Toward more effective TB patient care

In the yearly commemoration of World Tuberculosis (TB) Day (held last March 24), we always focus on reminding people to get screened, diagnosed and treated.

But it’s also necessary to call on people to help break the stigma against TB. People have to realize that anyone can contract TB or MDR-TB (multidrug-resistant tuberculosis). In places where there is a high prevalence of TB, like the Philippines, the chances of becoming infected are especially high.

When we accept this fact, it is easy to imagine how it feels to be sick and how we would want to be treated if we were a patient.

Let us also bear in mind that, while TB is curable, inaccessibility to treatment and drug-resistant bacteria are not the only factors that make tuberculosis challenging to address.

This is what I’ve learned from my deployment since 2017 to Zhytomyr, Ukraine, as project medical referent for Doctors Without Borders or Medecins Sans Frontieres (MSF). Zhytomyr is one of the regions in Ukraine with the highest rate of TB. Ukraine itself ranks second in Europe in MDR-TB cases.

Among my tasks has been to implement a comprehensive care model for MDR-TB patients at the Zhytomyr Regional Tuberculosis Hospital, in cooperation with the country’s Ministry of Health.

What is MDR-TB? When patients are given drugs or antibiotics that are incomplete, or are of poor quality, or when patients stop treatment before they are cured, this becomes an opportunity for bacteria to mutate and become drug-resistant.

This is how MDR-TB has developed. In the worldwide fight against antimicrobial resistance, the increase in resistance to TB drugs is especially worrisome. MDR-TB is difficult to cure because resistance has rendered the two most common TB drugs ineffective.

As a consequence, the treatment for MDR-TB is longer — up to two years, compared to six months for drug-sensitive TB. The traditional treatment also includes drugs that are not as effective and have proven severe side effects, like permanent deafness and psychosis.

Diagnosis of MDR-TB also takes time. It involves drug culture and susceptibility testing — techniques that can only be done in specialized laboratories using stringent procedures that take at least six weeks to receive results.

The delay in diagnosis stalls treatment prescription, and in the meantime, the patients worsen, and the transmission of TB continues in the community.

Ignored aspects of TB. The social and psychological aspects of the disease often end up neglected. TB is highly stigmatized. Patients fear seeing a doctor, and some deny their condition. This prevents the early diagnosis and treatment of the disease.

The monotony and isolation of hospital confinement, meanwhile, puts patients in despair. They end up feeling depressed and hopeless. As a result, some opt to leave treatment even before it is complete. Once out of the hospital, they suffer other problems like unemployment, rejection by family and friends and maladaptive coping by excessive alcohol drinking.

The mission of MSF is to go beyond the confines of centralized hospital treatment and apply a better model for treatment and care of MDR-TB patients. This model involves ambulatory treatment, integrated management of comorbidities such as HIV coinfection, and the provision of psychosocial support as an integral part of the program.

In early ambulatory care, patients begin treatment at the Zhytomyr Regional Tuberculosis Hospital. Once they are ready to continue care at home, they receive treatment as an outpatient through the nearest local medical facility in their community.

A support team made up of social workers, mental health professionals and nurses assists and guides patients in their struggles throughout this process, to make sure that patients complete the treatment successfully. This practice, so far, has increased treatment retention.

This month, MSF will begin a four-year research study into the effectiveness of its treatment model, which combines the use of a shorter treatment that spans nine to 12 months, more effective drugs, ambulatory care and psychosocial support, in treating MDR-TB in Ukraine.

By the end of 2019, MSF also will put up a Biosafety Level 3 Laboratory in the Zhytomyr regional TB hospital that will be able to quickly test for various drug-resistant TB bacteria. This will hopefully provide a faster turnaround time for diagnosing MDR-TB.

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Dr. Marve Duka is a Filipino doctor who joined Medecins Sans Frontieres or Doctors Without Borders in 2010, and has worked on TB, HIV and Hepatitis C in Kenya, Zimbabwe, Malawi and India. She is now in the Ukraine.