Science Speaks staff writer and Global Health Policy Research Coordinator Rabita Aziz attended the McGill University Summer Institute in Infectious Diseases and Global Health June 13-17.
MONTREAL – In health care, “test and treat” is considered the ideal. It’s a term most familiar to followers of HIV responses, in which treatment follows, rather than precedes, diagnostic testing — albeit sometimes by months or years.
But all too often, a public health leader from Mozambique said here, the more common practice in many settings is “guess and treat.”
In many developing and middle-income countries, clinicians will not offer a diagnostic test even if it’s available, Ilesh Jani of the Mozambique National Institute of Health said. Instead, they often base the treatment they prescribe on the symptoms patients report. When that doesn’t work they’ll craft a new treatment regimen based on their patient’s previous regimen.
In India, which has the highest tuberculosis incidence, prevalence and mortality globally, patients are typically seen by three different doctors before getting a tuberculosis test, Madhukar Pai of McGill University said. On average that takes about two months from when patients start showing symptoms, he said.
In a “mystery patient” study in India where trained actors presented at clinics with textbook tuberculosis symptoms, including crushing chest pain, fewer than a quarter of them were tested for tuberculosis. Instead, they were sent away with “a bunch of antibiotics, cough syrup, and steroids,” Pai said. A similar study in South Africa also found most patients showing tuberculosis symptoms are sent away without a test.
“The average practitioner uses treatment as a diagnostic,” Pai said.
The same study was done with Indian pharmacists who when approached by a patient “ask an average of one question, for one minute, for a one dollar fee,” he said.
“You can get any antibiotic through them without a prescription,” Pai said. The most popular, he noted, are fluoroquinolones. The U.S. Food and Drug Administration has recommended restricting fluoroquinolone use for uncomplicated infections as possible serious side effects outweigh its benefits.
In India, “practitioners don’t want to do lengthy diagnostics because they don’t want to wait and lose their patient, who can go to another doctor and get an antibiotic quickly.” Jani said, “People expect to go to a health facility and receive swift treatment.”
The inappropriate use of antibiotics and under-testing isn’t just an Indian phenomenon: Pai cited a study that showed Kenyan practitioners typically rank antibiotic use ahead of oral re-hydration therapy for diarrhea.
For diagnostic products to have impact and lead to patients being placed on appropriate treatment, clinicians must change the way they approach diagnosis and treatment, and patients must change their expectations, panelists agreed. But in resource-limited settings, sometimes health care workers have no choice but to guess and treat, they said.
“Some amount of empiricism is inevitable and necessary,” one said. “There are no labs in many places and even if there is a lab, there are no tests. So you have to do what you have to do.”
Follow Rabita on Twitter at @AzR86.