A forgotten epidemic

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A multi-drug resistant tuberculosis patient at Pham Ngoc Thach Hospital, Ho Chi Minh City
PHOTO COURTESY OF SGTT

Uncontrollable and also unnoticed, Tuberculosis kills 30,000 in Vietnam every year

At 41, Phuong looks skinny and pale.

She was diagnosed with Tuberculosis (TB) a couple of years ago and was successfully treated. But the disease came back stronger than ever early this year and Phuong was then diagnosed with multi-drug resistant (MDR) TB a condition in which patients resist the two main TB drugs, namely Isoniazid and Rifampicine.

The woman now lives with her husband and four children in a house of four square meters amid the labyrinthine alleyways of District 6, Ho Chi Minh City. The house is mainly for sleeping, while all other daily activities like washing and bathing are done at a relative's house nearby.

In such a narrow space, the risk that one or more of Phuong's family members have contracted the disease from her is unavoidable, said Dr. Nguyen Van Hoi, who is with an anti-TB team in District 6.

"TB is like an invisible enemy because it transmits through the air; anyone can contract it," said Dr. Nguyen Duc Bang, chief of the graphic diagnosis department at HCMC's leading TB hospital,Pham Ngoc Thach in HCMC.

He said even health workers are no exception, adding that one-third of his department's personnel have TB, while he himself was found with TB meningitis three years ago.

According to the World Health Organization, around one-third of the world's population has TB bacteria that can develop into the disease once the body becomes weak.

It was also reported that every TB patient is able to infect 10-15 others through close contact over the course of a year.

Dr. Phan Thuong Dat, chief of the drug-resistant TB department at Pham Ngoc Thach Hospital, said one of the current challenges to anti-TB programs is the increase in populations, especially in big cities, which are crowded with people and offer very little space for living.

At crowded public places like on a bus, once a TB patient coughs, numerous germs will spread and no one can avoid them, Dat said. Thus, "it is not strange that TB is not controlled well in big cities."

Dr. Le Truong Giang, chairman of HCMC Public Health Association and who has worked for the city's anti-TB program for many years, agreed, saying that the epidemic in the Vietnamese southern metro is one of the worst  in the world.

"It is a very long road to control and stop the TB epidemic, both globally and in Vietnam as well," Giang said.

Ignorance

In the late 1990s, HCMC introduced an advanced TB treatment methodology that reduced treatment time from eight months to six months and cut the number of repeat cases by two thirds.

However, a couple of years later the positive results decreased and the failure rate increased unexpectedly. This was then attributed to the lack of health workers, who were in charge of observing patients to make sure they took their medicines strictly as prescribed.

The problem still continues to this day.

Nguyen Thi Ngoc Trinh, who is in charge of an anti-TB program in Binh Hung Commune, Binh Chanh District, HCMC, said she now manages 68 TB patients.

It is worse in other areas in the city where a health worker manages nearly 200 TB patients besides working for other health programs.

Between 20 and 30 percent of registered TB patients do not follow treatment strictly, which greatly increases the risk of spreading MDR bacteria, according to Giang.

Explaining reasons why some patients do not follow public treatment completely, even though it is for free, Dr. Nguyen Phuc Hai with Pham Ngoc Thach Hospital said many poor patients stop treatment once they feel better to continue working for living.

Although they pledge that they will take medicine strictly at home, no one can be sure.

"The only thing is for sure is that the number of failure cases is increasing," said Hai.

He said that not finishing medicine and treatment completely helps lead to the development of MDR, he added.

He said helping patients finish up their medicine and treatment properly was also the responsibility of their families.

Under a treatment program initiated by Pham Ngoc Thach Hospital, families join as second observers making sure that patients take medicines at home in the afternoon, while health workers do the job at health clinics in the morning.

However, so far the program has not gained many positive results.

A survey undertaken by the hospital showed that two-thirds of the families observe well for the first month of treatment, and the rate dropped to less than half by the last month of treatment.

"The society cannot ask health workers to do the whole job, because they still have many things to do," said Dr. Tran Ngoc Buu with Pham Ngoc Thach Hospital.

If patients' families cannot encourage their loved ones to take medicines and follow treatment properly, no one else can do it, he stressed.

Giang also said that whether the TB epidemic can be controlled or not depended mostly on "the second observer."

Worsening

At a recent conference on TB, experts estimated that Vietnam now has 5,000-6,000 MDR patients, a number that is threatening to rise.

In District 6 of HCMC, for instance, the number of MDR patients increased from one in 2010 to 22 in 2011 and then 40 last year.

Dat said currently Pham Ngoc Thach's MDR department has 48 beds for patients who stay at least 15 days.

But the number of beds cannot meet demand, he said.

If MDR patients fail to get their disease treated, they will resist more drugs and develop "extensively drug resistant TB," the doctor warned. 

"At that time all the patients can do is wait to die because treatment is difficult, costly and ineffective," he said.

According to the Vietnam National Anti-TB Program, 1.5 percent of TB cases in Vietnam are extensively drug resistant.

A health official said given that in Italy, India and Iran, cases of totally drug resistant (TDR) TB have been recorded, Vietnam was still "lucky."

However, doctors said since it is easy to travel across borders now, there are chances that the worst kinds of TB will spread to other countries.

In fact, Dr. Shelly Batra, founder and President of Operation ASHA, an Indian-based TB fighting organization, was once quoted as saying in the TIME magazine that: "We are on the brink of another epidemic. If TDR spreads, we will go back to the Dark Ages."

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