Published in 3rd Quarter 2017
Tuberculosis (TB) – Prevention & Cure
Although, I am not a doctor but based of my experience in the field of medical health insurance, some literature review, Internet and interaction with some doctors and patients, I feel to highlight some useful information for the purpose of public awareness about Tuberculosis.
Pakistan currently ranks fifth amongst countries with highest burden of Tuberculosis alongside the fourth highest burden of Drug Resistant TB globally. In an estimated population of around 180 million with annual incidence of TB being 231 out of every 100,000, Pakistan produces about 420,000 new cases annually.
Tuberculosis (TB) is an important public health problem that is preventable and curable. This is a potentially serious infectious disease that mainly affects your lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air through coughs and sneezes.
Tuberculosis infections began increasing because of the emergence of HIV, the virus that causes AIDS. HIV weakens a person’s immune system so it can’t fight the TB germs. Many strains of tuberculosis resist the drugs most used to treat the disease. People with active tuberculosis must take several types of medications for many months to eradicate the infection and prevent development of antibiotic resistance.
Stigma regarding TB prevails in our society. Due to this, patient suffers from discrimination, rejection and social isolation. TB stigma is one of the barriers to TB control. Even when TB is cured, the “label” of having had TB sticks. The stigma related to TB negatively affects the life of a TB patient in the following ways:
- Patient does not reveal his ailment.
- People develop feeling of hatred towards the TB patient.
- It gives rise to gossip and speculations.
- Marriage prospects reduce.
- Family tensions and divorce rate may increase.
- Patient may lose his job.
- Patient and his family members are financially burdened.
- Patient worries about fulfillment of his responsibilities in the society
- Guilt and blame of TB infection
Although your body may harbor the bacteria that cause tuberculosis, your immune system usually can prevent you from becoming sick. For this reason, doctors make a distinction between:
Latent TB: In this condition, you have a TB infection, but the bacteria remain in your body in an inactive state and cause no symptoms. Latent TB, also called inactive TB or TB infection, is not contagious. It can turn into active TB, so treatment is important for the person with latent TB and to help control the spread of TB. An estimated 2 billion people have latent TB.
Active TB: This condition makes you sick and can spread to others. It can occur in the first few weeks after infection with the TB bacteria or it might occur years later.
- Signs and symptoms of active TB include:
- Coughing that lasts three or more weeks
- Coughing up blood
- Chest pain or pain with breathing or coughing
- Unintentional weight loss
- Night sweats
- Loss of appetite
Tuberculosis can also affect other parts of your body including your kidneys, spine or brain. When TB occurs outside your lungs, signs and symptoms vary according to the organs involved. For example, tuberculosis of the spine may give you back pain and tuberculosis in your kidneys might cause blood in your urine.
Visit your doctor if you have a fever, unexplained weight loss, drenching night sweats or a persistent cough. These are often signs of TB, but they can also result from other medical problems. Your doctor can perform tests to help determine the cause.
The Centers for Disease Control and Prevention recommends that people who have an increased risk of tuberculosis be screened for latent TB infection. This recommendation includes:
- People with HIV/AIDS
- IV drug users
- Those in contact with infected individuals
- Health care workers who treat people with a high risk of TB
Anyone can get tuberculosis, but certain factors can increase your risk of the disease. These factors include:
Weakened Immune System: A healthy immune system often successfully fights TB bacteria, but your body can’t mount an effective defense if your resistance is low. A number of diseases and medications can weaken your immune system, including:
- Severe kidney disease
- Certain cancers
- Cancer treatment, such as chemotherapy
- Drugs to prevent rejection of transplanted organs
- Some drugs used to treat rheumatoid arthritis, Crohn’s disease and psoriasis
- Very young or advanced age
Traveling or living in certain areas: The risk of contracting tuberculosis is higher for people who live in or travel to countries that have high rates of tuberculosis and drug-resistant tuberculosis, including Africa, Eastern Europe, Asia, Russia, Latin America and Caribbean Islands etc.
Lack of medical care: If you receive a low or fixed income, live in a remote area, have recently immigrated to the United States, or are homeless, you may lack access to the medical care needed to diagnose and treat TB.
Substance abuse: IV drug use or alcohol abuse weakens your immune system and makes you more vulnerable to tuberculosis.
Tobacco use: Using tobacco greatly increases the risk of getting TB and dying of it.
Health care work: Regular contact with people who are ill increases your chances of exposure to TB bacteria. Wearing a mask and frequent hand-washing greatly reduce your risk.
