Evaluation of phagocytic function of peripheral neutrophils in bronchial asthma

Original Article

Evaluation of phagocytic function of peripheral neutrophils in bronchial asthma

Priscilla Johnson¹ , Sheela Ravinder.S² , Late Geetha Rani³

¹Department of Physiology, SMC, ² Sri Ramachandra Medical College & Research Institute, SRIHER, Chennai – 600116
²Department of Physiology, SMC, ² Sri Ramachandra Medical College & Research Institute, SRIHER, Chennai – 600116
³Department of Physiology, SMC, ² Sri Ramachandra Medical College & Research Institute, SRIHER, Chennai – 600116

Corresponding Author: Dr. Priscilla Johnson, Department of Physiology, Sri Ramachandra Medical College & Research Institute, SRIHER, Chennai – 600116, priscillajohnson@sriramachandra.edu.in

Globally, nearly 300 million individuals are affected by bronchial asthma which poses a serious threat to the health of the individual and thus asthma seems to be one of the major cause of chronic morbidity and mortality throughout the world.[1] Evidence based studies show that the prevalence of asthma has increased considerably over the past 20 years, especially in children.

According to World Health Organization, an estimated 15 million Disability Adjusted Life Years (DALYs) are lost every year because of asthma, which in turn is attributed to1% – 18% of the overall global disease burden.[2] Asthma is causing an increase in socio-economic burden due to health care cost, absence from work leading to productivity loss. It also reduces the active participation of the affected individual in family life.

Globally, nearly 300 million individuals are affected by bronchial asthma which poses a serious threat to the health of the individual and thus asthma seems to be one of the major cause of chronic morbidity and mortality throughout the world.[1] Evidence based studies show that the prevalence of asthma has increased considerably over the past 20 years, especially in children.

According to World Health Organization, an estimated 15 million Disability Adjusted Life Years (DALYs) are lost every year because of asthma, which in turn is attributed to1% – 18% of the overall global disease burden.[2] Asthma is causing an increase in socio-economic burden due to health care cost, absence from work leading to productivity loss. It also reduces the active participation of the affected individual in family life.

To study the reasons for treatment interruption among patients presenting with history of treatment interruption at GHTM .

An observational study done at GHTM over the period of 6 months on patients with a previous history of ATT interruption. The reasons for treatment interruption were collected using a standardised questionnaire and the results were statistically analysed .

401 patients presented with history of treatment interruption during this period. Most of these patients were in the productive age group of 20 – 60 years (82.5%). 72 % were smokers. 82 % were alcoholic. 12 % of patients were not aware of the treatment duration needed for cure. 16 % had other comorbidities with Tuberculosis including DM, HIV, CAD, pancreatitis.10 % of patients had interrupted treatment more than one time. Most of patients interrupted after 2 months of ATT.

Major reasons identified for treatment interruption were a feeling of well being during the course of treatment (41 %), alcoholism (11%), migration (10%), family issues (5%) , drug related adverse events (17%),lack of knowledge of the disease and treatment duration required (4%). The drug related adverse events noted included gastrointestinal, joint pains and skin rashes.

Our study gave us some insights into the reasons for interrupting treatment and serves as a guidance to focus on pretreatment counselling with the goal of reducing treatment interruption thereby reducing the emergence of drug resistance TB.

Drug resistant TB has been known from the time the anti TB drugs were first introduced for the treatment of TB. Currently WHO estimated the incidence of Rifampicin resistance and MDR _TB in India to be around 147000.(1). The first national anti TB drug resistance survey for 2014 -16 (NDRS) was concluded recently and results published in 2017(2). As per this document among patients previously treated for Tuberculosis any drug resistance was detected in 36.2 % of patients, MDR TB was detected in 11.62 % of patients and XDR TB was detected in 0.91 % of previously treated patientsas compared to 22.5% , 2.8% and 2.3 % respectively among patients never exposed to ATT,. (2).

One reason cited for the development of drug resistance is an inadequate or poorly administered regimen.(1). The problem of drug resistance cannot be completely eliminated by systems of detection and treatment of drug resistance. More important is to prevent the emergence of drug resistant bacilli by taking ATT adequately in the first instance.

It is often noted in clinical practice that still many patients present to the pulmonologist with history of interruption of anti Tuberculous treatment. Understanding the reasons for interrupting treatment while on Anti Tuberculous medications and undertaking measures to prevent such treatment interruption will pave a way for ensuring that the patients will complete their treatment adequately and the transmission of Tuberculosis can be interrupted in the community.

This study was undertaken at GHTM, Tambaram sanatorium to study the reasons for treatment interruption among TB patients at GHTM, Tambaram.

To study the reasons for treatment interruption among patients presenting with history of treatment interruption at GHTM .

This study was an observational study done at GHTM, Tambaram sanatorium over a period of 6 months from January to June 2018. Among the patients with Tuberculosis, patients with history of interruption of Anti Tuberculous treatment were taken up for the study. Using a standard questionnaire data was collected including demographic profile, social behaviour, educational background, reasons for interruption of treatment and the adverse reactions of drugs. The results were tabulated and analysed statistically using a SPSS software.

401 patients presented with history treatment interruption during this period

Table 1: Age distribution of patients in the treatment interruption cohort.

Most of these patients were in the productive age group of 20 – 60 years(83%).

