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Improving the health of the population in Romania by increasing TB control

Project financed by the Norwegian Grants 2009 - 2014, within the RO 19 - Public Health Initiative.

Sorry, this entry is only available in Romanian.

Sorin Neacșu have had multidrug rezistant tuberculosis (XDR-TB). He ies cured now and he tells us his story without hesitation, and full of emotions. Even there are four years since he was declared cured, he is still impressed by the people that saved him, people from the Association for MDR-TB Patients Support.

The interview was filmed for the Improving the health of the population in Romania by increasing TB control, project financed by the Norwegian Grants 2009 – 2014, within the RO 19 – Public Health Initiatives.

I don’t know when I got tuberculosis, when I became ill. And I don’t know when I would have detected it if I hadn’t had some tests done, by chance. My wife went to the family doctor for a check-up and she also asked about my health insurance card. The doctor asked her about me and told her she had my insurance health card and I was supposed to visit the practice and receive it. I went there and she said: „There are some tests that are performed annually, if you want, you can have them done.” Since I was already there, I agreed and I did all the tests but the X-ray wasn’t among them and I said to myself if I did the other tests, I should do that too. The doctor told me it wasn’t included among the state-subsidised tests, I asked how much it was and when she said it was around RON 20, I had a chest X-ray done as well. I had done the other tests and the results had been good, so I thought nothing about it. The doctor performed two X-ray exams, a frontal and a lateral one and she detected TB. She said there was no time to lose and referred me to a pneumologist. This was around the beginning of May.

All the doctors asked me whether I had lost any weight, whether I was sweating and I don’t know what else… Of all these symptoms, I had none. On the contrary, because of the treatment, I feel bad now compared to how I was feeling before. I got weak at the knees, I started shaking, the person who performed the X-ray wouldn’t explain much to me, they only said someone from the internal medicine department would tell me all about it. I went there and the doctor spoke to me but I didn’t hear anything. I was… All I could think about was that I was going to die.

I didn’t know anything about this disease. I had heard about tuberculosis, I knew it was a lung disease and I knew the jokes with „you cough worse than a lunger”, but absolutely nothing about how one gets it or anything, nor about the disease itself or any other disease for that matter. I am 33 years old and I don’t think I had taken more than ten pills over the entire course of my life before this happened. I was even talking to an uncle of mine some time ago and he was saying „I had water in my lungs, I had a broken arm, a broken leg as well…” And I remember I said „I’ve had no health problems until now, but I have a feeling that when I do, it’s not going to be pretty”. Just like I had seen it coming!

This happened on a Friday. First thing on Monday I went to the “Dimitrie Gerota” Hospital, to see a doctor who proved to be a really special person, and she gave me a first line treatment. It was like I wasn’t taking anything. The doctors there were baffled by the absence of symptoms as well. They eventually performed a bronchoscopy to see what was actually going on, because I had no cavities in my lungs or anything of the kind. Two lines, as thick as a pen, were visible. I was hospitalised there for three weeks, they had me on that treatment which I didn’t complete because the antibiogram results came and showed that I had resistance to two drugs. The X-ray results were better after this treatment, compared to the first time, although resistance was present. They let me go home until the antibiogram results came. I resumed my life, but with less work, less effort. Then I got the news, which was like a second blow to me. I had never imagined that I would ever be hospitalised for anything else than an accident. I had never thought that I would become ill like this.

By that time, I was already better informed about tuberculosis, because after the first diagnostic the doctors talked to me and I also read a couple of things on Wikipedia, including about multidrug resistant tuberculosis. I didn’t know at the time that there were three types, all I was interested in was whether it was treatable or not. I found out that MDR, if the treatment was followed strictly, was curable but that one never quite returned to things just like they were before the disease. And I wasn’t affected by the fact that the treatment was lengthy, I mean this thing about the two-year treatment is not what is dampening my spirits, I am a fighter, but the treatment is very hard. Dizziness, sickness… I don’t know, just about until 6.00 in the evening you’re not yourself, you can’t do anything. When I am at home it’s easier, I don’t feel the treatment, but here, in the hospital, when I hear the sound of the drug trolley down the hallway and that smell of rubbing alcohol and… It’s hard. I’ve been in hospital for one month and half and I take 14 pills each day. I am negative, just as I was when I came, I have never been positive, I have never contaminated anybody.

