Malaria, drug-resistant TB flourish in Myanmar

By, Ed Cropley, Reuters, May 30, 2007

MAE SOT, Thailand - Simmering civil war, fake drugs and a non-existent health service in Myanmar are creating the perfect breeding ground for new, drug-resistant strains of killer diseases such as malaria and tuberculosis.

While the most immediate threat beyond Myanmar's borders is to Thailand, home to a large migrant and refugee population from the military-ruled former Burma, the long-term implications of neglect could be felt right across the globe, experts say.

At stake is a Chinese drug called artemisinin, the world's most powerful weapon against malaria, a disease that kills more than a million people a year, most of them children in sub-Saharan Africa.

The drug is most effective when used with other treatments in what are called artemisinin-based combination therapies (ACTs).

But doctors say taking ACTs incorrectly or in doses that include fake pills is one of the easiest ways of allowing the mosquito-borne parasite which causes malaria to build up immunity.

Such behavior appears to be commonplace, Thai health officials say, in Myanmar, where health spending is only a few dollars a year for each of the country's 53 million people.

Decades of civil war against ethnic militias in eastern Myanmar have worsened the situation; A study by the Thailand-based Backpack Health Worker Team showed the region's 500,000 internal refugees have malaria infection rates as high as 12 percent.

"So far, the malaria parasite has started to develop resistance to all drugs apart from those in the artemisinin family," said Francois Nosten, a French malaria expert in the northwestern Thai border town of Mae Sot.

"If this starts to happen, there is cause for real concern."

One drug-resistant strain born in southeast Asia has already made it to Africa, Nosten said. If an artemisinin-resistant variety reached the continent, the effects would be devastating.

"If we find evidence that it has changed to become resistant to artemisinin, we would have to contain it here -- but how you would do that, I just don't know," said Nosten, director of the Shoklo Malaria Research Unit, a field station attached to Bangkok's Mahidol University.

TB MAKES COMEBACK

While Nosten said there were no signs yet of malaria becoming immune to ACTs in the jungle-clad border region, the same cannot be said of tuberculosis, a disease that -- as with malaria -- had been on the retreat in Thailand.

Mae Sot general hospital, a sprawling complex overflowing with Burmese and Thai patients, has admitted 105 Thai and 38 Myanmar TB patients so far this year compared to 102 and 79 in the whole of 2006.

More worrying still, five cases were "multi-drug resistant," meaning patients have to undergo an expensive and arduous two-year course of pills and injections. Even then, there is only a 50 percent chance of survival.

Aid agency Medecins Sans Frontieres (MSF) (Doctors Without Borders), which is treating 15 "multi-drug resistant" Myanmar patients in a refugee camp in Thailand, is acutely aware of the problems of treating TB patients in fluid populations.

Treatment normally lasts six months, but many patients feel better after half way through and so stop taking the pills.

"There needs to be a huge push in TB education, in telling people the extreme importance of taking the treatment properly and not stopping as soon as you start to feel better," MSF Mae Sot's field coordinator Andres Romero said. "But with migrants, how do you follow up to ensure they have not become a defaulter? They've no mobile, no landline, no address."

STRUGGLING

Although wealthy and advanced by regional standards, Thailand's public health system in Mae Sot is struggling under the weight of dealing with an estimated 150,000 migrants from Myanmar -- and the diseases they bring with them.

Apart from a one-off payment from the Global Fund to treat TB in migrants, Mae Sot hospital gets no extra government cash for the thousands of Burmese flooding across the highly porous border, drawn by the prospect of free health care.

All the signs are of a hospital struggling to cope.

Its open-air corridors are choked with beds and patients hooked up to drips beneath whirring ceiling fans. Relatives of the sick, who range from landmine amputees to TB patients on respirators, lie curled up on reed mats beneath many of the beds.

"We treat every patient who comes here, Burmese or Thai, exactly the same. Not to do so would be completely unethical," director Kanoknart Pisultakoon said.

"Often the Burmese have tried to treat themselves and it hasn't worked so when they come to hospital they are very sick. Then, when they get better, they go back to Myanmar and tell their friends.

"The word spreads and every year, there are more migrants, more patients and more serious diseases," Kanoknart said. "It makes me worry for the future -- how we can control the migrants."

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Source: http://www.boston.com/news/world/asia/articles/2007/05/30/malaria_drug_resistant_tb_flourish_in_myanmar/

Drug Resistant TB Particularly Dangerous To People HIV-Pos.

By, 365Gay.com Newscenter Staff, May 30, 2007

(New York City) The case of a man with a rare and dangerous form of tuberculosis, ordered into quarantine, is of particular concern to people who are HIV-positive.

Called Extensively Drug-Resistant Tuberculosis, or XDR TB, it resists almost all drugs used to treat TB, leaving open only less effective options, according to the Centers for Disease Control and Prevention.

Some drugs have achieved cure rates for an estimated 30 percent of affected people, CDC says.

But, in people with HIV/AIDS the infection is generally fatal - 90 per cent of these cases end in death.