Table 2: Sex distribution of patients in treatment interruption cohort

Most of these patients were in the productive age group of 20 – 60 years(83%).

Table 3: Educational status of the patients

Many of the patients who discontinued treatment were found to be uneducated (34%)

Table 4: Smoking and alcohol usage in this group

72 % were smokers and 82 % were alcoholic.

Table 5: Awareness of duration of ATT intake in this group

.12 % of patients were not aware of the treatment duration needed for cure.
16 % had other comorbidities with Tuberculosis including DM, HIV, CAD, pancreatitis

Table 6: Duration of treatment before interrupting treatment

Most of patients interrupted after 2 months of ATT67 %)

Major reasons identified for treatment interruption were a feeling of well being during the course of treatment (41 %), alcoholism (11%), migration (10%) , family issues (5%) , drug related adverse events (17%),lack of knowledge of the disease and treatment duration required (4%).
The drug related adverse events noted included gastrointestinal (10%), joint pains(5%) and skin rashes(2%).

GHTM, Tambaram sanatorium is a tertiary referral centre for patients with all forms of Tuberculosis and serves as a nodal centre for the treatment of drug resistant Tuberculosis.

On a daily basis we encounter many patients who attend GHTM with history of discontinuation of ATT. This poses a challenge in achieving the goal of END TB strategy as these patients continue to spread the disease in the community and also pose a problem of likelihood of developing drug resistance. Strong systems to detect, successfully treat and ensure long term disease free status of TB patients are required to prevent emergence of resistance.(1). Basic diagnostic and treatment services in conjunction with ensuring that patients complete the treatment without interruption should receive priority if we are to achieve the dream of TB free India by 2025.

We searched the literature using Pubmed and Google scholar on the reasons for ATT interruption and found several studies from Africa and rest of the world including south East Asia.(3,4,5,6,) and also from North India(7,8,9). Literature on this topic from the Southern part of the state was sparingly low.Regional and social factors like migration, social beliefs, educational factors play a role in treatment interruption.

The studies cited (3-9) focussed on male sex, younger age of the patient, duration of treatment, alcohol abuse, low income, HIV positive status as reasons for treatment interruption while on Anti TB treatment. To our knowledge the issues of educational qualification and awareness of treatment duration and strict adherence to treatment have not been addressed so far.

In concurrence with the earlier studies, our study too revealed that male sex had a higher probability of treatment interruption than the females. Our study is also consistent with study done by Basa S(7) which showed a higher incidence of treatment interruption in patients in the productive age group of 20- 60 years.

We studied the educational qualification of these patients and found that many of them were uneducated. We also observed that as the educational qualification progresses the proportion of treatment interrupters reduces considerably. This highlights the importance of the need for health and hygiene education in patients who are less well educated and likely to interrupt treatment.

Alcohol abuse has been documented as a risk factor for treatment interruption in several studies(3,4,6,7). Never smoking was identified as a protective factor from treatment interruption in study by Cherkaoui I et al(6). In our study group we found that 72 % were smokers and 82 % were alcohol users which is consistent with other studies.

Awareness of treatment duration and need for uninterrupted treatment was lacking in 12% of this study group. This shows the need to focus on pretreatment counseling and reinforcing the need for an uninterrupted treatment. Smoking cessation and alcohol deaddication measures will play a larger role in this cause.

Comorbidities were another reason for treatment interruption in the study group reasons being increased pill burden and drug interactions while using multiple medications for several diseases. In our study we found most patients defaulting after 2 months of treatment unlike study by Kigozhi et al where interruption was more in the first two months of treatment. Most of these were due to a feeling of well being after the initial course of ATT.

If the goal of End TB strategy to eliminate Tuberculosis by 2025 is to be met it is imperative that every patient started on treatment should complete treatment without interruption so as to reduce the transmission of bacilli in the community and also to reduce the emergence of drug resistant bacilli. Our study gave us some insights into the reasons for interrupting treatment and serves as a guidance to focus on pretreatment counselling for better adherence to the regimen.

1. Guidelines on programmatic management of drug resistant Tuberculosis in India 2017
2. Report on National TB drug resistance survey 2014 -16 published in 2017; Department of health and family welfare, Government of India.
3. Factors influencing treatment default among Tuberculosis patients in a high burden province of South Africa. Kigozhi et al. International journal of infectious diseases. 54(2017).95 -102
4. Factors associated with default from treatment among tuberculosis patients in nairobi province,Kenya: A case control study. Muture et al. BMC Public Health 2011, 11:696
5. Determinants ofDefault from Tuberculosis Treatment among Patientswith Drug-Susceptible Tuberculosis in Karachi,Pakistan: A Mixed Methods StudyChida N, Ansari
Z, Hussain H, JaswalM,Symes S, Khan AJ, et al. (2015). PLoS ONE 10(11):e0142384. doi:10.1371/journal.pone.0142384
6. Treatment Default amongst Patients with Tuberculosis in Urban Morocco: Predictingand Explaining Default and Post-Default Sputum Smear and Drug Susceptibility Results.Cherkaoui I, Sabouni R, Ghali I, Kizub D, Billioux AC, et al. (2014)PLoS ONE 9(4): e93574. doi:10.1371/journal.pone.0093574
7. Study on default and its factors associated among Tuberculosis patients treated under DOTS in Mayurbhanj District, Odisha. Basa S, Venkatesh S. J Health Res Rev 2015;2:25-8