Living or working in a residential care facility: People who live or work in prisons, immigration centers or nursing homes are all at a higher risk of tuberculosis. That’s because the risk of the disease is higher anywhere there is overcrowding and poor ventilation.
Living in a refugee camp or shelter: Weakened by poor nutrition and ill health and living in crowded, unsanitary conditions, refugees are at especially high risk of tuberculosis infection.
Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your lungs, but it can spread to other parts of your body through your bloodstream. Examples of tuberculosis complications include:
Spinal pain: Back pain and stiffness are common complications of tuberculosis.
Joint damage: Tuberculosis arthritis usually affects the hips and knees.
Swelling of the membranes that cover your brain (Meningitis): This can cause a lasting or intermittent headache that occurs for weeks. Mental changes also are possible.
Liver or kidney problems: Your liver and kidneys help filter waste and impurities from your bloodstream. These functions become impaired if the liver or kidneys are affected by tuberculosis.
Heart disorders: Rarely, tuberculosis can infect the tissues that surround your heart, causing inflammation and fluid collections that may interfere with your heart’s ability to pump effectively. This condition, called cardiac tamponade, can be fatal.
During the physical exam, your doctor will check your lymph nodes for swelling and use a stethoscope to listen carefully to the sounds your lungs make while you breathe. The most commonly used diagnostic tool for tuberculosis is a simple skin test, though blood tests are becoming more commonplace. A small amount of a substance called PPD tuberculin is injected just below the skin of your inside forearm. You should feel only a slight needle prick.
Within 48 to 72 hours, a health care professional will check your arm for swelling at the injection site. A hard, raised red bump means you are likely to have TB infection. The size of the bump determines whether the test results are significant.
The TB skin test is not perfect. Sometimes, it suggests that people have TB when they really don’t. It can also indicate that people don’t have TB when they really do.
A false-positive test may happen if you have been vaccinated recently with the bacillus Calmette-Guerin (BCG) vaccine. This tuberculosis vaccine is widely used in countries with high TB infection rates. False-negative results may occur in certain populations including children, older people and people with AIDS who sometimes don’t respond to the TB skin test. A false-negative result can also occur in people who have recently been infected with TB, but whose immune systems have not yet reacted to the bacteria.
Blood Tests: Blood tests may be used to confirm or rule out latent or active tuberculosis. These tests use sophisticated technology to measure your immune system’s reaction to TB bacteria. QuantiFERON-TB Gold in-Tube test and T-SpotTB test are two examples of TB blood tests. These tests require only one doctor’s visit. A blood test may be useful if you are at high risk of TB infection but has a negative response to the skin test or if you have recently received the BCG vaccine.
Imaging Tests: If you have had a positive skin test, your doctor is likely to order a chest X-ray or a CT scan. This may show white spots in your lungs where your immune system has walled off TB bacteria or it may reveal changes in your lungs caused by active tuberculosis. CT scans provide more-detailed images than do X-rays.
Sputum Tests: If your chest X-ray shows signs of tuberculosis, your doctor may take samples of your sputum, the mucus that comes up when you cough. The samples are tested for TB bacteria. Sputum samples can also be used to test for drug-resistant strains of TB. This helps your doctor choose the medications that are most likely to work. These tests can take four to eight weeks to be completed.
If you test positive for latent TB infection, your doctor may advise you to take medications to reduce your risk of developing active tuberculosis. The only type of tuberculosis that is contagious is the active variety, when it affects the lungs. So if you can prevent your latent tuberculosis from becoming active, you won’t transmit tuberculosis to anyone else.
Protect your family and friends
If you have active TB, keep your germs to yourself. It generally takes a few weeks of treatment with TB medications before you’re not contagious anymore. Follow these tips to help keep your friends and family from getting sick:
Stay home: Don’t go to work or school or sleep in a room with other people during the first few weeks of treatment for active tuberculosis.
Ventilate the room: Tuberculosis germs spread more easily in small closed spaces where air doesn’t move. If it’s not too cold outdoors, open the windows and use a fan to blow indoor air outside.
Cover your mouth: Use a tissue to cover your mouth anytime you laugh, sneeze or cough. Put the dirty tissue in a bag, seal it and throw it away.
Wear a mask: Wearing a surgical mask when you’re around other people during the first three weeks of treatment may help lessen the risk of transmission.
Finish your entire course of medication
This is the most important step you can take to protect yourself and others from tuberculosis. When you stop treatment early or skip doses, TB bacteria have a chance to develop mutations that allow them to survive the most potent TB drugs. The resulting drug-resistant strains are much more deadly and difficult to treat.
