INTRODUCTION:
Tuberculosis (TB)
is a multi-systemic infectious disease caused by Mycobacterium tuberculosis,
a rod-shaped bacterium. TB is the most common cause of infectious
disease-related mortality worldwide (about 1.1 million to 1.7 million people
die from it each year worldwide). TB symptoms can be so diffuse that TB is
termed the "great imitator" by many who studied infectious diseases
because TB symptoms can mimic many different diseases.[1] People
infected with TB bacteria have a lifetime risk of falling ill with TB of 10%.
However persons with compromised immune systems, such as people living with
HIV, malnutrition or diabetes, or people who use tobacco, have a much higher
risk of falling ill.[2]
At least
one-third of people living with HIV worldwide in 2013 were infected with TB
bacteria, although they did not become ill with active TB.
People living
with HIV are 26 to 31 times more likely to develop active TB disease than
people without HIV.HIV and TB form a lethal combination, each speeding the
other's progress. In 2013 about 360 000 people died of HIV-associated TB.
Approximately 25% of deaths among HIV-positive people are due to TB. In 2013
there were an estimated 1.1 million new cases of TB amongst people who were
HIV-positive, 78% of who were living in Africa. WHO recommends a 12-component
approach of collaborative TB-HIV activities, including actions for prevention
and treatment of infection and disease, to reduce death rate. [3]
The tuberculin
test is a diagnostic method for detecting latent tuberculosis (TB) infection,
especially among disease contact cases. [4]Laboratory diagnosis of
mycobacterium infection is complicated by the fastidious growth requirements of
the bacillus organism. Delay in diagnosis can impede effective treatment and
surveillance of the disease. Control of Mycobacterium tuberculosis has also
been aggravated by the emergence of multidrug-resistant tuberculosis. [5]
The increasing prevalence of drug-resistant Mycobacterium tuberculosis, the
causative agent of TB, demands new measures to combat the situation. Rapid and
accurate diagnosis of the pathogen and its drug susceptibility pattern is essential
for timely initiation of optimal treatment, and, ultimately, control of the
disease. [6]
TB is a treatable and curable disease. Active,
drug-sensitive TB disease is treated with a standard six-month course of four
antimicrobial drugs that are provided with information, supervision and support
to the patient by a health worker or trained volunteer. Without such
supervision and support, treatment adherence can be difficult and the disease
can spread. The vast majority of TB cases can be cured when medicines are
provided and taken properly.[7] Adherence to tuberculosis (TB)
treatment is essential to control the disease. Directly Observed Treatment
(DOT) is considered the universal ‘standard care’ and has proven to be an
effective method of ensuring compliance with the treatment. Resource
constraints and technology improvements are generating increased efforts in
local TB control programs to develop efficient strategies to ensure patient
adherence to appropriate treatments.[8]
In TB endemic
regions, HIV-infected patients initiating ART, particularly men and those with
poor nutritional status, should be closely monitored for active TB at ART
initiation. In addition to increasing the access to ART, interventions should
be considered to improve nutritional status among HIV-infected patients.
[9] Patients receiving nominally free care for HIV/TB face large private
costs. Subsidized transport, fewer clinic visits, and drug pick-up points
closer to home could reduce costs for ART patients, potentially improving
adherence and retention. Large expenditure on alternative care among pre-ART
patients suggests that transitioning patients to ART earlier, as under TASP,
may not impose substantial costs on patients. [10] The oral
traditions of medicine and public health have it that malnutrition is an
important risk factor for the development of tuberculosis (TB).Malnutrition
profoundly affects cell-mediated immunity (CMI), and CMI is the principle host
defence against TB. It makes biological sense. [11]
TB incidence rates
were lower, and reductions in incidence were greater among NH residents;
community-dwelling older adults had higher TB rates and smaller reductions in
incidence. Interventions that promote timely detection and treatment of TB
infection and disease may be needed to reduce morbidity and mortality among NH
residents. [12].For most people, the prognosis of TB are good if
they complete the treatment protocols. The recurrence rate of TB is low
(0%-14%) and some may be due to re-infection. Drug-resistant TB is more
difficult to treat, and the prognosis is not as good. The same prognosis occurs
for those patients who are immune-compromised, in the elderly, and in patients
with previous infection and treatment for TB. [13] Controlling and
preventing tuberculosis (TB) continues to be a major public healthcare
challenge. Pharmacy and clinical records can thus contribute with important
information concerning newly-diagnosed inpatients, treatment regimens and
resistant strains. [14]
Site, design, span of work, source of data
Site
This study was conducted at Maharajah's Institute of Medical Sciences
(MIMS) Hospital, Vizianagaram. It provides all facilities and health
care services to the people in and around Vizianagaram. It has a separate
provision for the treatment of TB affected patients.
Design
In this observational study, a total of 135 cases were considered of all
age groups out of which 3 categories were made.In which, each category
containing a total of 45 cases. In each category 3 parameters were considered
as HIV, Malnutrition and Discontinuation of therapy. The graphical
representation was made for each parameter in each category.
