Children neglected in response to TB

By, Kakaire Kirunda (Uganda), HDN Key Correspondent Team, November 13, 2007

Visiting the Mbale Regional Referral Hospital, which serves more than a dozen districts in eastern Uganda, in late July, opened my eyes to the plight of children with tuberculosis (TB).

The hospital has no pediatric TB treatment formulations and medical workers at the facility kept advising mothers to take their children elsewhere, while a senior medical officer argued that the adult drugs could be used to treat children as long as trained health workers administered the right dosage.

Soon it emerged that the problem was not only limited to the eastern part of the country but was occurring in other regions as well. The drug shortage continues and hospital managers have been crying for help in vain, with some resorting to sending anonymous letters to the press to raise awareness.

Some hope for children with TB remains as delegates at the 38th World Union Conference on Lung Health work to find solutions to these problems, though representatives at the meeting have also expressed concern that the number of pediatric TB cases is rising around the world.

According to Professor Anthony D Harries, a technical assistant in HIV care and support under Malawi's Ministry of Health, the situation for children is made worse by the widespread thinking that TB and HIV are adult problems. Harries says that treating children with TB, particularly those who are living with HIV, is also made difficult by a variety of other factors.

"It is extremely difficult because we are dealing with unconfirmed tuberculosis in children. You can't get sputum smears. And of course testing very young children for HIV has problems as well," said Harries.

"And studies have shown all over Africa that you if you don't pick up those children before the age of two years then many will die before that age. So it is full of technical problems."

Statistics indicate that more than 250,000 children die of TB each year. Many of these deaths are believed to result from a lack of diagnosis. The current diagnostic methods are not effective in children and according to the Executive Secretary of the Stop TB Partnership, new diagnostic tests are desperately need to identify children with the disease.

"We are trying to do this through the Stop TB Partnership Working Group on New Diagnostics coordinated by FIND (the Foundation for Innovative New Diagnostics) … Not many children are diagnosed, they die with a diagnosis of coughing, pneumonia," Dr Marcos Espinal told Health & Development Networks (HDN).

But as the world waits for technologies that will help, there are a growing number of calls for universal access to treatment. As UNAIDS' HIV-TB advisor Dr Alasdair Reid says "I think we should be a lot more willing to treat . . . And there hasn't been a lot of advocacy."

Some scientists are suggesting that infants exposed to an adult with TB should be started on treatment. But Executive Director of the International Union Against Tuberculosis and Lung Disease, Dr Nils E Billo says that access rates to pediatric anti-TB medication are beginning to stabilize.

"You may have heard that UNITAID, the fund that was created with a levy on air tickets originating in some countries, has now got quite a substantial amount of funding. They are now in a position to fund pediatric formulations and the global facility is providing these. There are pediatric formulations now," Billo said during the conference.

In 2006, France, Brazil, Chile, Norway and the United Kingdom decided to create an international drug purchase facility called UNITAID to be financed with sustainable, predictable resources. As an economically neutral tool, taxing air tickets was considered the most suitable instrument.

According to UNITAID’s website, by the end of the year the facility will have provided TB treatment to 150,000 children in 19 countries and will support the provision of drugs to fight multi-drug resistant TB (MDR-TB) in 17 low-income countries.

However, as experts stated during several conference discussions, bureaucratic tendencies, poor distribution systems and a lack of coordination between TB and HIV service providers can make it difficult to implement such interventions.

Health & Development Networks 2007

Source: http://www.thecorrespondent.org/main.aspx

Global: Simple measures could radically reduce TB

By, IRIN PlusNews, November 14, 2007

Better healthcare measures could curb the tide of tuberculosis (TB) and other lung diseases, even with existing drugs and technology. This was the final message from the 38th World Conference on Lung Health, in Cape Town.

At the conclusion of the 4-day meeting this week, Nils Billo, executive director of the International Union against Tuberculosis and Lung Diseases (The Union), said that improving infection control, even using simple and cheap methods, could significantly reduce the spread of tuberculosis (TB) and its death toll, especially among people with HIV.

However, the 3,000 delegates heard that better drugs and vaccines for treating and preventing TB, and faster and more accurate diagnostics were needed if the disease were to be eradicated. Much of the research into finding effective, practical and affordable technologies is being done by not-for-profit partnerships, funded by government, donors and the private sector.