In countries where tuberculosis is more common, infants often are vaccinated with bacillus Calmette-Guerin (BCG) vaccine because it can prevent severe tuberculosis in children. The BCG vaccine isn’t recommended for general use in the United States because it isn’t very effective in adults. Dozens of new TB vaccines are in various stages of development and testing.
Medications are the cornerstone of tuberculosis treatment. But treating TB takes much longer than treating other types of bacterial infections. With tuberculosis, you must take antibiotics for at least six to nine months. The exact drugs and length of treatment depend on your age, overall health, possible drug resistance, the form of TB (latent or active) and the infection’s location in the body.
Recent research suggests that a shorter term of treatment, four months instead of nine, with combined medication may be effective in keeping latent TB from becoming active TB. With the shorter course of treatment, people are more likely to take all their medication, and the risk of side effects is lessened. Studies are ongoing.
Most common TB drugs:
If you have latent tuberculosis, you may need to take just one type of TB drug. Active tuberculosis, particularly if it’s a drug-resistant strain, will require several drugs at once. The most common medications used to treat tuberculosis include Isoniazid, Rifampin (Rifadin, Rimactane), Ethambutol (Myambutol) and Pyrazinamide etc.
If you have drug-resistant TB, a combination of antibiotics called fluoroquinolones and injectable medications, such as amikacin, kanamycin or capreomycin, are generally used for 20 to 30 months. Some types of TB are developing resistance to these medications as well.
A number of new drugs are being looked at as add-on therapy to the current drug-resistant combination treatment, including Bedaquiline, Linezolid etc.
Medication side effects:
Serious side effects of TB drugs are not common but can be dangerous when they do occur. All tuberculosis medications can be highly toxic to your liver. When taking these medications, call your doctor immediately if you experience any of the following:
- Nausea or vomiting
- Loss of appetite
- A yellow color to your skin (Jaundice)
- Dark urine
- A fever that lasts three or more days and has no obvious cause
- Completing treatment is essential
After a few weeks, you will not be contagious and you may start to feel better. It might be tempting to stop taking your TB drugs. But it is crucial that you finish the full course of therapy and take the medications exactly as prescribed by your doctor. Stopping treatment too soon or skipping doses can allow the bacteria that are still alive to become resistant to those drugs, leading to TB that is much more dangerous and difficult to treat.
To help people stick with their treatment, a program called directly observed therapy (DOT) is recommended. In this approach, a health care worker administers your medication so that you don’t have to remember to take it on your own.
Treatment for tuberculosis is a complicated and lengthy process. But the only way to cure the disease is to stick with your treatment. You may find it helpful to have your medication given by a nurse or other health care professional so that you don’t have to remember to take it on your own. In addition, try to maintain your normal activities and hobbies and stay connected with family and friends.
Keep in mind that your physical health can affect your mental health. Denial, anger and frustration are normal when you must deal with something difficult and unexpected. At times, you may need more tools to deal with these or other emotions. Professionals, such as therapists or behavioral psychologists, can help you develop positive coping strategies.
In my opinion, the awareness among general public about TB is insufficient and people should be given awareness about prevention, risk factors, importance of medical checkup for early detection and availability of treatment in Pakistan. Some special awareness programs are needed for rural population through electronic and print media (TV, Newspapers, Literatures and Social Media), health / medical insurers and hospitals. Ministry of Health must play its active role in prevention of TB. Although, they have started National TB Control Program which is a remarkable step. Govt. must ensure that Tests and Medication for TB should be available free of cost nearer in the urban and rural basic health centers.
Published in 1st Quarter 2017
Medical Service Providers (A Big Challenge for Health Insurance Industry in Pakistan)
I have attended a Seminar on Health Insurance in Pakistan – Opportunities & Challenges organized by Lahore Insurance Institute a couple of months ago. That was good effort to address the issues faced by insurance companies, but in my opinion, the actual purpose of this seminar is just the introduction and publicity of various insurance companies and their premium contribution to the health insurance industry. Some of the petty issues were discussed in the session and skipped the main issues which are highly damaging for the profitability of health insurance industry. This could have been fruitful if the solution of some major challenges was found and implemented by mutual consensus. The people from senior management of some major insurance companies were also present in the seminar but the lack of unity on policy making was seen amongst them which are also negative for the growth of health insurance sector.