That makes tracking down anyone who may have come in contact with the man particularly important. That he traveled from the US to Europe and then returned home via Canada makes the search for those people more complicated.

Like regular TB, people infected with XDR TB spew out the TB germs when they cough, sneeze or even speak or sing.

Persons who breathe in the air containing these TB germs can become infected, though it is believed people who have fleeting contact with a case aren't at much risk.

Only between five and 10 per cent of people who are infected come down with active disease, according to the CDC. The rest have what is called latent infection and they are not infectious to others.

The CDC has taken the rare step of releasing information on the infected man. The federal agency said that he may have spread the disease to passengers and crew on two trans-Atlantic flights earlier this month.

The patient flew from Atlanta to Paris on Mat 12, arriving on May 13, on Air France Flight 385. He returned to the United States on May 24, on Czech Air Flight 410, from Prague to Montreal.

The man then drove into the United States.

The hunt for people who may have come in contact with the man is underway in the US, Canada, Italy and Greece. The CDC said that anyone who may have come in contact with him should immediately see their doctor and be checked for TB.


Source: http://www.365gay.com/Newscon07/05/053007tb.htm

Scourge of TB rears its ugly head

By, The Nation, May 25, 2007

Public health campaign needed to educate the public on tuberculosis and to combat rise of drug-resistant strains

A resurgence of tuberculosis (TB), which was declared a global public health emergency more than a decade ago, has focussed the world's attention on the need to redouble efforts to try to contain the spread of this deadly disease. Thailand, which had been so successful in combating TB in the past, has contributed to the widespread misconception that the disease has already been beaten.

The disease, however, has come back with a vengeance in recent years mostly in developing countries, including Thailand. Public health experts have expressed concern about the emergence of drug-resistant strains of the disease and the Aids pandemic, which, they say, could combine to bring death and suffering to millions of people worldwide.

Thailand was caught by surprise when the World Health Organisation ranked the country 17th out of 22 countries in the world with the highest rates of TB infection. According to a Public Health Ministry estimate, the TB rate in densely populated areas like Bangkok could be as high as one in every 500 people.

Most infected people are not aware of the disease, which is caused by the Mycobacterium tuberculosis bacillus and can be spread through the air like the common cold. According to the WHO, if left untreated, one person with infectious TB will pass it on to an average of 12 to 20 people, and that two to four of these will develop infectious TB.


According to the WHO, even though the global TB rate may have stabilised over the past few years due to greater awareness among public health officials and control efforts, the actual number of people with TB has increased markedly as a result of an increase in the world's population. The world health body said there were about 8.8 million new TB cases and 1.6 million deaths due to the disease in 2005.


Thailand is a classic example of how a high rate of HIV/Aids infection can fuel a TB resurgence. It has taken Thai health authorities years to shed complacency and wake up to the threat posed by the HIV/Aids-TB combination to the country's public health system.


A recently released study by Dr Amara Soonthordhada entitled "TB Policy in Thailand: A Civil Society Perspective" exposes a striking lack of social and political commitment to control tuberculosis, one of the leading causes of death in Thailand.

Due to the absence of TB awareness among members of the Thai public, there is little understanding of how TB is spread and the fact that it can be cured. According to the study, many patients do not seek treatment because of the social stigma attached to the disease, a lack of information, and the high costs of the cure.

The emergence of drug-resistant strains of TB is a great possibility in Thailand where too many people have developed the habit of self-medicating by buying medicines, like antibiotics, from local pharmacies - many of which are not staffed by qualified pharmacists - and then not bothering to complete the whole course.

Health authorities are just now beginning to encourage people with TB to come forward to seek free treatment. TB can be cured with a treatment regimen that typically takes six months to complete. The most important thing is to ensure that patients take the right dose of medicine and complete the whole course to prevent strains of TB becoming drug resistant.

The Public Health Ministry's statistics shows that while TB rates fell by 50 per cent from 1985 to 1991, the HIV/Aids epidemic may have contributed to a resurgence of TB, which kills about 12,000 people a year in this country.

Public Health officials will find it difficult to identify people with TB. The standard, error-prone procedure for diagnosing tuberculosis was developed some 100 years ago and it involves putting sputum samples under a microscope and lab technicians identifying the bacteria that cause TB. That's why a public awareness campaign is very important to alert people of the looming public health threat.

For a country like Thailand where HIV/Aids and TB tend to combine with devastating effects, public health authorities must rationalise their work by merging HIV/Aids and TB treatment programmes in order to lower the death rate from TB, which is curable.

Extremely drug resistant TB becoming 'major threat' in India

By, New Kerala, May 22, 2007

A new study has found that extremely drug resistant TB, or XDR-TB, is fast on its way of becoming a 'major threat' in India.

MDR-TB (multi-drug resistant TB) describes strains of tuberculosis that are resistant to at least the two first-line TB drugs, isoniazid and rifampicin. XDR-TB is MDR-TB that is also resistant to three or more of the six classes of second-line drugs.