TB has suffered from a lack of attention by policy-makers and funders for decades because the disease was relatively well contained in developed countries. However, an outbreak of TB in New York in the 1990s, combined with the growing toll of TB among people with HIV/AIDS, has been putting the disease on policy and research agendas.

Diagnosing TB can be difficult, especially where healthcare facilities have limited or no access to expensive machinery such as x-ray machines, or laboratories capable of the lengthy culturing of sputum samples to detect the bacillus.

Better diagnostic tools, like fluorescent microscopes, are already available but have not been widely adopted because they require expensive lamps and a stable power supply, but researchers have successfully experimented with substituting the lamps with 1-watt light-emitting diodes.

Six promising TB vaccines are also being shepherded towards human clinical trials within the next year, but even if one of them proves sufficiently effective, it is unlikely to be available for worldwide use before 2015.

The Global Alliance for TB Drug Research announced that it has two new drugs for treating TB in development; one of them, moxifloxacin, is among the most advanced potential new TB drugs, and is about to go into a phase 3 clinical trial involving more than 2000 volunteers in Kenya, South Africa, Tanzania and Zambia.

The organisation hopes its new antibiotic will eventually be used as a substitute for existing medications, and help shorten the current 6-month treatment period with first-line drugs.

Unfortunately, moxifloxacin is not effective against highly drug-resistant forms of TB. The rising number of drug-resistant cases was a focus of this year's Lung Conference, along with the spread of TB among HIV-positive people.

TB cure rates are low worldwide, but particularly in developing countries with high burdens of the disease, often fuelled by HIV/AIDS. In South Africa, successful treatment for TB varies widely across provinces and districts: one district in Mpumalanga Province has reported cure rates of just 12 percent, compared to a national success rate of just under 58 percent, which is already well below the target of 85 percent recommended by the WHO.

Drug-resistant forms of TB have been driven by unsuccessful first-line TB treatment, with many patients failing to complete the 6-month course of medication. Much of the transmission of resistant strains of TB occurs in healthcare settings.

Multidrug-resistant (MDR) TB is resistant to at least two of the most effective and commonly used first-line treatments for the disease, while extensively drug-resistant (XDR) TB is also impervious to at least one of the second-line drugs. Worldwide, it is estimated that four percent of TB infections are resistant to multiple drugs, although the figure is as high as 20 percent in some areas.

The WHO says it needs US$2.15 billion to fully implement its MDR-TB and XDR-TB Response Plan 2007-2008. This could potentially save 134,000 lives over the 2-year period by treating 160,000 people with MDR forms of the disease, and another 16,000 with XDR-TB.

An estimated 14 million people worldwide are co-infected with TB and HIV, while more than two-thirds of people infected with TB in sub-Saharan Africa are also living with HIV/AIDS. The two diseases reinforce each other in the body, each weakening the immune system's defences against the other.

Conference delegates heard of the critical need to co-ordinate action against both diseases, to create an effective response to what some presenters characterised as an epidemic of co-infection. Speakers repeatedly pointed out that the fight against TB has been relatively poorly resourced, compared to the more high-profile HIV/AIDS fight.

On the day the Lung Conference ended, the Global Fund to Fight Aids, TB and Malaria announced US$1.1 billion in new grants, but TB accounted for only 10 percent of funding, compared to 48 percent for HIV/AIDS and 42 percent for malaria.

Among the calls for action at the conference was to make greater use of one of the most effective anti-TB drugs, Isoniazid, (also called isonicotinyl hydrazine, or INH). Research in Brazil found that it could prevent TB infection in HIV-positive patients by up to 75 percent, if used in conjunction with antiretroviral therapy.

But presenters also emphasised the positive impact that better healthcare management could make, including basic steps to prevent the spread of TB in healthcare settings: opening windows, reducing the number of TB patients in a ward, and even simply separating coughing - and therefore potentially infectious TB patients - from others.

The 2008 World Conference on Lung Health will take place in Paris.