When I told my wife I had tuberculosis, she said not to worry, that it will be fine. And she is supporting me. I’m not scared or anything. She had tests done and everything is fine, including with the little one, because we’re going to have a child.

Now what I have to do is continue my hospitalisation and hope that everything will be fine and I don’t get a third blow. A third blow would be if they detect resistance to other drugs as well. I am still waiting for some test results. And what also makes it hard is that I just sit around doing nothing. I haven’t gotten used, not even now, to just sitting around like this all the time. I am an active person. I fill my time here with long walks. When I get out of here, because we are not allowed too much effort, I will do light work. During the first six months in particular, we are not allowed to perform hard labour, like carrying bags of cement or similar. But carrying some merchandise or something like that from here to there is possible. It’d doesn’t mean that you can’t do anything for two years. This is how I am… I always have to do something; I can’t just sit around. I work as a driver but besides that, life has taught me to do a little of everything. I live in a house with a courtyard and I will be able to take out the garbage, I can help my wife with the chores, I can drive the car…

The group therapy sessions that the psychologist holds here are good, in particular for some of the patients… I encourage them a lot myself and I talk to them and try to make them be stronger because I know what they are going through, which is the same thing I am going through, and we talk from one patient to the other. I have always liked helping others.

I do not think my life will change in any way because of this disease or because of the treatment. I don’t see any change. I don’t even talk about the disease or about the drugs unless someone asks me. It gets worse if you do that. In the morning, you get over taking the pills and then you’re a normal person. If you want to! I believe that if one wants to get over this disease and the hardship one must be positive about it. Just tell oneself “I am going to get over it.” If you do nothing else but think about it all day long… What I was interested in all the time was only if one dies because of it or not, because we have a baby on the way.

As far as work is concerned, I told them about the disease and everybody understood, I have no problems in this regard, they are waiting for me to get back. I also announced my friends and they are very upset about what happened to me but they didn’t shun away from me, they came here and visited me. I didn’t let them inside the ward, I met them in the yard, I don’t want them to come in here and it’s not even indicated.

Of course, I will remember this experience. No doubt about it! And now I know what I have to be careful about in the future. I don’t know who I took the disease from. I only suspect that I took it from one of my colleagues at work who had a persistent cough and to whom I often said: “Get yourself to the doctor’s for a check-up because this does not look good at all!” “I did go, man, but I’m fine”. Then he said he was going somewhere but from what I noticed he didn’t go anywhere but instead took a leave of absence for some treatment… But this is only my suspicion, that he had tuberculosis and said nothing about it and I took it from him. I just as well could have taken it from the tramway or from someone else who coughed in my direction or…

I can’t say I was under stress or that my immune system was weak, I felt fine, I could even say I was the happiest man alive. Perhaps I was tired, I was getting only a few hours of sleep. I don’t sleep too much now either. I spend all night on my tablet, until 5.00 in the morning, then I sleep until 7.00, when the drug trolley comes, then I take the drugs, I fall asleep afterwards and so on. I used to sleep around five or six hours a night. I can’t sleep more than that. I can’t have a normal routine. And I don’t like almost anything here in the hospital, When I was first hospitalised I weighed 55 kilos, and I got to 45 in three weeks. I spent two weeks at home and returned with 53 kilos. Now, I lost weight again, I’m at around 50. Nevertheless, it’s much easier now than during my first hospitalisation. I just stay here to get better, it’s that simple!

I haven’t thought about how my life will be after I complete the two years of treatment. I will resume the normal course of my life. But when I get out of here I will go to the mountains and to the seaside even if it’s winter. I will take my family and we will go somewhere because we didn’t get to go on holiday this year.