XDR-TB leaves patients (including many people living with HIV) virtually untreatable using currently available anti-TB drugs.

The study was conducted by a team of researchers led by Sushil Jain at the World Health Organization and the Centres for Disease Control and Prevention.

As part of the study, researchers examined 3,904 lab samples at the Hinduja National Hospital in Mumbai, India.

Researchers found that 1,274 samples were positive for Mycobacterium tuberculosis. Of these, 32 percent were found to be MDR-TB, out of which 8 percent were XDR-TB.

Tuberculosis can infect many sites in the body but most commonly affects the lungs. All XDR-TB cases were in patients with pulmonary tuberculosis, or TB found in the lungs, which can be spread by coughing, sneezing, laughing or singing. Repeated exposure to someone with TB disease is generally necessary for infection to take place.

"An important finding was that the majority of patients with XDR-TB were of younger age group (their average age was 30 years), thus posing a major threat to our economically productive population," Dr. Jain said.

"Serious efforts are needed to tackle this deadly disease which may become a global emergency," he added.

XDR-TB has long existed in India but has been under-recognized and under-treated.

"Most labs in India are not equipped to perform drug susceptibility tests so exact prevalence is difficult to ascertain, and treatment in the absence of reliable sensitivity reports is difficult. Compounding the problem is the huge costs of treating these most difficult TB patients," he said.

The findings of the study were presented at the American Thoracic Society 2007 International Conference.

--- ANI

Source: http://www.newkerala.com/news5.php?action=fullnews&id=31843

TB is not a death sentence for people living with HIV

By, Kakaire A Kirunda, The Daily Monitor (uganda), May 22, 2007

"WHILE HIV PROGRAMMES HAVE ATTRACTED FUNDING, TB HAS MINIMAL FUNDING.
BUT THE INCREASING INTERACTION BETWEEN THE TWO DISEASES SHOULD HELP RAISE AWARENESS ON THE NEED FOR THE EMPOWERMENT OF COMMUNITIES TO TACKLE TB AS WELL. THERE IS NO REASON FOR PEOPLE LIVING WITH HIV/AIDS TO CONTINUE DYING OF TB"

Although preventable and curable, tuberculosis remains one of the most deadly infectious diseases in the world and it is the leading cause of mortality among people living with HIV.

When Erick Nangosya of Busiu in Mbale district discovered that he was HIV positive in 2004, he did not straight away embark on antiretroviral drugs. He was instead put on cotrimoxazole (Septrin) preventive therapy
(CPT) to ward off opportunistic infections.

But two years down the road in July 2006, Nangosya started feeling frequent fatigue and he sometimes slept without covering himself because of constant night sweatings. He even started having what he refers to as light coughs.

"I knew these were the usual treatable opportunistic infections.
However, two weeks into my leave in September, I started developing serious fever and started undergoing treatment in a clinic near home,"
Nangosya, a father of 12 children said. But his health continued to deteriorate by the day and he eventually lost appetite.

With no improvement in his health, Erick decided to seek further help from The AIDS Support Organisation (TASO) centre in Mbale where he is registered. Tests were carried out and it was discovered that he had pulmonary tuberculosis.

Although preventable and curable, tuberculosis (TB) remains one of the most deadly infectious diseases in the world. And it has turned out to be the leading cause of mortality among people living with HIV/ AIDS.

Upon being diagnosed with TB, Nangosya was in October 2006 put on critical treatment for two months. "It was really hard. TB treatment involves taking many big tablets. I was put on some capsules which were so bitter and yet I had to open the capsules and chew the powder.

It was a very hard moment. But considering that I had to secure my life, I had to persist and follow the medical advice," Nangosya recalled.

Two weeks into the eight-month road, Nangosya registered a dramatic improvement. However, worth noting is that it is usually at that stage of treatment that some TB patients start skipping daily dosages because of complacence. Some patients either interrupt their treatment because they feel better or imagine that they no longer need the drug.
This results in mutations leading to drug-resistant bacteria that complicates the recovery process and sometimes death.

STAYING ON TREATMENT

So how has Nangosya managed to hang on to treatment to date?

"I hang on for the sake of my life because I know that TB is a killer disease. I was going to die so I had to force myself back to life. I was forced to take treatment as prescribed. But all in all, I should say that adherence to treatment has played a big role in my steady recovery."

Nangosya is set to complete his treatment at the end May 2007. He said that when a person is undergoing TB treatment, family support as well as care by colleagues at the work place is vital for patients co-infected with HIV and TB. "My wife did a lot and was very courageous. You become forgetful. My wife became part of me so she kept reminding me to take my medicine. Also my workmates at TASO committed themselves towards seeing me improve."

And given that volunteers who would help people living wth TB and HIV in communities take their daily dosages were abandoning the cause, Nangosya said that the family support needed strengthening. He suggested that even if this meant the government giving handouts to families of people living with TB, so be it.

"Much as friends can help, they can't be around all the time. And it would be unfair to keep them off their work just to come and remind you to take your medicine. It would be easier done by a family member," he said.

