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Game change in Tuberculosis?


According to the World Health Organization (WHO) there will be 10 million new cases of tuberculosis (TB) this year in the developing world. But the good news is that effective therapy will prevent the deaths of many of these patients. However, by the time the sick patients are diagnosed and treated, they will have infected many others in their community. Indeed, this 'failure of interruption' continues to keep the global epidemic of TB alive and well. Prompt diagnosis is thus key to treating and preventing the spread of TB.

Unfortunately, the techniques of TB diagnosis are antiquated. The most widely used method to test sputum ( 'khakar' in Nepali) for the TB bug is called the Ziehl-Neelsen stain, which is a 125-year-old technique. If TB was still prevalent in the Western world, there would surely have been major new breakthroughs in diagnostic techniques, but basically TB is a poor man's disease. So it was welcome news when a few days ago, WHO endorsed the GeneXpert device, a rapid test for TB, as "a major milestone for global tuberculosis diagnosis".

Unlike the Ziehl-Neelsen technique, GeneXpert does not need an expert to prepare a sputum slide and look for a bug under the microscope. This new molecular approach is more straightforward. After the patient spits into a cup, the sample is placed in an 'espresso' machine that examines the sample's DNA to see if it contains the genetic signature of TB. A simple, reliable 'yes' or 'no' answer is available in two hours. Importantly, GeneXpert can also determine within two hours if the bacteria is resistant to rifampicin, the most effective of the four-drug cocktail prescribed for TB. This allows treatment to account from the outset for resistant bacteria, and to tailor therapy accordingly.

However, the initial costs of about US$30,000 for the machine and at least US$20 for tests are daunting for the developing world. Unskilled workers can carry this test out with minimal training, but electricity is required. From hospitals in Bihar to the well-appointed Hinduja Hospital in Mumbai, great satisfaction has been expressed about the usefulness and accuracy of the device. But the cost continues to be an important issue, regardless of the scientific enormity of the breakthrough.

1. Bishwa
very good innovation, we need this in Nepal.

2. Salil

Considering the wrath Tuberculosis can bring, 30 K is not a very big sum and neither is a 20 dollars per test charge. People can always put 'in our context though' thing here and there goes the issue in the bin. For the Nepalese who spend lavishly from cigarettes to drinks, the cost is not much to ask though.

Old things are not necessarily bad, The Z-H stain that has stood the test of time for as long as the writer mentions is an invaluable test for us. We can not take those machine all over Nepal, mat be a precious few hospital can afford it.

I question the ethics amongst the Nepalese medical diaspora who seemingly lack in morality charging exorbitant and self-ascertained prices for tests that has not been regulated. I know of a hospital in Lalitpur that charged a cool Rs 100 per stitch a patient's wound got and if it were on a white skin, or for that matter a dark one, then the price would treble of course. Where are we in controlling those malpractices?  If we can be spendthrifts on those issues, why not save for the technology Dr Basnyat suggests? Is any body listening?


3. Siddhartha Yadav
Thank you Dr. Basnyat for yet another interesting article. Indeed, if TB was prevalent in the Western world, we would have had many diagnostic and therapeutic advances till now. Research and innovation has never been our strength. But we need to focus on this aspect of our education now to be able to tackle local problems like this one. I admire how you have led world-class research trials on typhoid and altitude illnesses. I hope many more researchers from Nepal can emulate your path to develop cheap and effective treatment and diagnostic tools for locally prevalent illnesses including tuberculosis. 

(11 JAN 2013 - 17 JAN 2013)