To those who are ill with tuberculosis I wish them strength to go through with the treatment, to complete it because it’s the only chance to live, if they want to go on. And then, they don’t get other people sick. Something should be done about the legislation too. And I mean this when I say it. Because what upsets me most is not that I got sick, because I finish the treatment and that’s it. But It does upset me that my body is bombarded with medicines like in the shooting range, I follow this hard treatment for two years and then I go home only to get the bacillus again from who knows what other individual who failed to take, failed to observe their own treatment. It hurts me if the state does nothing about it!

*The patient’s name was changed upon his request

Article by the Romanian Angel Appeal Foundation

 

Vasile C. knew nothing about tuberculosis when he was diagnosed with multidrug resistant TB. He doesn’t know who he got it from but, being from Bucharest, he says he could have gotten it from anyone in the crowded capital city buses, from citizens together with whom he stood in line to pay the bills or just as easily from the street. He can hardly wait to get out of hospital in order to catch a few beautiful days of autumn to go fishing in the Delta. Then, he can return without worries to his office where he works as an interior designer.

 

“I discovered I had TB at the beginning of the year. I had a coronarography done for a heart problem and then, among other investigations, they also performed a chest X-ray. And they told me that I had certain lesions and that I was a TB suspect. Without having any symptoms whatsoever, at any time, without even coughing… I first went to “Victor Babeș” (e.n. – the “Dr. Victor Babeș” Clinical Hospital for Infectious and Tropical Diseases in Bucharest), the doctor looked at my X-ray and said: “Mr C., it doesn’t appear to be tuberculosis, so don’t worry.” That was immediately after the holidays, in January.

Then, for my own peace of mind, I also went to the Vitan dispensary, where they recommended me to get a tomography exam. Indeed, on the first X-ray, you could not see very well what it was, but the CT showed very clearly that I had TB. Then, I started hospitalisation, first at “Victor Babeș” for three weeks. I got out of the hospital feeling better and I continued the treatment at home for another month, through the dispensary. When the antibiogram result came they found out I had resistance to Sinerdol and Isoniazid and since then, I’ve been here. So, for three months or so.

I knew nothing about tuberculosis. I knew it was a rare disease, and that for the most part it had been eradicated, but I had no idea. I didn’t even know how it manifested, how it is treated, for how long… The only thing I knew was that this disease causes coughing. But I didn’t know one feels tired, drowsy…

I didn’t even know that it was contagious, that you take it from other people. I have no idea from whom I took it. Neither from whom, nor when. I realise now that I could have taken the disease from the public transportation means, from the post office where I would go to pay the bills, from the family doctor’s office too, because it’s crowded… from anywhere. Now I am very well informed about what it means. When I was diagnosed I started asking about tuberculosis, I did some research to see what this disease meant. I had this state of anxiety at first, because I had had absolutely no symptoms. Not a single one! No cough, no fatigue, I didn’t even lose two pounds…

I don’t know whether this happened because I arrived at the doctor’s when the disease was in its early stage, if this is even so, because the X-ray showed a cavernous area – a hole – but probably the body resisted longer. What I was told at the dispensary about the absence of symptoms was that had I waited for a month or two, the symptoms would have certainly started.

My daily treatment consists of 17 anti-TB drugs, plus one injection, for six months. This is in addition to the supplements I take to mitigate the side effects of the anti-TB drugs, which are vitamin B1, two liver supplements, two pills for the stomach… When I found out how many drugs I was going to take… The first time, at “Victor Babeș,” I was shocked. There, I would take 14 pills. When I saw them, they seemed quite many, when I came here, I was given even more! At “Babeș” it wasn’t so hard for me to take them, because I wouldn’t take them all at once. I would take one pill every ten or fifteen minutes and would not feel any side effects. Instead, here I take them all at once… It’s not hard for me to swallow them, but afterwards, when they start working, I feel sort of dizzy, I feel discomfort in my stomach for half an hour or so… In the end, it is a handful of pills… It’s a state of general sickness, but I’ve gotten used to it. As for side effects, I have nothing except the pain in my knees which is caused by the increased uric acid that cannot be eliminated properly. Nevertheless, thank God, I don’t have serious problems!

I have become negative, this is what the first two tests showed, now I’m waiting for the results on the third. It’s a little less than three months since I’ve been here, I could be discharged in a week or so. I also had an X-ray done, and Dr. Popa said it looked pretty good, that the evolution was favourable.