Span of work
The study was conducted for a period of eight weeks in a total population
of 135 patients’ presented with tuberculosis.
Source of data
Patient data relevant to the study was obtained from the following
sources:
RNTCP (Revised
National Tuberculosis Control Programme) Treatment Card
Direct patient interview
The above mentioned criteria fulfill the materials required for the
study.
METHODOLOGY:
In this observational study, a sequential order was followed and
correlated the factors which were observed in the study.
1. Collecting the data
2. Obtaining the RNTCP chart.
3. Management of disease.
4. Patient Counseling
5. Evaluating data in various
strategies like
a. Type
of treatment
b. Economical
status of a patient
c. Body
Mass Index
d. Discontinuation
Therapy
In this study, as it is an air-borne disease, it has to be conducted with
utmost care. At first, as a pharmacist we should counsel patients regarding the
importance of medication adherence, diet intake. Collection of RNTCP chart of
the patients plays a key role in determining their stage of the disease.
RNTCP Treatment card contains three categories as follows:
·
Category – i : New Case (Pulmonary
Smear-Positive, Seriously ill Smear-Negative
Or Seriously ill Extra Pulmonary)
·
Category –ii : Retreatment (relapses,
failure, treatment after default, others)
·
Category –iii: New Case (Pulmonary
Smear-Negative, not seriously ill: or Extra Pulmonary, not seriously ill.
We have collected 45 cases of each of three categories. In each category,
again we have observed:
I.
HIV cases in which 45 cases were
considered as First parameter.
II.
Cases of Malnutrition present among 45
cases were taken as Second parameter.
III.
Patients who discontinued the treatment
among those 45 cases which was taken as third parameter.
After collection of all data, analysis has to be done. Graphs were
plotted for
Category Vs No. of HIV cases,
Category Vs No: of Malnutrition cases,
Category Vs No. of Discontinuation Therapy cases.
AN OVERVIEW OF
RESULTS:
In the
observational study of management of Tuberculosis, the following parameters
were observed.
Flow chart
–1:-Comparison of Category Vs HIV Patients
Flow chart
-2:-Comparison of Category Vs Malnutrition Patients
Flow Chart–
3:-Comparison of Category Vs Discontinued Therapy patients
DISCUSSION:
In relation with parameter i
\In all the 3
categories; 12 HIV cases in category-I, 19 HIV cases in category-II, 10 HIV
cases in Category-III were observed. As Tuberculosis is an example of opportunistic infection in HIV patients, as
the immune system is suppressed in HIV patients abnormally chances of
Tuberculosis infections was more observed.
In relation with parameter ii
In all the 3
categories, 9 cases in category-I, 8 cases in category-II, 6 cases in
category-III who are suffering with under nutrition were found. The reason for
occurrence of under nutrition is due to financial problems and lack of proper
guidance regarding the importance of proper nutrition. Undernourishment is most
often due to insufficiency of high quality food available to eat. This is often
related to high food prices and poverty.
In relation with parameter iii:
Discontinuation
of therapy by the patients leads to re-occurrence of Tuberculosis. The reasons
may be due to:
1. Patient non-compliance
2. Ignorance over importance of
strict medication adherence.
3. Distance from Tuberculosis
Treatment Center.
In all the 3
categories; 9 cases in category i , 11 cases in category ii , 7 cases in
category iii were found to be discontinued the treatment due to above mentioned reasons. In category ii, more
number of patients discontinued the treatment. The reason may be due to
Multi-drug therapy which includes five drugs (Isoniazid, Rifampicin,
Pyrazinamide, Ethambutol, and Streptomycin) 3 times a week. Because of the
addition of Streptomycin in category ii, it may cause irreversible ototoxicity,
nephrotoxicity, tinnitus, vertigo and also causes severe nausea and vomiting.
CONCLUSION:
Parameter i in all the 3 categories, shows that HIV cases were easily
prone to tuberculosis. HIV is one of the major reasons for the prevalence of
TB; the reason may be abnormal depression of immune system. So, the patients
have to be educated about the importance of initiation of Anti-retroviral
therapy and immune stimulants during the course of TB treatment which is useful
for enhancing the life span of TB patients.
Parameter ii in all the 3 categories shows that many patients were found
suffering from malnutrition may be due to Gastroenteritis, HIV, poverty &
financial challenges. Intake of highly nutrient food makes the patient to
relieve from tuberculosis. The government of India has to take necessary steps
to provide nutritional food to people suffering from malnutrition. The print
media and the press should take responsibility to spread the problems related
to the malnutrition influence on TB affected patients.
Parameter iii, in all the 3 categories involves patients who discontinued
the treatment because of several reasons. Strict medication adherence and
patient compliance is very much essential for effective control of
Tuberculosis. The pharmacist has to play a vital role to monitor patient and
explain the importance of continuation of therapy of RNTCP.
ACKNOWLEDGEMENTS:
The author likes to express his gratitude towards the Maharajah’s
Institute of Medical Sciences (MIMS) Hospital. Also thank my parents my wife
and friends for their constant support and encouragement.
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