWARENESS
Common people should be aware of TB transmission and the importance of completing the full course of treatment for TB. All this awareness could be reached by health communities to people.
6) SURVEILLANCE SYSTEM
To take initiatives and control measures timely it is necessary to develop a surveillance system that monitors the spread and prevalence of MDR-TB.
VACCINE
There is a vaccine called Bacille Calmette-Guérin (BCG) is used to prevent severe forms of TB in children in some countries including Pakistan. The BCG vaccine is not generally used in the United States as the risk of acquiring tuberculosis is minimal here, the vaccine doesn't always produce prevention in adults, and it can affect certain TB tests. But sometimes, it might be prescribed for children who are around adults with untreated TB or drug-resistant TB, most of the time, and can't avoid being near them. This decision should be made with the help of a TB expert. BCG vaccine should not be administered to immunocompromised and pregnant women but no negative impacts on the fetus of this vaccine have been observed. To prove its safety further studies are needed.
CHALLENGES in MDR-TB TREATMENT:
Treatment for MDR-TB worldwide is challenging due to a lack of resources and the negative consequences experienced by patients undergoing treatment. These effects include neurological issues, auditory toxicity, hepatitis, rash, and renal problems.
1)Emergence of XDR-TB:
Mutations in MDR-TB strains have led to the rise of extensively drug-resistant TB (XDR-TB), which is a significant concern. As XDR-TB strains are resistant to second-line injectable drugs and fluoroquinolones, it more complicates the treatment.
2)Risk Factors and Transmission:
Wrong antibiotic usage and person-to-person transmission added to the rise of MDR-TB strains. The importance of proper tuberculosis prevention and treatment management is highlighted by previous tuberculosis infection history as it is a significant risk factor for MDR-TB.
3)Impact on Health and Mortality:
In developing countries with a lack of or limited resources, implemented challenges in treatment as MDR-TB can affect various body parts beyond the lungs. The situation becomes more complicated when Patients with HIV infected with MDR-TB or XDR-TB, increase mortality rate.
4)Effects of the COVID-19 Pandemic:
The rise of the COVID-19 pandemic has disrupted MDR-TB management, leading to issues such as medication supply chain disruptions and increased mortality among patients with both COVID-19 and underlying lung conditions like tuberculosis.
Each of these points describes the difficult challenges associated with MDR-TB treatment and the urgent need for effective strategies to address them.
IMPROVED TREATMENT STRATEGY FOR MDR-TB
Historically, it was hard for treatment and there are not many studies available that have assisted doctors to know the best way to treat it. Only one in three people with MDR-TB began their treatment in 2020 but only 59% of them completed it successfully. So, what we need the most in the present era is better, shorter, and easier treatments. A study called STREAM Stage 1 revealed a new treatment plan for MDR-TB. A 9-month treatment that comprised different drugs, like moxifloxacin and isoniazid, along with some others were tested for the first 16 weeks. The purpose of this study was to compare it with older 20-month treatment that was recommended by the World Health Organization (WHO) from 2011 to 2018. The study showed that the shorter 9-month treatment produced better results than the longer one.
TUBERCULOSIS RESEARCH ADVANCEMENT
Tuberculosis (TB), spreads through respiratory contact and mainly affects the lungs but could be reached any tissue. Factors that contribute to drug resistance include late diagnosis, insufficient medication protocols, insufficient supervision, and lack of social support programs. Tuberculosis Research Advancement Centers (TRACs) are like specialized facilities set up by a group called NIAID in 2022 to assist researchers in the study of tuberculosis. The purpose of these centers assemble different kinds of experts to work together and share resources. They provide mentorship and support which ultimately help new researchers get into studying tuberculosis. The main goal is to improve the understanding of tuberculosis so that improvement in the treatment of this disease could take place and help these researchers become leaders in tuberculosis research.
TUBERCULOSIS RESEARCH ADVANCEMENT IN PAKISTAN
Even though lots of global efforts, TB remains a main health concern with an alarming prevalence in Pakistan. Within its 210 million population, 1.5 million are suffering from TB, ranking Pakistan sixth worldwide for TB cases. The rise of drug-resistant strains, including multidrug-resistant TB (MDR-TB), represents a severe challenge. MDR-TB, affects approximately 15,000 individuals in Pakistan, with Punjab reporting the highest incidence (51%), followed by Sindh (23%), Khyber Pakhtunkhwa (15%), and Baluchistan (3.5%). Young people, aged 10 to 25, are particularly susceptible due to weakened immunity and poor dietary habits. A high percentage (4.2%) of rifampicin resistance is revealed in recent analysis in newly diagnosed TB cases, significantly higher in previously treated cases. Efficient strategies must be implemented to control TB, highlighting early detection, intensive awareness campaigns, and sticking to WHO guidelines for MDR-TB management.