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South Africa: TB and Aids Campaigns Urged to Co-Operate

By, Miriam Mannak, Inter Press Service (Johannesburg), November 10, 2007

Tuberculosis (TB) in Africa cannot be dealt with while TB and HIV/AIDS organisations refuse to set aside their differences, health experts said Friday during the 38th Union World Conference on Lung Health, underway in Cape Town, South Africa.

"So far, many TB and HIV programmes in Africa - or anywhere in the world - do not co-operate with one another, despite the strong connection that exists between HIV and TB," noted Paula Fujiwara, senior technical advisor and director of the HIV department of the Union Against Tuberculosis and Lung Disease, the international coalition that has organised the Nov. 8-12 meeting, held annually.

"In some African countries for instance, 75 percent to 80 percent of the people living with TB are co-infected with HIV."

Fujiwara said jealousy was one of the major factors in the lack of collaboration between the two camps: "HIV has always been the big kid on the block, with TB being the little brother. HIV programmes and organisations seem to be afraid that TB takes away attention and funding."

TB is an airborne disease that principally affects the lungs; it is passed on, in part, through coughing and sneezing. Tuberculosis bacteria are able to remain dormant in a person, becoming active again in the event that the patient's immune system is weakened, as in the case of HIV infection.

Active TB is highly contagious and although treatable, potentially deadly -- especially for those who have AIDS. The disease is the leading cause of death among Africans infected with HIV: according to statistics from the World Health Organisation, 90 percent of people living with HIV/AIDS in Africa die within months of contracting TB.

It is estimated that 590,000 people die of TB each year in Africa, the only continent where TB rates are rapidly increasing. This is partially due to the high numbers of HIV infections in this region. Sub-Saharan Africa is home to more than 60 percent of HIV positive people worldwide.

In a bid to prompt HIV and TB activists to join hands, the Union Against Tuberculosis and Lung Disease has drawn up a strategy that allows the diseases to be tackled simultaneously -- termed 'Integrated Care for TB Patients Living with HIV/AIDS' (IHC).

Collaboration in addressing TB and HIV and cross-testing of HIV and TB patients are central to the strategy, which is being tested in various countries, including the Democratic Republic of Congo, Zimbabwe and Uganda.

"In 2005, only seven percent of HIV patients worldwide were tested for TB," said Alasdair Reid, HIV/TB advisor to the Joint United Nations Programme on HIV/AIDS.

"That is shocking. By testing people living with HIV for TB we can save thousands and thousands of lives each year. And, it is feasible. The problem is the lack of co-operation between the different organisations that deal with TB or HIV."

A new model for distribution of funds is also required, Reid added. "Currently, money is raised for either HIV or TB, and funds dedicated for HIV can't be used for TB or vice versa."

"This has to change. When you want to tackle HIV you need to tackle TB, especially in Africa where so many people are co-infected."

Winstone Zulu, an activist from Zambia who is living with HIV/AIDS, said the time had come for organisations to work together.

"We cannot successfully fight AIDS when we don't fight TB," he noted. "Unfortunately many people still don't seem to understand the necessity of combating TB, especially in Africa. They do not see the connection between both diseases."

"One needs to understand that in Africa, people are not dying because of HIV or AIDS. They are dying of TB," Zulu added.

"I contracted TB in 1996 and it was truly the only disease in my entire life that nearly killed me. I have been living with HIV for 17 years and I have always been fine, due to the anti-retroviral treatment that I am taking. This all changed when TB hit me. The chest pains, the night sweats, the fatigue were unbearable."

Anti-retrovial treatment comprises various drugs that prolong the lives of people who have contracted HIV.

"Luckily I received treatment on time and after a few weeks I felt much better," said Zulu. "For four of my brothers, however, help came too late."

The Cape Town meeting has as its theme 'Confronting the challenges of HIV and MDR in TB control and care'.

MDR - multi-drug resistance - of TB is a source of growing concern among health workers and researchers, as is extensive drug-resistant tuberculosis (XDR-TB).

While Multidrug Resistant TB can withstand at least two of the main drugs used in initial treatment of the disease (termed "first-line drugs"), XDR-TB is also resistant to various second-line drugs.

