Viewpoint by Cameron Kaiser, MD, Medical Consultant for Tuberculosis, Riverside County Department of Public Health, California and guest WGND blogger.
Antibiotics are, to the typical patient, always the quick fix. Despite our best attempts to convince them that their viral bronchitis will get better without that course of amoxicillin, anyone who has worked a primary care clinic knows the pressure to throw antibiotics at the problem, even when we ourselves know it’s not the answer, because our patients perceive it as the fast track to health. A couple weeks, they reason, and the infection is over. Normalcy ought to resume. Then you tell them they have tuberculosis, and “normalcy” is at least six months away, if everything goes according to plan. And tuberculosis is a wily enough contender to make sure everything won’t.
In our county in southern California, where the majority of tuberculosis cases are followed by our public health department, I personally as the treating physician am well acquainted with this drawn-out battle with my patients’ illness. It requires me to be the cheerleader to reassure them that all these pills will eventually lead to a good result and the risk of reactivation will be beaten back into improbability. It requires me to repair my relationships with patients after a first attempt at cure caused some inexplicable medication intolerance or worse. It requires our overworked department staff to put out thousands and thousands of worker-hours monthly in both directly observed therapy contacts plus innumerable phone messages to make sure that medications get to patients, are taken properly, and side-effects and complications are noted. And most of all, it requires the patience and trust of our tuberculosis patients to tolerate such a complex regimen with a nebulous target and a raft of setbacks.
These problems are especially magnified for our multi-drug resistant patients. A regular four-drug tuberculosis regimen is already long, complex, laden with potential for side effects and not a guaranteed cure, but MDR regimens are years in length, even more complicated with injectables and unusual medications, likely to be more toxic, and without good efficacy data particularly as increasingly resistant strains now demand unconventional regimens with at best anecdotal evidence. Many of these patients will enter lifelong surveillance afterwards (in our jurisdiction, we follow all of them regularly), some will relapse, and some will die. Given that the burden of many of these unfortunate patients falls on already cash and labour-strapped public health jurisdictions such as our own, the tremendous direct and indirect costs of treatment are a significant yet frequently unrecognized impact on stressed public services. Even in low-prevalence areas the care of an MDR patient can consume a large part of a budget for an extended period of time, and in high-prevalence areas the eventual outlay for a collection of cases can be astronomical and perpetual.
It is a moral and public health imperative that dangerous communicable diseases like tuberculosis be treated, first because of the disease’s tendency to disproportionately affect those who are least able to be treated, and second because of its potentially serious impact on those around them who are exposed and may themselves acquire latent or active disease. The ability to do so effectively is slowly becoming more and more undermined by a limited selection of drugs and an onerous baseline regimen that has not significantly changed in decades.
As a treating physician, I have my own particular wish list for what I’d like the direction of new drug development to turn towards. Nearly everyone who treats tuberculosis patients wishes for a routine that is less toxic, has novel activity, and takes less time. Clearly, any new regimen offering these advantages would be welcomed and widely embraced for its clear benefit.
In ‘Part Two’ Dr. Kaiser will share his thoughts and specific suggestions on R&D approaches that can aid in improving TB drug treatment.
Cameron Kaiser, MD is the medical consultant for tuberculosis for the Riverside County Department of Public Health in southern California. This essay reflects his views and not necessarily those of the department or the county. He can be reached at ckaiser@co.riverside.ca.us.