In Pakistan, a lot of insurance companies are providing health insurance coverage to the corporate sector through various hospitals and other medical service providers like clinics, dentists, laboratories and pharmacies etc. I felt that there is a need to highlight some serious issues which the health insurance industry has been facing from a long time from medical service providers. Now, these issues become a big challenge for the profitability of our health insurance sector. Some of them are elaborated below:
Increase in Medical Services Rates:
A number of big as well as small hospitals are continuously increasing their medical services rates which include room charges, consultant fee, surgeon fee and other charges etc. They are increasing the rates without taking into account the rate of inflation. Although, the rate of inflation is around 7.74% but the increase in overall rates of medical services is more than 30% on an average which is damaging for the health insurance industry in Pakistan. On the other hand, hospitals are making the maximum profits.
Increase in Medicines Rates:
Another factor is the prices of medicines which are increasing rapidly. Due to this increase, the cost of medical treatment is rising which is a serious concern for the insured patients as well as the insurance companies. Some medicines which are not manufactured in Pakistan are very costly due to duties and taxes imposed by the government on their import.
Insufficient Medical Facilities:
In rural areas, across Pakistan, there are a number of small clinics and medical stores which are unlicensed and operated by unqualified persons. They are actually called as “Quaks” which are practicing just on the basis of their years of experience. They are treating the patients and prescribing the medicines. Although, they are not authorized to do so, but they are mistreating the patients and making bills which is a loss factor for the health insurance companies.
In rural as well as some urban areas, some doctors do not issue a receipt of consultation charges. The patients have to write the doctor’s fee their self on the prescription which is not a fair deal. In this scenario, the patients write the amount as per their own will and submit the same for reimbursement from the insurance company. Same is the case with medical stores in which most of them do not provide the proper medicines bills.
One of the major factor which is damaging the health insurance industry is the over billing by the medical service providers i.e. hospitals, clinics, dentists, laboratories and medical stores. They are in practice of making bills more than the actual costs on the request of insured patients. If these types of bills are overlooked by the claims department of the insurance company, then this may be the potential loss / claim leakage which will ultimately disturb the profitability of the health insurer.
Now a days, this is the normal practice of the medical service providers i.e. hospitals, clinics, dentists, laboratories and medical stores to make fake bills on patient’s request. This means if a patient is insured, his temptation to avail medical benefit triggers which ultimately leads him to make fake bills. Some of the medical service providers frequently helping these insured patients in making fake bills also verify the same when a person comes from insurance company for authentication. This type of verification and authentication is very difficult and hectic task for the health insurance company and if this is not done properly, it will ultimately be the potential loss factor for the insurance company as well as the health insurance industry.
Undue Hospital Admissions:
We all know the hospital industry is becoming the fastest profit earning industry in Pakistan and a lot of hospitals are in practice of making undue hospital admissions and convert OPD treatments into IPD cases, only due to this the patient is insured and the insurance company is bearing the cost of the admission. In this scenario, the patient doesn’t bother whether admission is necessary or not because the patient does not have to pay anything from his pocket. Thus, insurance company has to bear the cost of undue and unjustified hospital admissions which is also a serious loss factor for the health insurance sector.
Now a days, some Gynecologists are converting a Normal Delivery into Cesarean Section just for the sake of their ease and making more money. This malpractice is the most damaging for patients in terms of their health as well as for the health insurance companies in terms of cost.
As per my recommendations, the health insurance companies should take strong measures to identify the above issues and deal with strict compliance. Also, all health insurance companies in Pakistan should form a combined database in which the detailed information should be given of any of the above activity by any medical service provider so that all the insurance companies must be aware of any future activity of that provider and also blacklisted. They should also form a committee of key personnel of health insurance companies whose work is to schedule meetings on monthly basis to cater these issues and make policy decisions on the basis of the same. Secondly, Ministry of Health should play their active role in identifying the malpractice and misuse of bills, documents of medical service providers and take strict action against them according to the Law of Pakistan. Pakistan Medical and Dental Council (PMDC) have to monitor closely the activities of doctors, gynecologists and dentists etc. and take strict action against them timely. Lastly, being an insured and insurer we must obey the Principle of Insurance; Utmost Good Faith so that these types of issues can be mitigated.
Published in 3rd Quarter 2016
Obesity (The root cause of all diseases)
Based on my experience in the field of medical health insurance, some literature review, Internet and interaction with some patients, I feel to highlight some useful information for the purpose of public awareness about Obesity which is a root cause of all diseases.
The term ‘obese’ describes a person who is very overweight, with a lot of body fat. Obesity is a condition where a person has accumulated so much body fat that it might have a negative effect on their health. If a person’s bodyweight is at least 20% higher than it should be, he or she is considered obese.