However, Nangosya does not completely ignore the role of the community in the fight.

"What is failing the community response is funding. While HIV programmes have attracted funding, TB has minimal funding. But the increasing interaction between the two diseases should help raise awareness on the need for the empowerment of communities to tackle TB as well. There is no reason for people living with HIV/AIDS to continue dying of TB."
While Nangosyas' story raises important issues in TB management, a lot of stigma still surrounds the disease given its infectious nature.

IGNORANCE OF PEOPLE

"It is ignorance of people who have TB. What they ought to know is that once a patient finishes treatment for the first two weeks, they no longer constitute a threat to public health," he said.

"And people should also remember that thousands of others are living with the infection and are potential candidates for the disease once their immunity is compromised."

None-the-less, Nangosyas is suggestive of giving former and current patients a platform to talk about their treatment so as to convey to potential casualties that TB can be cured and that the disease does not discriminate, thus eliminating social stigmas associated with it.

Online at: http://www.monitor.co.ug/socpol/socpol05222.php

Genetic Tests May Help Improve Patients' Response To Tuberculosis Medication

By, Medical News Today, May 12, 2007

Experts have today highlighted the role that genetics may play in treating the current global tuberculosis (TB) pandemic. Paul van Helden and colleagues, from Stellenbosch University in South Africa, outlined the role that different genetic mutations may play in determining how a patient will respond to the commonly used TB medication isoniazid. These observations are published in the May issue of the journal Personalized Medicine.

It is estimated that at least 8 million people develop active TB annually, of whom 2 million die. It has been the cause of a global health emergency for over 10 years owing to factors such as social stigma, patient compliance and lack of investment in a thorough TB control program. Recently, these factors have resulted in the worrying emergence of drug resistance, leading to multi-drug resistant (MDR) and extensively drug resistant (XDR) strains of TB becoming prevalent. This is a particular problem in the developing world, where the majority of patients with TB also have HIV, making effective eradication extremely difficult.

Isoniazid is an important, commonly used and relatively inexpensive first-line TB drug. It is metabolized in the liver at different speeds in different individuals, giving rise to 'fast, intermediate and slow acetylator' phenotypes. Previous work has linked these phenotypes to different genetic variants, primarily present in the NAT2 gene. The authors believe that the standard drug dose currently administered to patients, regardless of their acetylator status, may not be appropriate for certain people. Individualization of isoniazid therapy may help to prevent adverse drug reactions experienced by a small percentage of patients thought to be 'slow-acetylators' of the drug. Conversely, 'fast-acetylators' may not be receiving sufficient amounts of the drug to combat TB successfully, therefore increasing the likelihood of a relapse and development of drug resistance.

The authors underline the need for further research into this area. However, they believe that on confirmation of the importance of the genetics of isoniazid metabolism 'a simple test to determine acetylator status would be desirable' and that 'these could be located at the same laboratories that currently perform diagnostics for TB.'

About Personalized Medicine

Personalized Medicine translates recent genomic, genetic and proteomic advances into the clinical context. The journal provides an integrated forum for all players involved - academic and clinical researchers, pharmaceutical companies, regulatory authorities, healthcare management organizations, patient organizations and others in the healthcare community. Personalized Medicine assists these parties to shape the future of medicine by providing a platform for expert commentary and analysis.

About Future Science Group

Future Science Group, based in London has developed an innovative publishing portfolio to reflect post-genomic medicine. The sequencing of the human genome was a colossal milestone in the evolution of healthcare, with repercussions for all those involved in the healthcare chain. Through its imprints, Future Medicine, Future Drugs and Future Biology, the Future Science Group provides healthcare practitioners and research professionals with a unique source of objective, cutting-edge information on exciting trends emerging in the light of these advances. Our flagship title Pharmacogenomics has evolved to become a leading source of commentary and analysis from international opinion leaders. Momentum toward an individualized approach to medicine is increasing as the value of linking diagnostic and therapeutic approaches becomes ever clearer. For more information please access www.future-drugs.com, www.futuremedicine.com and www.future-biology.com


Source: http://www.medicalnewstoday.com/medicalnews.php?newsid=70620&nfid=rssfeeds

Washington Post Examines Global Spread Of XDR-TB

By, Medical News Today, May 8, 2007

The Washington Post on Thursday examined how extensively drug-resistant tuberculosis -- TB that is resistant to the two most potent first-line treatments and some of the available second-line drugs -- is "raising fears" of a pandemic that could "devastate" efforts to control TB and "prove deadly" to people with HIV/AIDS and other diseases. According to the Post, XDR-TB has been detected in 37 countries. Some health experts say that at least half the people who contract XDR-TB will die of the disease. According to the Post, Russia has become a "petri dish" for TB drug resistance. About 22,000 people in the country have some form of drug-resistant TB, and an unknown number of those have XDR-TB, the Post reports. At least 30% of people receiving treatment for TB in the country do not complete their drug regimens, which increases the chance of developing resistance. Russia also has about one million people living with HIV/AIDS, which further exacerbates the TB situation, the Post reports.

