Multidrug-Resistance Tuberculosis (MDR-TB)

By Dr Ekiria Kikule
Community Health .

MDR-TB in Kenya
Drug-resistant TB (DR-TB) is a reality in Kenya.

90 cases notified to the National TB and Leprosy Programme (NTLP) between Jan 2008 and March 2010 Actual national burden in Kenya not known
A drug-resistance survey currently underway to ascertain national burden in Kenya The National TB Reference Laboratory (NTRL) able to diagnose MDR-TB.
2

Emergency of MDR-TB
Multidrug-resistant tuberculosis (MDRB)

occurs when the TB bacteria become

resistant to at least Isoniazid (H) and

Rifampicin (R), the two most powerful

anti-TB drugs. MDRTB can be difficult & expensive to treat and a threat to life.
3

Emergence of MDR-TB
By the 1950s introduction of anti TB drug therapy which reduced the number of patients There was 98% chance of cure. Challenges in ensuring this level in resource poor countries has resulted in an increasing incidence of the TB bacteria resistance to the most effective drugs.
4

Factors contributing to MDR-TB:

Poor drug adherence - Poor DOT
Drug delivery disruptions
lack of transportation long distances to health facilities

Drug stock-outs in some facilities Social barriers such as stigma, discrimination and poverty Non-compliance with the guidelines by prescribers
5

Other causes of MDR-TB

Previous treatment for TB especially if prolonged Contact with another patient with MDR-TB

Immigrations from areas with high incidence MDR-TB

HIV seropositivity

Substance abuse like tobacco

Homelessness, sleeping in many places no f/up Incorrect drug administration Poor drug quality Failure of the patient to take the drug consistently
6

Presentation of MDR-TB
Chronic cough - almost always even after treatment Sputum, usually made of pus Haemoptysis, sometimes it can be large or small. Pain in the chest Shortness of breath - usually a late presentation Fever, sweating especially at night Loss of weight Mild fever Anaemia
7

Management of MDR-TB (1)

Arrange for DOTS
Convenient place Health workers

Patient may be admitted to H/facility to start treatment. Educate patient & family about TB disease, treatment, & possible side effects of treatment Re-assure patient/family about possible side effects.
8

Management of MDR-TB (2)

Explain that cure is possible with good adherence Emphasize consequences of poor adherence death; infect family and friends Arrange for check sputum exam for acid -fast bacillus after 2 months,5 month and at the end of treatment. Check the patient's attendances for treatment every month
9

Management of MDR-TB (3)

Arrange for home visit if the attendance for treatment is not good Give info about TB and its treatment to those who can read and interested to know more about their condition. Arrange treatment as near as possible to the patient's home or his work. If needed, time clinic so that the patient doesnt have to miss work or waiting for a long time In 1ry stages of treatment - patient should be isolated.
10

Management of MDR-TB (4)

Explain carefully to patient the date and place of his next attendance and give him a card. If there is a local calendar different from the standard international calendar give him the date in the local calendar he will understand better

Check for personal problems e.g. work-related, marriage, what his neighbors will say, give advice but arrange for counseling
11

Management of MDR-TB (5)

If not on DOT - check the number of pills left when patient comes for review & more drugs. This will tell you whether he has taken all the doses Ask him in a sympathetic manner why he has not taken drugs. This will help you give the right advice. If the patient does not get better or does not return for review, the best and quickest way to get the patient is by home visit - to persuade him to return. That is why a patient has to leave his contacts and home address.
12

Management of MDR-TB (6)

Treatment in 3 phases:
1. Short term (8wks) intensive chemotherapy to try to kill most of the TB organisms. 2. Maintenance treatment for 4-10months (depends on drugs available) to clear off the rest of the organisms especially when resistant 3. Surgical treatment, drug therapy for resistant TB. If a disease is confined to one or at most two lobes, removal may offer a better chance of cure than continued drug treatment
13

Prevention and Control 1.

DOT where patient is seen swallowing medication under trained supervisor. Well trained H/worker to administer the TB drugs to patients to avoid development of resistance

Counseling for patients and family members to enhance drug adherence

14

Prevention and Control 2.

Encourage to report side effects like itching, rash, blisters, nausea - not to just give up treatment & cause resistance to drugs. Health Education for every one who comes to the health center. Give BCG to children and adults who have a negative tuberculin test. Promote HIV prevention & control
15

Impact of MDR-TB on Community

Stigma community avoids patient/family

MDR-TB increases cost & duration of TB treatment

Costly diagnosis Costly treatment

Increases family poverty

Family to look for money for treatment Bread Earner weak & unproductive

16