Tuberculosis in the UK and Malaysia
Farah Apoo compares the management of TB in these two countries
Tuberculosis (TB) remains the most infectious disease worldwide despite the availability of effective vaccines and drugs treatments. In 2005, WHO estimated the number of notifications was still increasing globally especially in South-east Asia and Africa. (1) The slow progress in TB control transpires from inadequate and poorly managed TB treatment. The long duration of treatment, use of multiple drugs with adverse effects and non-compliance all further complicate the management of TB in patients.
To better appreciate the disease on a global scale, I decided to look at the current practices on TB control in UK and Malaysia; two countries from different regions and developmental stages. By taking into account the different incidence rate and national policies, the article hopes to provide a qualitative observation and an objective understanding on how TB patients are managed in both countries.
In the UK, the number of annual notifications has been steadily increasing since 1987 and was largely contributed by the non-UK born population; incidence rose from 78 to 94 per 100,00 between 2000 and 2004.(2) The overall incidence was 14.6 per 100,000 in 2006. (2) WHO classified Malaysia as an ‘intermediate’ TB burden country in 2004. In the last 20 years, the incidence rate has been stagnating although there was a slight upward trend between 2004 and 2006; from 60.3 to 62.6 per 100,000. (3) In the UK, the national policy follows the recommendation made by National Institute of Clinical Excellence (NICE) in 2006. In Malaysia, the current national guidelines published by the Ministry of Health had been implemented since 2002.
One striking difference between the two countries is the implementation of directly observed therapy (DOT), where patients take medications under supervision. It is selective in the UK and universal in Malaysia. The practice in the UK arose from a Cochrane systematic review in 2003 that found no significant difference in treatment completion in patients receiving DOT compared to those who self-administered. (4) One RCT in the review favoured DOT in population groups whom adherence is likely to be problematic. (5) The recommendation endorsed the allocation of resources in other interventions that have been proven to be effective in improving adherence, such as empowering patients with knowledge and motivation.
Malaysia first implemented DOT in 1999 based on a publication by WHO in 1994 that provided a framework for effective TB control. (6) DOT is one of the five-point policy package known as Directly Observed Therapy-Short Courses (DOTS). The other components are political commitment, sputum microscopy, secure dug supply and a recording and reporting system. DOT has been shown to be effective especially in high-burden countries with limited resources. (7) Although it is criticized for reducing patients’ autonomy, it is important to note that before its implementation there has been no concentrated effort of similar magnitude to promote compliance. The key is making the treatment patient-centred through simultaneous interventions and not the mechanical act of observing patients swallowing medications per se. For the above reason, WHO also gives other measures in addition to DOT such as organizing services to be close to the patients’ home, considering patients’ needs, and providing incentives in the form of free medications and monetary reimbursement. (8) In Malaysia, medications are fully funded by the government. Charity organizations give travel allowances and pocket money to underprivileged patients.
Another difference is the availability of human resources; medical officers, nurses and other healthcare personnel trained in TB care. TB clinics in the UK are usually led by consultants in respiratory medicine, whereas in Malaysia TB patients rarely get specialists’ input save for complicated cases. Funded by Primary Care trusts in the UK, one-to-one services by a key worker enable continuity of care and patient-provider partnerships. In Malaysia, all TB care are limited to hospitals and community clinics. Patients-centred health counselling as advocated by the national guidelines is often impractical in busy clinics run by state hospitals. Some continuity of care is possible between the patients and the health personnel supervising their DOT in the community clinics, but the contact is often limited in time and lacks clear educational intent.
Poor adherence is strongly associated with treatment failure and relapse. WHO advocates treatment completion rate to exceed 85% as modelling shows case numbers begin to decrease beyond this level. (6) In 2005, the treatment completion rate in the UK reached 69%. Of the remainder, 18% have been lost to follow up whilst the rest have not completed treatment due to various reasons such as treatment failure (patients who remain or become smear positive again during treatment), defaulters (patients whose treatment was interrupted for 2 months or longer), patients been transferred out or died. (9) In Malaysia, 57% completed treatment in 2005, whilst 28% and 15% were lost to follow up and have not completed treatment respectively. (10) Both countries fell short from the target set by WHO.
As a medical student on clinical placement in TB clinics run by hospitals in both countries, I had the opportunity to uncover patients’ experiences. Mrs. T from the UK needed discontinuation of drugs treatment after she developed severe vomiting and deranged liver biochemistry. She was reluctant to restart treatment. Mr. H from Malaysia works full-time and has a family to support. Having to take an hour off work each day for DOT at the community clinic became an inconvenience for himself and a concern for his employer. These are examples of real problems faced by patients on long-term multiple anti-tuberculosis drugs that can adversely affect their compliance.
To improve treatment completion rates to the level promoted by WHO, patients’ problems have to be pre-emptively addressed. The sure way is through provision of personalized care that puts patients‘ needs and problems at the core. Such care is possible in the UK under existing outreach services in the community. More effort is needed to ensure widespread delivery of such services especially to high-risk populations. In Malaysia, limited resources need to be balanced with treatment priorities hence DOT remains the most cost-effective means available. Training more persons in DOT in the community can improve the delivery of patients-centred care. More importantly, DOT is not meant to work in isolation; simultaneous interventions directed at improving compliance and the other components of DOTS should complement its practice.
Farah Apoo
4th Year Medical Student
Manchester Medical School
Stopford Building
Oxford Road
Manchester PR3 19PL
UK
Farah.Apoo@student.manchester.ac.uk
(1) World Health Organization. Tuberculosis; Fact Sheet No 104. http://www.who.int/mediacentre/factsheets/fs104/en/
(2) French C., Antoine D. Tuberculosis in Migrant Health; Infectious disease in non-UK born populations in England, Wales and Northern Ireland : A Baseline Report 2006. Health Protection Agency; 2006. ISBN 0901144843
(3) National TB / Leprosy Control Unit. National TB Statistics. Kuala Lumpur. Ministry of Health. 2006
(4) Volmink J., Garner P., Directly Observed Therapy for Treating Tuberculosis. Cochrane Database of Systematic Reviews. 2003. Issue 1. Art No.:CD003343.DOI:10.1002/14651858. CD003343.pub3
(5) Kamolrotanakul P., Randomized Controlled Trial of Directly Observed Treatment (DOT) for patients with Pulmonary Tuberculosis in Thailand. Transactions of the Royal Society of Tropical Medicine & Hygiene. 1999; 93(5) pages 571-7
(6) WHO. Tuberculosis Programme. Framework for Effective Tuberculosis Control. Geneva. WHO/TB/94.179
(7) Raviglione MC., Kumaresan J., Bilio N., et all. Evidence for action: WHO Response; DOT, DOTS and the need to act now. Best Practices. 2002; Issue 2.
(8) Maher D., Gupta R., Uplekar M., et all. Directly Observed Therapy and Treatment Adherence. The Lancet. 2000; 356(9234) pages 1032
(9) Human Protection Agency for Infectious Diseases. Enhanced Tuberculosis Surveillance- Treatment Outcomes Surveillance. http://www.hpa.org.uk/
(10) WHO Report 2007. Global Tb Control- Surveillance, Planning, Financing. http://www.who.int/tb/publications/global_report/2007/