HIV/TB coinfection also has helped fuel the "major TB infection zone" in South Africa, the Post reports. According to a Yale University study, 52 out of 53 people diagnosed with XDR-TB in a rural hospital in the country died. Most of those who died, including six health care workers, also were HIV-positive and died an average of 16 days after diagnosis. In addition, a study published last year in CDC's Morbidity and Mortality Weekly Report that was based on a survey of TB labs on six continents found that the prevalence of XDR-TB increased from 3% of TB cases to 11% of cases between 2000 and 2004.

Comments

According to Mario Raviglione, head of the World Health Organization's Stop TB Department, XDR-TB likely will mutate into a completely drug-resistant form of TB if it is not contained. "We will be left with surgery and prayers," he said, adding, "It's a desperate situation." Doctors and medical ethicists also are attempting to address the situation of people with XDR-TB who are not cooperative with treatment. Some have said that countries will have to consider forcing these people into isolation. "We have to face the possibility that restrictive measures may be necessary to control what could become a global pandemic," Ross Upshur, director of the University of Toronto's Joint Center for Bioethics, said. He added that although he is not advocating detention as a first response, "if voluntary measures fail, people do not have the right to infect others." Other experts have said forced isolation is impractical in poor countries and might drive the disease underground (Finn, Washington Post, 5/3).


Source: http://www.medicalnewstoday.com/medicalnews.php?newsid=69958&nfid=rssfeeds

Drug-resistant TB raises pandemic fear

By, Peter Finn, Washington Post, May 4, 2007

Detected in 37 nations, the strain poses a high risk of death to people with HIV-AIDS

Evidence of TB has been found in ancient skeletons and mummified remains. From the 17th century to the 20th, it was a major killer in the United States and Europe, taking the lives of notable people such as the poet John Keats, the composer Frederic Chopin, the writer Stephen Crane and the actress Vivien Leigh. A virulent strain of tuberculosis resistant to most available drugs is surfacing around the globe, raising fears of a pandemic that could devastate efforts to contain TB and prove deadly to people with immune-deficiency diseases such as HIV-AIDS.

Known formally as extensively drug-resistant TB, or XDR-TB, the strain has been detected in 37 countries.

It arises when the bacterium that causes TB mutates because antibiotics used to combat it are carelessly administered by poorly trained doctors or patients who don't take their full course of medication. Rather than being killed by the drugs, the microbe builds up resistance to them.

At least 50 percent of those who contract this strain of TB will die of it, according to medical experts.

In trying to stop the spread of the disease, which can be transmitted through coughing, spitting or even speaking, health officials have imposed sometimes extreme controls on infected people.

Robert Daniels, a 27-year-old dual Russian-U.S. citizen, underwent months of treatment for TB in Russia, where he often led a homeless existence. After telling people that he was feeling better, he flew from Moscow to New York on Jan. 14 last year, then on to Phoenix, Ariz.


Microbe mutation

In fact, his disease had not disappeared. The microbe causing it had mutated, apparently helped by his failure to complete a drug regimen in Russia. Weeks after arriving in Phoenix, Daniels was again coughing and losing weight.

Doctors in Phoenix diagnosed his illness as the new resistant strain of TB. Daniels again failed to follow doctors' orders, authorities say.

So health officials got a court order, and he was locked up in the prison wing of a Phoenix hospital, where he has spent the past nine months in hermetically sealed isolation.

"It's not right," Daniels said in a telephone interview. "I'm not a criminal."

Two events last year alerted the medical community to a frightening new version of the disease.

The Centers for Disease Control and Prevention, drawing on a survey of TB labs on six continents, reported that the prevalence of the super strain of TB increased from 3 percent of patients to 11 percent between 2000 and 2004.

In the United States, 13,767 TB cases were recorded in 2006, the lowest rate of infection since reporting began in 1953. A retrospective analysis by the CDC found 49 cases of the new strain in the country since 1993.

The CDC survey was followed by a report from Yale University researchers that the superbug had raged through a rural hospital in South Africa in 2005 and early 2006, killing 52 of 53 who contracted it, including six health care workers.

The victims, apparently infected by airborne transmission of the virus, died on average just 16 days after diagnosis; most of them also had HIV.

"We have to come to grips with this quickly," said Vladislav Yerokhin, director of the Central Tuberculosis Research Institute in Moscow. "This is not just a threat for TB patients. This is a serious threat for the general population."


Source: http://www.chron.com/disp/story.mpl/chronicle/4774190.html

Virulent New Strain of TB Raising Fears of Pandemic

By, Peter Finn, Washington Post, May 3, 2007

MOSCOW -- A virulent strain of tuberculosis resistant to most available drugs is surfacing around the globe, raising fears of a pandemic that could devastate efforts to contain TB and prove deadly to people with immune-deficiency diseases such as HIV-AIDS.

