Created by:  Carmen Berg, Zahra Kanji, Kakul Srivastava

BACKGROUND INFORMATION

What is being done to combat poor treatment compliance? 
       Poor compliance with the current drug system has sparked programs like DOT (Direct Observed Treatment) in developing countries. DOT is a system which insists upon checking that every patient takes every pill they need to. Even though this system gets the job done, it is a very tedious one. The number of patients infected by TB times the number of pills they must take adds to a staggering number.

Definitions
1.  MDR-TB  -  (Multi-drug Resistant Tuberculosis)
TB that is resistant to at least two of the main drugs used to treat TB (INH and Rifampin).  TB can become resistant if the treatment isn't treated long enough, doesn't receive the right drugs or isn't medicated properly.
 
2.  Isoniazid (INH) - Oral tablet to treat TB.  Daily dosage of 300 mg.  Side effects: liver problems, neuropathy (pain or tingling in hands and feet), fever or rash.  Drug tips: take food to reduce stomach problems, take vitamin B6 to reduce neuropathy, do not drink alcohol (increases liver problems).

3.  Rifampin (Rifampin) - Oral tablet to treat TB.  Daily dosage of 600 mg.  Side effects:  upset stomach, heart burn, nausea, headache, drowsiness or dizziness.  Drug tips:  take medication on an empty stomach on hour before a meal or at least two hours after.
 
 

PROJECT DESIGN
 
Problems and Solutions
Protocol

Implementing  TB treatments in developing countries is a challenge in itself because medical facilities in third world countries are poorly equipped.  Many things that we take for granted here are not readily available there, such as electricity and clean water.  We tried to keep these limitations in mind in designing ways to improve TB treatment.

Our research team, during the spring semester at MIT, thought of a few other alternative methods to the DOT system. These are listed below with the specific problem were were trying to solve and our solutions to them.
 

PROBLEMS	SOLUTIONS
The drugs have a sour taste to them.	Mix drugs with sugar substance to make pills taste more like candy.
The drugs are hard to swallow.	Administer drugs using transdermal patches.
The treatment is long and has poor follow through.	Introduce a reward at the end of each month
It is hard to remember to take the drugs daily.	1.  Create a handy dispenser, easy to carry around in a visible area.  2.  Entice companies such as Coke to run the DOT system. Take required pill, get a free bottle of Coke.  3.  Create slow release, once-a-day formulations.

 
Other problems that we thought were the cause of the poor compliance were the supply of pills at local clinics and the general public's belief in Western medicine and pills.
 
After researching all the above options, we realized that many of the solutions were not feasible in the near future.  For example, novel drug delivery systems for TB drugs are not perfected for usage currently.  Although none of these solutions are feasible, we found another way to address the TB problem in developing countries:  creating a TB drug sensitivity testing kit.

The TB drug sensitivity testing kit could be useful in a variety of situations.  By finding out what TB drugs a person is susceptible to, the use of unnecessary antibiotics can be curbed and MDR can be reduced.  In addition, this test can be used as a diagnostic tool in areas where widespread resistance to a particular drug is suspected.

Protocol for TB Drug Sensitivity Kit in Developing Countries
This protocol is a modified version of TB sensitivity testing protocol in the following sources:

Public Health Mycobacteriology:  A Guide for the Level III Laboratory.  US Department of Health and Human Services.  1985.
Antimycobacterial Susceptibility Testing.  The National Committee for Clinical Laboratory Standards.  1990.
 

Chemicals needed:  Sodium hydroxide, sodium citrate dihydrate, N-acetyl L-cysteine (NALC), Middlebrook 7H-10 basal medium, distilled water, glucose and TB drugs to be tested.

To Isolate Specimen:

•  Make a 4% Sodium Hydroxide solution by adding 4.0 g of NaOH to 100 ml of distilled water in a 150 ml bottle.
• Make a 2.9% sodium citrate dihydrate solution by adding 2.9 g of sodium citrate dihydrate to 100 ml of distilled water in another 150 ml bottle.
• Mix 25 ml of each solution together.  This can be stored if capped tightly.  When the solution is ready to be used, add 0.25 g of N-acetyl L-cysteine (NALC).  Once this is added, the solution can be stored for only 24 hours.
• Transfer up to 10 ml of sputum from patient into a 50 ml plastic centrifuge tube with screw lid.  Add an equivalent volume of the NaOH/sodium citrate/NALC solution.
• Mix the contents of the centrifuge tube with the lid tightly capped for 5-20 seconds, avoid extreme agitation.
• Let the tube stand for 15 minutes at room temperature for decontamination.
• Pour into graduated cylinder and dilute to the 50 ml mark with distilled water.  Pour back into centrifugation tube and mix by swirling or inversion.
• Centrifuge the mixture at 300 rpm for 15 minutes.  Pour off supernatant into a splash proof container and decontaminate lid of tube by swabbing it with phenol.  Recap tube.
• Resuspend sediment in 1-2 ml of distilled water.
• Mix and then make dilutions as follows:
• Take 1 ml of resuspended solution and add 9 ml distilled water.  This is the 1/10 dilution.  Then take 1 ml of this 1/10 dilution and add 9 ml distilled water.  This is the 1/100 dilution.  Then take 1 ml of the 1/100 dilution and add 9 ml of distilled water.   This is the 1/1000 dilution.
• The solutions are now ready to be plated on agar plates.

• Suspend 3.6 g of Middlebrook 7H-10 basal medium in 180 ml of freshly distilled water and add 1.0 of reagent grade glycerol.
• Swirl base into suspension and sterilize by filtering through a 0.22 um filter.  Then add 20 ml of OADC enrichment.
• Add the required amount of drug (see chart).
• Plate on a quadrant of a petri dish.
• Allow to solidify at room temperature without exposing it to daylight.
• Repeat for each drug condition being used.

Examples of equipment and chemicals in TB Testing Kit.
 

Our protocol design is fairly basic.  Due to the fact that TB is such a serious problem today, we felt that this kit may help the current situation while our other ideas may provide future solutions.  Future projects such as an easy drug delivery system should still be pursued that will increase the cure rate of TB in developing nations.

Our protocol is based on research and current methods used in the US.  It has not been tested using TB mycobacteria and thus cannot be guaranteed to provide accurate results.  This protocol should be tested in a laboratory to determine if it accurately determines drug susceptibility.