Source: http://allafrica.com/stories/200711110002.html

TB-HIV deadly combo threatens Africa

By, The Times of India, November 4, 2007

Drug-resistant tuberculosis and HIV have merged into a double-barreled epidemic that is sweeping across sub-Saharan Africa and threatening global efforts to eradicate both diseases, according to a report released on Friday.

Over-burdened health systems are unable to cope with the epidemic and risk collapse, said the report, which calls for urgent measures to curb its spread.

A third of the world’s 40 million HIV/AIDS sufferers also have TB, and the death rate for people infected with both is five times higher than that for tuberculosis alone.

The situation is aggravated by surging rates of multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB precisely in those areas where the rates of HIV infection are highest. MDR and XDR tuberculosis are resistant to some or all of the standard drugs used to fight the disease.

"Now the eye of the storm is in sub-Saharan Africa, where half of new TB cases are HIV co-infected," said Veronica Miller, co-author of the report and director of The Forum for Collaborative HIV Research, which issued the study. "Unlike bird flu, the global threat of HIV/TB is not hypothetical — it is here now," she said.

One third of the world’s population carries the tuberculosis bacterium, but the disease remains latent in nine out of 10.

HIV, however, changes the equation: Of those whose immune systems have been compromised by HIV, 10% will develop active tuberculosis each year, according to the report.

"In today’s world, a new TB infection occurs every second. When one considers that much of this transmission occurs in areas with high HIV prevalence, the imminent danger of a global co-epidemic is clear," said Diane Havlir, head of the World Health Organisation’s TB/HIV working group.

TB control has been severely destabilised in regions with high rates of HIV, the study says.

In one community of 13,000 people outside of Cape Town, South Africa, the TB patient case load increased six-fold between 1996 and 2004, the researchers reported.

"There has been a staggering increase in TB in this community, and this has been replicated right across southern Africa," Stephan Lawn, a medical researcher at the University of Cape Town, said in a statement.

Source: http://timesofindia.indiatimes.com/TB-HIV_deadly_combo_threatens_Africa/articleshow/2515583.cms

TB vaccine sickens HIV-infected children: report

By, Maggie Fox, Reuters, November 2, 2007

WASHINGTON (Reuters) - A vaccine aimed at protecting children in developing countries from deadly tuberculosis may be killing and sickening some vulnerable infants infected with the AIDS virus, researchers said on Friday.

They said the Bacille Calmette-Guerin or BCG vaccine, which is made using a bovine version of tuberculosis, appeared to be causing serious infections in some babies and young children who are HIV-infected.

"One study found a 75-percent mortality rate in children with BCG disease, and 70 percent of those children were HIV-infected. Clearly, this is a problem in need of immediate attention," said Dr. Mark Cotton, a pediatrician and HIV researcher at Stellenbosch University in South Africa.

Cotton's findings are part of a report issued on Friday about the health emergency caused globally by the double whammy of HIV and TB.

The AIDS virus destroys the immune system, and tuberculosis has made a return globally because of this. Usually a latent infection, activated TB can kill quickly.

"Now the eye of the storm is in sub-Saharan Africa, where half of new TB cases are HIV co-infected, and where drug-resistant TB is silently spreading," said Veronica Miller, director of The Forum for Collaborative HIV Research, a global independent public-private group that includes researchers, patient advocates, and government and industry.

"It is here now. But the science and coordination needed to stop it are utterly insufficient."

The human immunodeficiency virus infects an estimated 40 million people globally. There is no cure and when untreated, it steadily destroys the immune system. Patients are vulnerable to a range of infections including TB.

BILLIONS INFECTED

TB infects one-third of the world's population. Without proper treatment, 90 percent of people infected with both die within months.

Usually, tuberculosis only becomes an active infection in one out of 10 people over a lifetime. But 10 percent of HIV patients who also have TB develop activated tuberculosis every year.

The BCG vaccine is given at birth in most developing countries. But because it uses a live microbe, in people with weakened immune systems it can itself cause disease.

"It is especially a problem where they have delayed access to diagnosis of HIV or delayed access to antiretroviral therapy," Cotton said in a telephone interview.

"It also is quite hard to diagnose it," he added. "We don't know how widespread it is across Africa."

Cotton said an estimated 400 per 100,000 HIV-infected infants in the Western Cape of South Africa had become sick from the BCG vaccine.