Pakistan ranked 9th out of 188 countries in terms of obesity, according to the Global Burden of Disease Study published in The Lancet medical journal. A staggering 671 million people now fall within the obese category and 78 million of them in the United States, which accounts for five percent of the world’s population, but more than a tenth of its grossly overweight people.
China and India with much larger populations, trailed 2nd and 3rd in the top 10 obese countries with 46 million and 30 million people respectively, followed by Russia, Brazil, Mexico, Egypt, Germany, Pakistan and Indonesia. Nearly a third of adults and a quarter of children today are overweight.
There are many ways in which a person’s health in relation to their weight can be classified, but the most widely used method is body mass index (BMI). BMI is a measure of whether you are a healthy weight for your height. You can use the BMI healthy weight calculator to work out your score.
For most adults, a BMI of:
18.5 to 24.9 means you are a healthy weight
25 to 29.9 means you are overweight
30 to 39.9 means you are obese
40 or above means you are severely obese
BMI is not used to definitively diagnose obesity, because people who are very muscular sometimes have a high BMI without excess fat. But for most people, BMI is a useful indication of whether they are a healthy weight, overweight or obese.
A better measure of excess fat is waist circumference, which can be used as an additional measure in people who are overweight (with a BMI of 25 to 29.9) or moderately obese (with a BMI of 30 to 34.9).
Usually, men with a waist circumference of 94cm (37in) or more and women with a waist circumference of 80cm (about 31.5in) or more are more likely to develop obesity-related health problems.
You can calculate your Body Mass Index (BMI) with the help of below BMI Table:
Risks of Obesity:
It is very important to take steps to tackle obesity because, as well as causing obvious physical changes; it can lead to a number of serious and potentially life-threatening conditions, such as:
- Type 2 diabetes
- Coronary heart disease
- Some types of cancer, such as breast cancer and bowel cancer
Obesity can also affect your quality of life and lead to psychological problems, such as depression and low self-esteem.
Causes of Obesity:
Obesity is generally caused by consuming more calories, particularly those in fatty and sugary foods than you burn off through physical activity. The excess energy is stored by the body as fat.
Obesity is an increasingly common problem because for many people modern living involves eating excessive amounts of cheap, high-calorie food and spending a lot of time sitting down, at desks, on sofas or in cars. There are also some underlying health conditions that can occasionally contribute to weight gain, such as an underactive thyroid gland (hypothyroidism), although these types of conditions don’t usually cause weight problems if they are effectively controlled with medication.
Treatment of Obesity:
The best way to treat obesity is to eat a healthy, reduced-calorie diet and exercise regularly. To do this you should:
- Eat a balanced, calorie-controlled diet as recommended by your GP or weight loss management health professional (such as a dietitian)
- Join a weight loss group
- Take up activities such as fast walking, jogging, swimming or tennis for 150 to 300 minutes (two-and-a-half to five hours) a week
- Eat slowly and avoid situations where you know you could be tempted to overeat
You may also benefit from receiving psychological support from a trained healthcare professional to help change the way you think about food and eating. If lifestyle changes alone do not help you lose weight, a medication called Orlistat (with brand names of i.e. Orlifit, Orslim, Xenical etc.) may be recommended. If taken correctly, this medication works by reducing the amount of fat you absorb during digestion. Your physician will know whether Orlistat is suitable for you. In rare cases, weight loss surgery may be recommended.
Obesity can cause a number of further problems, including difficulties with daily activities and serious health conditions. Day-to-day problems related to obesity include:
- Increased sweating
- Difficulty doing physical activity
- Often feeling very tired
- Joint and back pain
- Low confidence and self-esteem
- Feeling isolated
The psychological problems associated with being obese can also affect your relationships with family and friends and may lead to depression. Obesity reduces life expectancy by an average of 3 to 10 years, depending on how severe it is. It is estimated that obesity and being overweight contribute to at least 1 in every 13 deaths in the world.
In my opinion, the awareness among general public about Obesity is insufficient and people should be given awareness about prevention, risk factors, importance of medical checkup and availability of treatment in Pakistan. Although, there is no quick treatment for obesity. Weight loss programs take time and commitment and work best when fully completed. The healthcare professionals involved with your care should provide encouragement and advice about how to maintain the weight loss achieved. Regularly monitoring your weight, setting realistic goals and involving your friends and family with your attempts to lose weight can also help. Remember that even losing what seems like a small amount of weight, such as 3% or more of your original body weight and maintaining this for life, can significantly reduce your risk of developing obesity-related complications like diabetes and heart disease.