What I do know is that this treatment will not affect my job, because my work does not involve physical effort, staying in the sun and so on. I work mostly at the office. I do field work too, from time to time, but I will not be doing that for a certain period. I am on medical leave but I will work out a schedule for my medication anyway. Now I cannot work, I have the injections too, but afterwards I will go to work. I announced all my colleagues, they had their tests done, everyone is fine.

I didn’t have any problems because of the disease. Neither my bosses, nor my colleagues who are closer to me and with whom I work said anything about it. It’s something that can happen to anyone and it simply happened to me. My colleagues didn’t know anything about tuberculosis either, but I told them. I explained it to them, they also had their X-rays done… My family members also had their tests done and have no problems. I talked to them about tuberculosis, because they didn’t know anything either.

I see this period of my life as a trial. It just happened, it’s nobody’s fault. It is hard, it’s true. One whole summer in the hospital… It will remain a less pleasant memory but I will get over it. I didn’t need private counselling, meaning to talk to the psychologist here, but the group therapy sessions were helpful because I got very good information from Ms Andreea Dumitrescu. She gave us homework, so that we could read a thing or two, she encouraged me… These meetings were very useful. But it’s good that I didn’t lie in bed, that would have made things very hard. Perhaps the first week was the most difficult for me, because I kept thinking that I was going to stay here three months, but then I got used to it. I told myself that was how things were, I was to stay here for three months, get better and be done with it!

When I leave this place, it’s all up to me to take my pills and that’s it. My friends know about my disease, they are by my side, I have no problems from this point of view. Just like my family, they came to see me in the hospital, we talked, they didn’t shrug away from me, I didn’t feel marginalised.

The very first thing that I am going to do when I get out of here, out of “Nasta,” will be to go to the dispensary and work out a treatment schedule. Then, for what is left of the autumn I want to go on a small trip to the Delta. I like fishing. In fact, what I am most sorry for is this, that I couldn’t go fishing. Then, in two years, when I finish the treatment, I hope I will be completely cured.”

 

* The patient’s name was modified upon his request.
Article by the Romanian Angel Appeal Foundation

 

Liliana G. is 28, she is a real estate agent and in October she was admitted to the “Marius Nasta” Institute of Pulmonology where she was diagnosed with multidrug-resistant tuberculosis.

I live in a village in Teleorman County, but I work in Bucharest. Everything started with a food poisoning at the end of September, when I was taken to the Municipal Hospital. There, among other tests, I also had a chest X-ray and the doctors saw a spot. They gave me a treatment for pneumonia, which I took for two weeks and then I went to have another X-ray, but the situation had not changed, so I ended up at “Nasta”.

I was not even aware that tuberculosis still existed. The doctor here told me: “You are suspected of TB”. I had the tests done and the results showed that the disease was resistant. For me, it was a shock. I did not even know what resistance meant… Then, I found out. I had expected to stay in hospital for three months at most, then to go home and go on with the treatment for six to eight months, but I was told it was going to last longer. I am here since October 18, and I’m supposed to leave mid-December.

My immune system was very weak, and the tests showed this too. Nobody in my family had ever had tuberculosis, nor had any of our neighbours, I simply took the microbe from somewhere and I suspect it was from the public transport means or from work. I found out that it is spread by air, and I work a lot with people, I am a real estate agent. All sorts of clients come, one never knows… What happened to me, I don’t wish it on anybody. I was working very much, six days a week, ten hours a day, plus commuting to and from home. I was very weak. I live in Teleorman and sometimes I would travel the 50 km distance to work in Bucharest, and used public transport.

I have pictures of my family, of my nieces, next to my bed. My family visits me every week here. I live with my father and my sister. They were heartbroken when they found out I had tuberculosis, they couldn’t cope with it, they were feeling that they had no strength left, as if the world had just ended. We lost my mother five years ago, and when this happened it was like seeing them reliving it all over again… I told myself that if I complain about it would do them no good either. I gathered my strength for them.