Known formally as extensively drug-resistant TB, or XDR-TB, the strain has been detected in 37 countries. It arises when the bacterium that causes TB mutates because antibiotics used to combat it are carelessly administered by poorly trained doctors or patients don't take their full course of medication. Rather than being killed by the drugs, the microbe builds up resistance to them.

At least 50 percent of those who contract this strain of TB will die of it, according to medical experts. In trying to stop the spread of the disease, which can be transmitted through coughing, spitting or even speaking, health officials have imposed sometimes extreme controls on infected people.

Robert Daniels, a 27-year-old dual Russian-U.S. citizen, underwent months of treatment for TB in Russia, where he often led a homeless existence. After telling people he was feeling better, he flew from Moscow to New York on Jan. 14 last year, then on to Phoenix.

In fact, his disease had not disappeared. The microbe causing it had mutated, apparently helped by his failure to complete a drug regimen in Russia. Weeks after arriving in Phoenix, Daniels was again coughing, feeling weak and losing weight.

Doctors in Phoenix diagnosed his illness as the new resistant strain of TB. Daniels again failed to follow doctors' orders, authorities say. So health officials got a court order, and he was locked up in the prison wing of a Phoenix hospital, where he has spent the past nine months in hermetically sealed isolation.

"It's not right," Daniels said in a telephone interview. "I'm not a criminal."

Daniels has become a case study in the bleak choices society faces in dealing with the new strain and attempting to balance protection of individual rights with protection of the public.

Evidence of TB has been found in ancient skeletons and mummified remains. From the 17th century to the 20th, it was a major killer in the United States and Europe, taking the lives of such notable people as the poet John Keats, the composer Frédéric Chopin, the writer Stephen Crane and the actress Vivien Leigh.

Even in the antibiotics age, TB has remained a scourge in poorer countries and communities. Today, one in three people globally is estimated to be infected with dormant TB, according to the World Health Organization (WHO). Most will never get sick, but in one in 10 cases the bacterium becomes active when the host's immune system is compromised. Worldwide, an estimated 1.7 million people die every year of the disease.

Two events last year alerted the medical community to a frightening new version of the disease. The Centers for Disease Control and Prevention, drawing on a survey of TB labs on six continents, reported that the prevalence of the super strain of TB increased from 3 percent of patients to 11 percent between 2000 and 2004. It reached 15 percent in South Korea and 19 percent in Latvia. There are no statistics yet about the new strain in Russia, China or Africa, areas with major TB populations .

In the United States, 13,767 TB cases were recorded in 2006, the lowest rate of infection since reporting began in 1953. A retrospective analysis by the CDC found 49 cases of the new strain in the country since 1993.

The CDC survey was followed by a report from Yale University researchers that the superbug had raged through a rural hospital in South Africa in 2005 and early 2006, killing 52 of 53 who contracted it, including six health care workers. The victims, apparently infected by airborne transmission of the virus, died on average just 16 days after diagnosis; most of them also had HIV.

"We have to come to grips with this quickly," said Vladislav Yerokhin, director of the Central Tuberculosis Research Institute in Moscow. "This is not just a threat for TB patients. This is a serious threat for the general population."

After the fall of the Soviet Union in 1991, rising poverty and a disintegrating medical system unleashed a TB epidemic in Russia and other post-communist countries. In 2005, the number of newly diagnosed cases in Russia reached 119,226, and 32,148 people died of the disease, according to the Ministry of Health and Social Development.

Up to 70 percent of TB patients in Russia are homeless, unemployed, in prison, former prisoners or alcohol abusers; 30 percent or more of patients break off their treatment, boosting resistance to anti-TB drugs.

In addition, Russia has an estimated 1 million people who are HIV-positive. That is an explosive combination, according to Murray Feshbach, an expert on Russian demography at the Woodrow Wilson International Center for Scholars in Washington. "It's potentially catastrophic for Russia," he said.

Today, South Africa is also a major TB infection zone. "The pressure of TB is enormous in our setting, and the majority of AIDS-related deaths are due to TB," said Gilles van Cutsem, medical coordinator with Doctors Without Borders in Khayelitsha, a large township on the edge of Cape Town, South Africa.

"People are wary about transmission within the community, as well as within health structures, from patients to patients and from patients to staff," van Cutsem said. "Considering that a great proportion of the health staff is also HIV-positive, this is even more of a concern."

Active TB bacteria are treated with four standard drugs. In most cases, patients quickly become non-infectious and start to feel better, although they are considered cured only after a full course of treatment, lasting about six months.

By the 1980s, doctors had begun to notice that some patients were resistant to these first-line drugs, particularly the two most potent ones, isoniazid and rifampicin. Their condition was defined as multidrug-resistant TB.

When the first line of drugs fail, doctors fall back on more expensive ones that have toxic side effects but can cure the condition after being used for 18 to 24 months. However, it is extremely difficult to keep patients taking the drugs for such a long period.

