This podcast is about the global impact of tuberculosis and malaria. The changes wrought by HIV on tuberculosis and the outcomes have been discussed. Strategies and challenges in the control of tuberculosis have been elaborated (El-Sadr, 2004). Tuberculosis (TB) has seen 8.2 million new cases in 2003, most of it in high-burden nations. 1.8 million deaths have been noted, 98% of which occurred in the least developed countries. TB and HIV together have contributed to 250,000 deaths. The multi-drug regimen for TB has been established in 63 countries. The world has 1 billion TB cases of which 10 million are found in the US. New TB cases to the tune of 8.8 million were found in 2005 (WHO, 2007). Fifteen thousand of the 8 million new cases are found in the US. Less than a thousand infected people have died in the US out of the 3 million in the world. The incidence is high in Pakistan, the Philippines and many parts of Africa: more than 300 per 100000 population (El-Sadr, 2004). Most parts of Europe and Asia, some parts of Africa and South America have a lesser incidence of 100-300 infections per 100000 population. At one glance at the map of estimated incidence in 2000, it is found that more than 90% of the world has TB, the incidence ranging from more than 300 to 10-50 per 100000 population. People living with HIV/AIDS come to about 34-46 million worldwide and the distribution is pandemic (El-Sadr, 2004).
Infection with the tubercle bacillus
Following infection with the tubercle bacillus, the risk factors that give rise to illness due to recent infection are HIV infection, fibrotic lesions and silicosis. Infection 7 years ago could give rise to infection if the person has cancers of the head and neck, hemophilia, immunosuppressive treatment, has hemodialysis, is underweight or diabetic, or smokes heavily (El-Sadr, 2004).
HIV-positive TB cases are seen maximum in South Africa in the incidence of more than 200 per 100000 population (El-Sadr, 2004). Again the whole of Africa shows the maximum incidence when compared to the rest of the world. The highest incidence rates of malaria are found in Africa at more than 100 per 100000 population. The highest burden is found in Asia. By the year 2000, notification rates of HIV/TB co-infection increased tremendously. It is disheartening to note that the leading cause of death in Africa is HIV/AIDS which accounts for 22.6% of the dead (El-Sadr, 2004). Other causes of death are lower respiratory infections, diarrhoeal disease, measles and ischaemic heart disease. TB has mostly been associated with AIDS-related deaths; one-third of AIDS-related deaths are due to TB. 38% of AIDS patients have TB. Next in priority comes pyogenic pneumonia. The success of treatment in AIDS-related TB has been recorded to be around 80% (El-Sadr, 2004).
Treatment problems of TB
Resistance to multi-drug regimen was a problem in the treatment of TB. The success rate of treatment in such cases was less than 50%. This was mainly due to the limited availability of second line drugs. Toxicity of these second line drugs is another cause for reduced success rate. The cost of treatment with the second line came to $5000. Resistance was commoner in Latvia, India and Estonia (El-Sadr, 2004)
The Directly Observed Therapy (DOTS) is the first line treatment for TB. Strategies for TB control include the DOTS Therapy, prevention of TB and improvement of TB outcomes. The WHO TB Control Strategy includes the government commitment, diagnosis among symptomatic patients, using SCC (Standardized short course chemotherapy) along with DOTS, sufficient supply of drugs and backing things up with an efficient recording and reporting system.
The DOTS therapy has a lot of limitations. The duration of therapy, inconvenience and cost are limitations. HIV associated TB also has a limited success with DOTS. Multi-drug resistance is seen with DOTS. The HAART therapy in HIV infections allows the treatment period to be free of TB infection (El-Sadr, 2004). The mean survival in patients co-infected but treated with monotherapy is 1435 days while the patients with double or triple therapy survive for 3548 days. If there is no therapy the survival is just 459 days. The Sub-Saharan population with combined infection shows the maximum number of deaths after using ART (anti-retroviral therapy). The reasons could be an overlapping of drug toxicities, drug interactions, paradoxical reactions or an adherence of multiple regimens (El-Sadr, 2004).
Conclusions of review of podcast
The conclusions were that TB is a major global health problem. The incidence and mortality of TB increases with added HIV infection (El-Sadr, 2004). The DOTS therapy has limitations. New tools must be urgently instituted for TB control. Drugs with a shorter duration of treatment must be found. Drugs must also be found for patients resistant to the usual treatment. Antiretroviral therapy must be readily available for co-infection with HIV. Co-infections must be dealt with joint interventions (El-Sadr, 2004).
New Steps being taken
The Global Plan to Stop TB has been launched. It covers the years 2006-2015 (WHO, 2007). The main target is to reduce the global incidence rate by 2015. The supplementary target for the Stop TB partnership is to halve the 1990 prevalence and death rates by 2015. The main method of achieving this is by treatment of patients with active TB. The DOTS therapy and the multi-drug resistance TB constitute the main strategy (WHO, 2007). The epidemic is on the threshold of decline. Assessment surveillance and analysis are being made. Standard data collection is uniformly performed the world over. The monitoring system is another significant factor. The Stop TB partnership targets which were set by the World Health Assembly was to have diagnosed 70% of sputum-positive people and 85 % cured through DOTS. The global burden which includes the per capita prevalence and death rates will be reduced by 50% of the levels at 1990 by the year 2015. By 2050 this is to be further reduced to 1 case per million population per year (WHO, 2007).
The components of the strategy include the pursuit of the high quality of the DOTS expansion and enhancement. The challenges in the treatment like the drug resistance and the treatment of prisoners and refugees and other high-risk groups were to be addressed (WHO, 2007). The healthcare system was to be strengthened. Care providers from the private and public sectors were to be organized for the program. Community participation and empowerment were to be advocated. Research was to be promoted. Sputum culture can be used for diagnosis but the sputum examination is necessary for suspected cases. Global Tuberculosis Control 2007 is an ambitious and effective global approach to control TB.
References
El-Sadr, W. (2004). Infectious Diseases(TB/Malaria) Panel. Podcast of Global health Seminar Series, Web.
Columbia University Medical Center World Health Organisation. (2007). Global tuberculosis control: surveillance, planning, financing.