I did not have adverse reactions to the treatment, but I trained myself not to have any. If I have a bad day, the pain starts, but I prefer not to think about it. It is very important to have the support of your family, to know there is something waiting for you when you get out of the hospital, and so I only thought about what was making me feel good. I willed myself not to have any pain. If I felt a little pain in my leg, I would say it was nothing. And so far I haven’t had any adverse reactions to the drugs.

I have a degree in psychology and I told myself I had to be able to be in control of this. I also attended the flight school in Băneasa, to become a flight attendant. I worked for a time at a company until it went bankrupt. Now, I will no longer be able to work in this profession, because of the TB diagnosis. I worked for three years at the real estate agency. They are still waiting for me, I told them about the diagnosis and they said that all I had to do was get better and that they would wait for me. But I can’t do it. After I get out of here I will stay at home for two or three months and then I will look for a job that will enable me to work less, eight hours a day at least, because I can’t spend too much at home anyway.

What happened will definitely change me, because I will be more careful about my diet. I was not eating enough. I used to eat once a day, in the evening, because I had no time. Even if I wanted to eat, I was always on the field, and when I was at the office, I was speaking to clients on the phone. The phone was driving me crazy, it would never stop ringing. I would grab something to eat and just as I sat down some client would come and I had to get up.

Otherwise, the disease does not discourage me, it makes me stronger.

* The patient’s name was modified upon her request.

Grațiela Chiriac is the chief of the pulmonology laboratory in Bacău, one of the 8 laboratories equipped with high-end technology through the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control”. Dr Chiriac is laboratory doctor and member of the Laboratory Working Group of the National Tuberculosis Prevention, Surveillance and Control Program. We asked her what would be the advantages of the new equipment of the laboratory network.

How does rapid diagnosis help the patient?

The patient’s benefit is considerable, since they can receive the diagnostic early, together with conclusive information about the sensitivity of the infectious strain. Thus, the patient has the opportunity of a treatment initiated early and tailored according to the result of the drug sensitivity test. In these circumstances, the doctors take the right decisions regarding the treatment and the development of chemo-resistance is avoided, as it would make the cases difficult to treat. The liquid media diagnostic method implies inoculation in a liquid media tube, with a standardized technique, and placing it in the equipment which shall monitor the culture. The positive result, which basically confirms the disease, is obtained in 7 – 14 days, and the final result in 42 days. Comparing with the method on solid media, the benefit is obvious: the time to obtain the positive culture is of 7 – 14 days, versus 21 – 60 days; a complete result, culture and drug sensitivity test in 21 days, versus 50 days or even 4 months.

What does this new technology mean for the doctors working in the field?

For the clinicians, the purpose of the activity within the tuberculosis network is to initiate an adequate treatment, as soon as possible, and for the doctors in the laboratories to establish a correct diagnostic, as soon as possible. Correct diagnostic means the isolation of the strain which determines the disease, identifying it as belonging to the Tuberculosis Complex, testing and determining the sensitivity to drugs.

How many patients were diagnosed so far, with this new method, in the laboratory you run?

By the end of June 2015, we had processed through this method 151 culture samples and sensitivity tests. Bacău is among the counties with a tuberculosis incidence above the country average and with an increased number of re-treatments (ed.: relapses, defaults or failures to previous treatments). That is why is necessary to do cultures on liquid media, to ensure a rapid result. In 2008, we considered the idea of the semi-automated MGIT, at that moment being a routine method in Europe. It was a really special moment, although the method is quite time consuming (each tube was manually passed through the fluorescence reader). The automated method we use now, which indicates with sound and visual signals the positive state of one tube, is beyond comparison, even if it took 7 years to get to this point.

Starting with March 2015, 1,000 people with multidrug resistant tuberculosis shall receive complete, continuous and quality treatment. By the end of June, 139 MDR TB patients were enrolled countrywide and receive treatment within the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control”.

The doctors in the local tuberculosis dispensaries monitor the health status of the patients enrolled in the program, thus helping them not to give up the treatment. We asked Dr Ariadna Petronela Fildan, MDR coordinator in Constanţa county, which are the advantages of this integrated system of patients treatment. Medical sciences PhD and associated professor at the Faculty of Medicine of the Ovidius Univerity, Dr. Fildan has been a pulmonology doctor at the Constanţa Pulmonology Clinical Hospital starting with 2008.