INITIATIVES FOR CONTROLLING TB IN PAKISTAN
Managing multidrug-resistant tuberculosis (MDR-TB) requires a complete strategic plan at both national and provincial levels. Pakistan's government has adopted innovative strategies aligned with WHO guidelines to overcome the MDR-TB crisis. The announcement of TB as a national emergency in 2001 brought the establishment of the National TB Program (NTP), which aims to reduce to half the TB incidence by 2025 compared to 2012 levels. WHO's TB infection control (TBIC) policy, embraced in 2009, was added to Pakistan's national TBIC plan. In 2010, NTP presented the Programmatic Management of Drug-Resistant Tuberculosis (PMDT) model, with the help of WHO and the Global Fund. The PMDT program involves a macrosystem incorporating international organizations and a microsystem that further comprises national and provincial TB programs and NGOs. NTP started free clinics nationwide for drug-resistant TB treatment and contact tracing under the Mandatory TB Case Notification project, which resulted in increased success rates and a decline in mortality. Provincial TB programs (PTP) reflect NTP's goals. The Public-Private Mix model (PPM), started in 2014, increased case notifications, especially in specific age groups. Directly Observed Treatment, Short course (DOTS) was incorporated in all provinces according to WHO guidelines. In 2021, during the End TB Summit, President Dr. Arif Alvi spotlighted Pakistan's annual TB cases and called for international collaboration to end TB by 2030. During the COVID-19 pandemic, measures such as co-screening for TB and COVID-19, home delivery of medicines, safety protocols, mental health support for healthcare workers, and patient follow-up were executed in cities like Karachi to alleviate the effects on TB diagnosis and treatment.
INITIATIVES AND CHALLENGES IN ADVANCING THE FIGHT AGAINST TUBERCULOSIS
WHO Investment Case
WHO has started an investment case for TB screening and preventive treatment ahead of World Tuberculosis (TB) Day, highlighting the advantages of spreading these initiatives in Brazil, Georgia, Kenya, and South Africa. The case spotlightes significant health and economic benefits with up to US$ 39 return on every dollar invested. This initiative's main goal is to support countries in reaching the targets set at the 2023 UN High-Level Meeting on TB.
Initiatives and Challenges
Despite worldwide efforts, TB still causes 1.3 million deaths yearly and affects millions more. The investment report highlights the importance of evidence-based initiatives to decrease TB prevalence and mortality, adhering to global health coverage goals.
However, the availability of TB diagnosis and treatment services has improved globally, and scaling up availability to preventive treatment has been slow. Preventive treatment should be offered to high-risk groups such as those with HIV and household contacts of TB patients as it is necessary in accomplishing the WHO's End TB Strategy.
Addressing Multidrug resistance tuberculosis MDR-TB
Multidrug-resistant TB (MDR-TB) is still a challenge, with only about 2 in 5 affected individuals getting treatment. There is a need to improve investment in new diagnostics, drugs, and vaccines to overcome TB effectively.
World Tuberculosis Day 2024 theme
The 2024 World Tuberculosis Day theme is 'Yes! We can end TB!', defines hope in combating the epidemic through leadership, investments, and sticking to WHO recommendations. Meeting in 2023, Following commitments made at the UN High-Level, the main goal is to convert these commitments into actionable steps, including implementing the WHO Director-General’s flagship initiative on TB for 2023-2027.
Targets and Commitments
Worldwide targets approved at the 2023 UN High-Level Meeting include approaching 90% of people in need of TB prevention and care services, emphasizing WHO-recommended rapid tests for diagnosis, promising availability of a safe and effective new TB vaccine, and closing funding gaps for TB implementation and research by 2027.
CONCLUSION
In conclusion, tuberculosis (TB) persists as a significant global health concern, causing millions of deaths yearly and creating challenges in both treatment and prevention, specifically with the rise of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant tuberculosis (XDR-TB). Although a lot of efforts have been made by organizations such as the World Health Organization (WHO) and national governments, TB continues to burden healthcare systems worldwide and take lives.
The fight against TB requires a versatile approach, including improved diagnostic tools, efficient treatment techniques, improved infection control measures, and increasing public awareness. Interventions such as the establishment of Tuberculosis Research Advancement Centers (TRACs) and national TB programs, along with investment in new diagnostics, drugs, and vaccines, are important in advancing TB research and treatment.
In countries like Pakistan, where TB rates are high, more efforts at the national and provincial levels, including the execution of strategic plans and innovative programs like the Programmatic Management of Drug-Resistant Tuberculosis (PMDT) model, are necessary for controlling the spread of TB, specifically drug-resistant strains.
The theme of World Tuberculosis Day 2024, "Yes! We can end TB!", tells the importance of adherence to global commitments collective action, and leadership in combating the TB epidemic. With targets set at the 2023 UN High-Level Meeting on TB and ongoing efforts to convert these commitments into actionable steps, there is hope for progress in ending TB by 2030.
However, challenges such as limited resources, deficiencies in TB diagnosis and treatment services, and the impact of external factors like the COVID-19 pandemic revealed the need for continues investment, innovation, and collaboration in the fight against TB. By addressing these challenges and working together, we can move towards a future free from the burden of tuberculosis.
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