The new strain, a step up in resistance from the multidrug-resistant variety, has appeared more recently. An estimated 22,000 Russians have TB that is resistant to drug therapy to some degree. An unknown number of them have the new super strain.

If it is not contained, it will almost certainly mutate again into a completely drug-resistant TB, according to Mario Raviglione, director of WHO's Stop TB Department.

Some experts believe that may have already happened. Doctors reported this year that a 49-year-old woman in Italy died after 625 days of hospital treatment; all the drugs they tried failed.

The world is facing a return to the era before antibiotics when the white plague, as TB was known, was often a death sentence, according to Raviglione. The only treatment option then involved risky surgery in which doctors collapsed or removed an infected lung or attempted to cut out diseased tissue.

"We will be left with surgery and prayers," Raviglione said. "It's a desperate situation."

New drugs are in the pipeline but still years away, and patient non-cooperation could quickly undermine their effectiveness. "Monitoring patients is not easy when you are talking about a man who drinks a half a liter of vodka a day, or has no home or no family or no job, or all of the above. Those are our TB patients, " said Sergei Borisov, deputy director of the Phthisio-Pulmonary Institute in Moscow.

Some doctors and medical ethicists have said that countries will have to consider forced isolation of uncooperative patients, a public health strategy that evokes the sanitariums of decades ago.

"We have to face the possibility that restrictive measures may be necessary to control what could become a global pandemic," said Ross Upshur, director of the Joint Center for Bioethics at the University of Toronto. "I'm not advocating detention as a first resort," he added. "But if voluntary measures fail, people do not have the right to infect others. At the same time, people should be treated humanely, and they should have access to counsel, and they shouldn't be placed in a prison setting."

Other experts say such an approach might merely drive the disease underground and is impractical in poor countries.

"Forcing one uncooperative patient into isolation is fine, or even 10 patients or 100 patients," Borisov said. "But what about our situation in Russia, where 25 percent of the patients are uncooperative? Are we going to lock up thousands of patients? And where will we put them? Doctors cannot be prison guards."

Daniels, for instance, was often homeless when he was in Russia, according to him and his wife, Alla Danielova, an English teacher. Daniels said he bounced among friends' houses, partying and trying to ignore the bloody sputum he was coughing up. "I knew I was going to have to treat it, but I had other plans at that time," he said. "I didn't think it was a big deal. Now I know better."

Daniels acknowledged that he had visited a fast-food restaurant and stores in Phoenix without a mask but denied that he had stopped taking his medicine there. "That's a nasty lie," he said.

He said his condition is now improving. He has petitioned the court to be moved out of the prison ward and, ultimately, released. But last week a judge rejected his plea and ordered him to remain in medical confinement.


Source: http://www.washingtonpost.com/wp-dyn/content/article/2007/05/02/AR2007050202831.html

Extent of XDR-TB in South Africa unknown

By, Mail & Guardian Online, May 3, 2007

The extent of multidrug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) strains of TB in South Africa was not currently known, the World Health Organisation (WHO) said on Wednesday.

"We know there are quite a lot of MDR and XDR-TB, although we don't know the extent," said Dr Fabio Scano, a tuberculosis expert from the WHO.

Scano is in South Africa as part of a two-year collaboration with the government to provide technical support and advice in the fight against the disease.

"There are a lot of interventions under way but we have yet to see the results ... the fight against TB is a marathon, not a sprint," he said.

Since TB was "magnified by" HIV, it was the biggest public health challenge both nationally and internationally, he said.

According to the Health Department's latest figures, 237 of 350 XDR-TB patients identified in South Africa so far -- 68% -- have died. A total of 112 are on treatment and one patient has defaulted on treatment.

KwaZulu-Natal has the country's largest share of cases, with 221 out of 247 patients -- 89% -- having died. The survivors are all on treatment.

Special advisor to the Health Minister, Professor Ronnie Green-Thompson, said the high number of XDR-TB cases identified in the province could be due to it being well-equipped for TB testing.

"I don't think that KwaZulu-Natal is unique," he added.

Scano said an epidemiological investigation was under way in that province and the rest of the country to better understand the extent of the disease.

While the government would provide the resources to fight the disease, its magnitude meant South Africa would have to look elsewhere for funding.

It had already approached the Global Fund to Fight Aids, TB and Malaria. The WHO had said it was "very willing" to help, said the Health Department's deputy director general, Nthari Matsau.

There was much ignorance in other Southern African Development Community (SADC) countries about the extent of the disease.

"The other countries don't know whether they have it or not. South Africa so far is the only country [in the SADC region] that has the capacity and the capability to test for XDR-TB," said Matsau.

Scano said the government was increasing the cure rate for TB. He called for a "sustained support and fight" and said suspected TB cases needed access to HIV testing.

Deputy Health Minister Nozizwe Madlala-Routledge said the department would work closely with the Home Affairs Department to try to identify patients entering the country, but acknowledged it was difficult.

"We can't just grab everybody coming into the country and put them through tests."

She said measures to control the disease would include putting ultraviolet lights in waiting rooms at hospitals to kill the bacteria that caused TB.