In this project, what does patient-centred approach mean?

The core of the project is the patient, everything – from human to material resources –gravitating around him, aiming to heal the patient and contain the spread of the disease. Once the multidrug-resistant tuberculosis diagnostic confirmed, the fight with the disease begins, fight which is based on well established rules. First of all, the patient is informed by the attending doctor about the new diagnostic methods, the therapeutic options, the duration, advantages and possible complications of the therapy, concurrently underlying the fact that the disease can be defeated if the treatment if followed on a continuous basis, without interruption for the entire duration indicated by the doctor. One shall try to motivate the patient in order to enter the program, bringing as supreme argument the cure and the chance to a normal life. Each patient represents a specific case; they don’t come only with a diagnostic and a disease we must treat, but with an emotional, cultural and social background which we must consider when trying to motivate the patient. We try to answer to all the questions related to the disease and treatment, to provide them as much information as possible, in a clear way, tailored to the personal level of understating.

How important is the medical care accompanied by psychological care, how does this actually take place in hospitals? Which are the advantages and what is the difference between the new possibilities and what was done before?

Evidently, the psychological support is very important; a trained person can find the methods adequate to each patient to motivate them not to give up the treatment. In fact, the most important aspects in the success of a treatment are, first and foremost, the compliance and ensuring continuity. Psychological counselling at the initiation of the treatment but also during the entire course, when complications – some quite difficult to deal with and to control – might appear, is a major contributor to the therapeutic success. Unfortunately, not all the hospitals have trained staff and in this situation is our hospital in Constanţa as well. To bridge the gap, the discussions with the patient take place with the participation of the attending doctor, the chief of department or the chief of dispensary (according to the case, if the patient is hospitalized or in ambulatory), the medical director and the program coordinator. The advantages we have at this moment are considerable, starting with the fact that we can have an MDR TB diagnostic in a few hours, compared to a few months, through access to the newest molecular diagnostic methods, continuing with access to modern therapy, ensuring continuity, the treatment regimens being those established by the MDR commission, according to the international guidelines.

Social support: what is the role of the social vouchers?

The role of these vouchers is a motivational one. It has been observed that providing monthly “bonuses” – if the patient came to the doctor and was given the treatment in the presence of the doctor or nurse – increases the treatment compliance rate. As it is very well known, many of the patients face serious material difficulties and thus any help is welcome.

What feedback do you have from your patients, regarding this approach?

The patients are satisfied because they have the continuous treatment ensured, have an additional chance, by being included in this program, and understand the importance of the correct administration, without interruption, of the medication, because this is the only way they can be cured.

How many patients are enrolled in this program in Constanța?

Currently there are five patients enrolled for complete regimens and eleven patients enrolled for social support in order to increase their compliance to treatment. We hope as many as possible will be accepted.

What is the situation in the county regarding tuberculosis?

In Constanţa County, the tuberculosis incidence decreased constantly in the past 10 years, from the 3rd place at national level to the 12th place. Last year 634 cases of tuberculosis, new cases and relapses were notified, representing an incidence of 87.6 versus 89.9 per 100,000 inhabitants, in 2013. 38 cases were notified in children. What we noticed for the first half of this year is the high number of severe cases registered in our hospital, extended, milliary forms, meningo-encephalitis. Until now we had 13 deaths due to tuberculosis, which probably can be explained by the long latent period between the occurrence of the symptoms and the visit to the doctor.

Marian Istrate is 41 years old, lives in Bucharest and in April 2015 was hospitalized at the “Marius Nasta” Pulmonology Institute in Bucharest, with the diagnostic of multidrug resistant tuberculosis. He left at home his wife and their 19 years old daughter who just had the bachelor degree exam, worried that there are chances he would have given them the Koch bacillus. In an interview conducted in his room from “Marius Nasta” Institute, Istrate told us how he ended up being diagnosed with tuberculosis and what his hopes for the future are.