"The problem is the vaccine is usually given within the first few days of life," Cotton said. But babies are not tested for HIV infection until about 6 weeks of age, meaning many infants are unknowingly being given a vaccine that is dangerous for them.

Cotton said it might be possible to simply vaccinate children with BCG after it is known whether they are HIV-infected.

"But once you interfere with a program and make it a bit complicated, it can have repercussions as well, so it is a bit of a dilemma," he said.

The best result would be to have earlier diagnosis and treatment of HIV. Children infected with HIV can be given an antibiotic, isoniazid, to prevent TB infection, Cotton said.

South Africa: Govt Comes Under Fire for Failing to Stem XDR-TB

By, Anso Thom, Health-e (Cape Town), November 1, 2007

South Africa's health department has come under fire from activists and HIV/tuberculosis experts for its failure to respond to extensively drug resistant (XDR) TB with claims that one of the critical drugs to stem this epidemic is not available in KwaZulu-Natal, the hotbed of the outbreak.

The criticism has come in the run-up to the 38th Union World Conference on Lung Health starting in Cape Town next week.

"Almost nothing has happened," said Dr Nesri Padayatchi, Site Manager of the Centre for the AIDS Program of Research in South Africa (CAPRISA) and former head of King George Hospital where KwaZulu-Natal's multi-drug resistant (MDR) and XDR TB patients are treated.

Padayatchi said that despite being alerted to the XDR strain as far back as 1995 and again in May 2005, the response from the provincial and national health department was "nothing".

She said that since the global spotlight turned to Tugela Ferry, where the XDR outbreak was first reported, the national health minister called a World Health Organisation meeting and committed to a seven point plan.

"To date, three points have been addressed, and only in Tugela Ferry. Because of the media and civil society attention more money and staff has been sent to Tugela Ferry. But what about the rest of the country? Almost nothing has happened and we really have not made any progress," said Padayatchi.

She said a visit to King George Hospital had confirmed that more beds had been made available, but that staff had informed her that PAS, one of two drugs used to treat XDR, was no longer available from the supplier.

This year, 2 500 MDR cases have been diagnosed in the province while only 600 of these have been treated at King George.

"The national community may be concerned, but the national health department has done very little to address what is a global problem," said Padayatchi.

Stephen Lewis, former United Nations Special Envoy for HIV/AIDS in Africa and currently co-director of AIDS-Free World said the MDR and XDR epidemics spoke of "extraordinary negligence".

"It's a global health scandal of monumental proportions," said Lewis.

Figures released during the teleconference revealed that each year, nearly two million people die of TB, a curable disease.

Failure to properly address TB has led to deadly, drug-resistant strains.

"Despite global commitment to treat 1.6 million people with drug-resistant TB by 2015, little progress has been made," said a statement from the Open Society Institute's Public Health Programme.

Today, of the more than 420 000 new cases of drug-resistant TB annually, only 2 percent are receiving treatment.

Drug-resistant TB is more complicated and expensive to diagnose and treat, especially for HIV-positive people.

South Africa is grappling with ways in which to treat the growing and slowly overwhelming number of MDR TB patients.

On Tuesday, a patient was shot and wounded and a security guard stabbed at the Sizwe Tropical Disease hospital in Edenvale, east of Johannesburg, after a protest by TB patients turned violent.

Newspaper reports said the drama started when about 50 MDR TB patients blocked the hospital's entrance, demanding better treatment and an end to what they called prison-like conditions.

Patients said they were being treated like prisoners while their families were only informed of their condition once they had died.

Brooklyn Hospital, the main treatment centre for MDR-TB treatment in the Western Cape, is bursting at the seams, with patients forced to wait weeks for a bed.

Dr Paul Farmer, Founding Director of Partners In Health, shared "the cheerful part of the story".

He revealed that community based interventions introduced in Peru 12 years ago had led to 10 000 MDR TB patients accessing effective treatment.

Farmer is currently assisting with the introduction of a similar intervention in Lesotho whereby community health workers assist MDR patients at home and address issues such as adherence and infection control.

"We need to get our act together before turning to the global community," said Padayatchi. "There are a lot of simple things we can do right away."

Source: http://allafrica.com/stories/200711010718.html