Can We Engage Private Pharmacies To Help Control Drug-Resistant Tuberculosis?

Antibiotic resistance and infectious diseases have long been high on my list of things to worry about, with multi-drug-resistant tuberculosis vying for top honors. In 2015, 10.4 million people became ill with tuberculosis, and 1.8 million died, making TB one of the top causes of death globally. Six countries account for 60% of the cases: China, India, Indonesia, Nigeria, Pakistan and South Africa. As I noted in a previous post, India is critically important to control of drug resistance as well as tuberculosis, as it has the highest TB burden, with 2.2 million infections annually, as well as the largest antibiotic consumption.

In most of these countries, physicians are not the first point of contact for those seeking healthcare. Instead, about 50% of TB patients’ first contact with the health system is from a private drug seller. Keep in mind that in many countries, antibiotics (and other medicines) are readily available over the counter, fueling resistance, as people who get their meds without benefit of a physician often are misdiagnosed and get the wrong medication or the wrong dosage, or don't take the medication long enough, etc. Further complicating treatment is that many patients with TB—up to 50% in some parts of Africa—also suffer from HIV/AIDS, greatly complicating treatment, and TB is a major cause of death in co-infected patients.

Recent studies show why patients getting care from pharmacies are such a huge concern. In a study by Madhukar Pai and colleagues, standardized “patients” with classic symptoms of TB were sent to pharmacies. The patients complained of 2-3 weeks of cough and intermittent low-grade fever. If asked, they admitted to weight loss as well. Only 13% of the patients were referred appropriately to a physician. Instead, 17% received an antibiotic—often a quinolone, which can contribute to drug resistance—and/or a steroid. (Steroids are bad because they can mask symptoms of TB and because they suppress the immune system)...