“I don’t know, I have several problems, and the most important is Crohn’s disease, which I have been fighting for 10 years now. (ed.: Chron’s is a chronic inflammatory disease, localized in the digestive tract wall). Because of this disease I had a stroke, trombophlebitis, there were several things linked to each other. Then some biologic treatments for the Chron’s disease appeared and the doctors proposed to follow them.

Thus, as I ended up doing all sorts of investigations in hospitals, in 2007 they discovered I had pleurisy. Then, in 2013, they noticed a spot on the right superior lobe of the lungs and the doctors told me I had TB. I followed 1st line treatment, except that the spot didn’t become larger, but it didn’t shrink also. And I thought to myself: if I cut my finger, then it swallows, it gets infected or it heals. But in my case the spot remained there, even after the treatment.

I took the TB treatment for 6 months, plus the biologic treatment for my disease and it went ok. I used to go to Fundeni, but I wasn’t hospitalized, I was going twice a month and get a dose every two weeks. And at the end of last year they changed my treatment with an intravenous one. I had only two doses and during New Years Eve, in December 2014, I had fever, chills. It passed after 2-3 days or so and, after about half a month, I thought I should go to the hospital to see what’s going on.

I had an X-ray and they told me I had a tumour. And I had to have a bronchoscopy done afterwards and it didn’t turn out to be TB, cancer, or any tumour, but some sort of pneumonia. I was put for 20 days on Cefort iv treatment, and in the sputum sample didn’t appear anything. In March, they put me on 1st line treatment, but the spot remained. By end of April, a lady doctor calls me, telling they did the drug sensitivity test and that it turned out multidrug resistant tuberculosis. “Wouldn’t I better go and buy a coffin?” I said to myself.

On 29 April I was hospitalized. It is suspected that I took it (ed. the bacillus) from somewhere in a hospital. At least 2 month I’ll stay here at “Nasta”. To my surprise, I coped with the treatment, although I was afraid I couldn’t do it. As a patient here, one begins to get used with the idea of the disease, of tuberculosis, of severe diagnostic. I still have bad nausea, sometimes I even feel sick to drink water. It has to pass, you end up saying to yourself.”

 

Marian Istrate is only one of the thousands of patients with multidrug-resistant tuberculosis in Romania, to whom the lack of high performance methods of rapid and correct diagnosis of the disease made loose precious time. Two years – the time when Marian was incorrectly treated for sensitive tuberculosis – represent a period when multidrug resistant tuberculosis would have been cured, with the proper and timely initiated medication.

Access to rapid diagnostic, thanks to the high-end equipment procured through the project “Improving the Health Status of the Romanian Population in Romania by Increasing Tuberculosis Control” allows receiving the diagnostic in very short time (from few hours up to few days) and beginning the correct treatment, offering the patients like Marian Istrate the chance to be cured and have a normal life.

*Marian Istrate is a fictional name; we decided to change it at the patient’s request.

We asked Dr. Daniela Homorodean how the national laboratory network looks now, what are the challenges of the specialists’ activity and what will the new equipment bring. This is what she said for us:

“For the current situation in Romania, doing a microscopic exam for tuberculosis control is not enough. For a better surveillance of the endemic we need, for each patient, microscopic exam, as well as culture and drug sensitivity test. In the sputum we examine routinely for the pulmonary tuberculosis there must be 10,000 bacilli per millilitre of product, for us to be able to see one bacillus at the microscopic exam.

When bacilli appear, which we see coloured through special colorations at the microscopic exam, the lesions of the lung are quite advanced. Then, using other methods, we increase the chances to highlight the bacilli in early stages of the diseases, when the lesions are not so advanced. Thus, the chances of curing with less scars and lesions on the lung increase, because tuberculosis is a treatable infectious disease which can be cured. But, if the lesions are too extended, then it is cured through fibrosation, a scar-like tissue is formed. It is a fibrous tissue which doesn’t allow the lung to normally expand and relax. The bigger the lesions, the more extended is the fibrosis.