Radebe said locking up XDR-TB patients who refused to take steps to avoid infecting others was not yet an option.

"We feel we have not yet reached a point where we can consider those extraordinary measures."

The Associated Press reported on Tuesday that a 27-year-old XDR-TB patient was being held in a jail in the United States because he failed to take precautions to avoid infecting others. He also did not heed instructions to wear a mask in public.

Matsau said the department recognised the importance of separating patients, but said having TB was not a criminal act.

"There are much more acceptable and humane ways," she added.

In March the Health Department got an interim High Court order compelling 13 MDR-TB patients back to their beds after they forced their way out of Pretoria West Hospital. They went to the Sizwe Tropical Disease Hospital in Edenvale, east of Johannesburg, insisting they be treated as outpatients. They had received treatment there previously.

Matsau said patients might try to run away becasue treatment took a long time. Drug addicts, delinquents or breadwinners not wanting to lose money were also more likely to run away.

"An average person generally detests being controlled in that kind of situation," said Matsau.

MDR-TB could develop if standard TB drug treatment was misused or not adhered to. More expensive and harmful second-line drugs would then be required. If this course of treatment was mismanaged, XDR-TB could result, making treatment options and chances of a cure far narrower.

According to medicalnewstoday.com website, countries with good TB control programmes could cure between 50 to 60% of XDR-TB cases.

Successful treatment however depended on the extent of drug resistance, the severity of the disease and whether a patient's immune system had been compromised. - Sapa


Source: http://www.mg.co.za/articlePage.aspx?articleid=303829&area=/breaking_news/breaking_news__national/

TB is that time bomb

By, Johnjoe McFadden, Mail & Guardian Online, May 1, 2007

One hundred and twenty-five years ago, a virtually unknown German country doctor called Robert Koch stood before the Physiological Society of Berlin and announced that he had discovered the cause of tuberculosis (TB). This was probably the most astonishing and significant statement in the history of medicine. Yet the disease he discovered still kills one to two million people per year and new strains of the TB bacillus threaten to undo the progress of 125 years.

TB was rife in the 19th century and responsible for about one in seven deaths. The list of famous people who fell victim to the disease, including Keats, Chopin and the Bronte family, gives a measure of its impact.

Trained as a physician, John Keats knew the significance of the drop of blood coughed on to a bed sheet: “That drop of blood is my death warrant. I must die.” And his prognosis was accurate -- he succumbed within a year.

So Koch’s claim made headline news around the world and offered hope of a cure. Early in the 20th century, Paul Ehrlich (who had TB himself) led the search for “magic bullets”. Yet, it was not until the 1950s that the antibiotic streptomycin was shown to be capable of killing the TB bacillus.

But problems emerged in the shape of resistant strains. Trials sponsored by the medical research council showed effective treatment required a combination of drugs over a six-month period.

Six months is a long time, particularly in the developing world, so it is no surprise that most deaths from TB today are in Africa and Asia. The HIV/Aids pandemic has increased the level of infection as the virus makes victims more susceptible to TB. In 1993, the situation deteriorated to the point where the World Health Organisation (WHO) declared TB a global emergency; thanks to its efforts, the incidence of disease has since levelled off and, in some places, has fallen.

But extensively drug-resistant TB (XDR-TB) is threatening to undermine these gains. The first sign of TB fighting back came in the 1990s, when there was an outbreak in New York of TB that was resistant to normal frontline drugs. There were scores of deaths and more than $1bn of spending was needed to bring it under control.

But spending at that level is not an option for developing countries. The town of Tugela Ferry in KwaZulu-Natal recently experienced an outbreak of XDR-TB among HIV-infected people. Of the 53 victims, 52 died of the disease, on average within 16 days.

XDR-TB is a product of inadequate treatment, and the key to managing it is improved infection control and new drugs. But lab resources remain basic in poor countries and, although research funding for TB has increased, it is still dwarfed by spending on other, less immediately real threats. Smallpox hasn’t killed anyone for decades but, because of its association with bioterrorism, it receives as much research funding as TB.

Most Westerners see global warming as a much bigger threat. The Global Plan to Stop TB, an international partnership backed by the WHO, would cost an extra $1,1-billion in 2007, a fraction of the cost of implementing the Kyoto agreement on carbon emissions or the £26-billion to replace Trident. The cost of providing antiretroviral drugs for the world’s estimated six million Aids victims would be about $1,5-billion.

Drug-resistant TB is already common in Asia, and some eastern European countries have the highest rates of XDR-TB. Cheap travel and increased migration ensure that it will spread. If we fail to act now, says Paul Nunn, coordinator of Stop TB, we will be faced with the “need to solve a human catastrophe at vastly greater expense”. -- © Guardian News & Media Ltd 2007

Johnjoe McFadden is professor of molecular genetics at the University of Surrey and an editor of Human Nature: Fact and Fiction

Source: http://www.mg.co.za/articlePage.aspx?articleid=306211&area=/insight/monitor/