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Friday, October 13, 2006

World Health Policies against Tuberculosis, must change.

Niña con TBC, pulmonar. Cortesia : El Mundo.España.







The results of a well planned research, with controls, appropiate rational and statistical methods, can have repercussions and unsuspected reaches. The increment at world level, during the last years - of cases of resistance and extremely resistance to tuberculous medications, pushed us toward foreseeing that something didn't walk well in the programs of precocious diagnosis and treatment of Tuberculosis (TBC). If you analyze carefully the Figure.1 of a research appeared yesterday in the NEJM, you will verify certain wrong public health policies, implanted in our country mercy to counseling of experts of the WHO (World Health Organization), followed without considerations for authorities of the Ministry of Health of our country. Executives of the WHO, established some years ago as method of fighting TBC at world level - the realization of precocious diagnosis of TBC, subjecting all suspect of suffering the illness, to sputum analysis (tint and microscopic recognition of the germ). Offering to the positive cases, free treatments (4 standardized medications, during 6 months), without having concomitant studies of sensibility to antibiotics or chemoterapic drugs, to consider them distractors and complicated. This politics have driven to that 5-10 % of cases, diagnosed as negative, were to the long one being positive.

And, when negative patients coming from high risk populational groups, were subjected to analysis of more sensibility and specificity (automated or cultivations in Lowenstein Jensen, medium : L - J), it was that - although in smaller percentage - a small number of positive cases, continued giving negative results. The new method :Mycroscopic Observation-Drug Susceptitbility (MODS), created by British, American and peruvian investigators capable to diagnose, quick (cultivate and sensibility in 7 days, against the 22 of L/J), cheaper (2 dollars for patient, against the 52 of the automated methods), has allowed to discover almost the entirety of cases of TBC (among negative and positive cases), with a surprising efficiency. As it will be understood, the cases informed as negatives continued disseminating the illness, likewise a fraction of those reported as positive -not adequatelly treated- because the standardized treatment ( without patterns of sensibility), that they received, was not the appropriate one. This way, the cases non treated and those improperly treated, were conditioning resistance and multiresistance to drugs, antiTBC. Although to combat TBC, it is necessary to bet on social policies that offer appropriate nutrition, covering in housing, basic services and appropriate lifestyles, we demand in defense of the human life to the Ministry of Health of Peru that leaves aside the standardized treatments and impose as state policy, individualized antiTBC treatments (cultivations and tests of sensibility), to all diagnosed Peruvians of TBC or suspects of having the disease , without discrimination.

Politicas de diagnóstico y tratamiento contra la TBC, deben cambiar.

Los resultados de estudios de investigación bien planificados, con controles, métodos racionales y estadisticos apropiados, pueden tener repercusiones y alcances insospechados. El incremento –a nivel mundial, durante los últimos años- de casos de resistencia y multiresistencia a medicamentos antituberculosos, hacia prever que algo no andaba bien en los programas de detección precóz y tratamiento de la Tuberculosis (TBC). Si analizan críticamente, la Figura.1, de un trabajo de investigación aparecido el dia de ayer en el NEJM, constatarán lo errado de ciertas politicas de salud pública, implantadas en nuestro pais a sugerencia de expertos de la Organización Mundial de la Salud (OMS), seguidas sin miramientos por autoridades del Ministerio de Salud Pública de nuestro pais. Ejecutivos de la OMS, establecieron hace algunos años –como método de combatir la TBC a nivel mundial- la realización de diagnósticos precoces de TBC, sometiendo a todo sospechoso de padecer la enfermedad, a análisis de esputo (tinción y reconocimiento microscópico del germen). Ofertando a los casos positivos, tratamientos gratuitos (4 medicamentos estandarizados y únicos, durante 6 meses), sin contar con estudios concomitantes de sensibilidad a antibióticos o quimioterápicos, por considerarlos distractores y complicados. Los resultados de esta politica han conducido a que entre un 5-10%, de casos diagnosticados como negativos, resulten a la larga siendo positivos.

Y, cuando pacientes negativos procedentes de grupos poblacionales de alto riesgo, fueron sometidos a análisis de mayor sensibilidad y especificidad (automatizados o cultivos de Lowenstein Jensen:L-J), resultaba que -aunque en porcentaje menor- un número pequeño de positivos, continuaba dando resultados negativos. El nuevo método :Microscopic Observation–Drug Sensitiviy (MODS), creado por investigadores británicos, americanos y peruanos de diagnóstico rápido (cultivo y sensibilidad, en 7 dias, contra los 22 del L/J), económico (2 dolares por paciente, contra los 52 de los métodos automatizados), permite descubrir la casi totalidad de casos de TBC (entre falsos negativos y positivos), con una eficiencia sorprendente. Como se comprenderá, los casos informados como negativos continuaban diseminando la enfermedad y una fracción de los reportados como positivos -no se curaban -porque el tratamiento estandarizado, sin patrones de sensibilidad- que recibian, no era el adecuado. Asi, los casos no tratados y los inadecuadamente tratados, estaban condicionando resistencia y multiresistencia a drogas, antiTBC. Aunque para combatir la TBC, es necesario apostar por politicas sociales que brinden adecuada nutrición, cobertura en vivienda, servicios básicos y apropiados estilos de vida, exigimos en defensa de la vida humana al Ministro de Salud del Perú, que deje de lado los tratamientos estandarizados e imponga como politica de estado, tratamientos antiTBC, individualizados (cultivos y pruebas de sensibilidad), a todos los peruanos diagnosticados de TBC o sospechosos de tenerla, sin discriminación alguna.

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