There are about 100 laboratories that diagnose and have as scope of work the bacteriologic diagnosis of tuberculosis, spread in all the counties. In each county there is a lab doing tuberculosis diagnosis. Starting with 2003, we began to run visits in the laboratory network and we selected some enthusiasts among the colleagues working in TB labs, good professionals, willing to participate in the control and guidance visits in the laboratories in the country. Immediately after we had the opportunity to accredit the laboratories according to the EU quality standards. Initially, 38 laboratories out of 50 proposed got accreditation, because only those met the criteria. Through the methods we’ve had so far, we got results after two or two and a half months, when we found out whether the germs eliminated by the patients were sensitive to the antimicrobials or resistant.

In eight regional laboratories and two national ones – Bucharest and Cluj – we have now the possibility to run genetic testing, in 24 or 48 ours, for the presence of the microbe in the sputum and the resistance of that microbe to the most powerful drugs – Isoniazid and Rifampicine. The resistance to these two drugs defines the multidrug-resistant TB. If the microbe is resistant to these two drugs, other substances, more powerful and more expensive, some of them with toxic effects, should be added to the treatment. It is best if, from the beginning, the patients accept the treatment so that the microbes not gain resistance, follow exactly the treatment without missing one single doze and not give up some of the drugs, because they think that three or four are too many. It is a big mistake, because from a treatable and curable disease, the person can develop a form difficult to treat and maybe impossible to cure. Then, such a non-compliant patient could make other people ill, and they will have since the beginning drug resistant tuberculosis. To find out about these cases as soon as possible, the genetic tests received through the Norwegian funds are essential. These are equipments which function with specific reagents and need special fit-up design. The reagents are procured also from Norwegian funds.

Through these projects, 9 cars shall be procured for the transport of products from the periphery to the diagnostic centres, so that by collecting the products we shall have rapid and quality diagnosis. It is not at all cost-efficient to keep a laboratory that only tests 3 sputa per day.

In 1999 we had other funding from the World Bank and five laboratories received the same equipment for doing culture on liquid media. Through that project, the laboratories had reagents for one year. Then, due to lack of funding, some of the laboratories stopped their activity, some others continued, but at a very low level, for serious forms.

We have to make sure that all the laboratories provide comparable diagnosis. The patients are quite mobile during the months or years of illness and go from one hospital to another. Or maybe they travel, get sick and get another set of tests. The results are compared with the previous bacteriological tests and they should be comparable, so that the monitoring can be correct and real and we can use the same scale and system of expressing results. I really like to believe that we had good results in the laboratories. It’s not a pleasure to work daily with sputum – not the best sight – but if you can deal with it and consider it a necessity, then you understand the relief of establishing a positive diagnosis and telling the patient that they have tuberculosis, not cancer. It is indeed, a relief.”

Simona (37) is an economist in Bucharest and she was told she has MDR-TB almost two months ago. She has been in hospital ever since.

“I got TB from my brother-in-law, who is also hospitalized here.

It started with pneumonia – I started coughing, so I went to the doctor and he told me I had an untreated pneumonia. I underwent treatment with antibiotics; then the doctor did an X-ray and told me it looked better. I told him I had come for my pneumonia but also because I had a case of TB in the family. He said that if I had had TB, the antibiotic he had given me would not have had any effect.

The next time I came for an X-ray, the doctor told me he had the impression there was something else there, that it was no longer pneumonia. One week later, I got a call from the clinic and I was told to come urgently. The DST had come out with tuberculosis.

I have never been ill, neither have I taken drugs, underwent treatment or been admitted to any hospital. I had a good immune system, I eat healthy, I do not smoke and I do not drink coffee or alcohol. In 37 years, I have never been in hospital. If I felt ill, I would let the system fight on its own, and I would not take drugs.

Sunday before I left for the hospital, I cried a lot. Everything was new for me: from an active and healthy person, suddenly I had to be hospitalized.

At first, it was difficult in the hospital; I would wake up in a state of panic in the morning, when I had to take the medication. I felt fear and rejection inside. It is not easy because there are days when I simply cannot walk and I can barely articulate words. There are days and days…

I have to be strong and take it easy. You need to encourage yourself and learn to do things on your own. Everything starts with you.”

 

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