Today, on World TB Day, Canada can - and should - celebrate its leadership in fighting tuberculosis abroad. In addition to the $30-million Canada invests in international TB control each year, it recently committed $450-million to the Global Fund to Fight AIDS, Tuberculosis and Malaria.
TB control is a sound investment that provides health and economic benefits. The Copenhagen Consensus 2008 diseases-challenges paper noted that a $19-billion investment in TB control could generate a net gain of $1.7-trillion in wealth in the global economy by increasing the number of healthy workers.
What works for the global economy can work for Canada. Canada, however, is failing to reduce TB rates right here at home. Without new efforts, Canada will fail in its commitment to the United Nations Millennium Development Goal of halving domestic TB rates by 2015.
First Nations are among the most vulnerable for this preventable disease, with infection rates 29 times higher than the rest of the population - rates that have not decreased since the 1990s.
Canadian researchers are about to embark on a quest for an answer that could make treating latent tuberculosis a lot easier and, it is hoped, more frequently successful.
Led by McGill University's Dick Menzies, they are on the verge of launching an international clinical trial to see if latent TB can be treated as effectively with a drug regime that takes less than half the time and may pose a lower risk of serious side-effects than the current standard of care.
"The study is very much needed," says Michael Gardam, director of the tuberculosis clinic at Toronto Western Hospital, who was involved in a pilot study but is not taking part in the clinical trial.
The clinical trial, which is being funded by the Canadian Institutes of Health Research, will be announced today in Montreal.
Nearly 6,000 people with latent (inactive) tuberculosis will be enrolled in five cities across Canada as well as in the West African countries of Benin and Guinea, and Brazil, South Korea, Australia and Saudi Arabia.
Half will receive the current regimen used to try to cure latent TB infection, once-a-day treatment with the drug isoniazid for nine months. The other half will receive the drug rifampin for four months.
Both groups will be followed for 28 months from recruitment to see how many go on to develop active TB - which should tell if rifampin is as efficacious as isoniazid. Dr. Menzies says the study will take about seven years.
James Nawchtwey's new photographs appear alongside the Time article - The Forgotten Plague:
Thousands of years after Tuberculosis ravaged ancient cultures stretching from Greece to Egypt, more than a century after the bacillus responsible for the disease was first identified and decades after the first antibiotic-based treatments appeared, TB continues to thrive. In 2005 the disease was diagnosed in 9.2 million more people, almost exclusively in the developing world, and 1.7 million people died from it. More alarming is a growing subset of TB cases, estimated at half a million, that are resistant to more than one of the handful of anti-TB drugs. While they still make up only 5% of the total annual TB burden, these cases of multidrug-resistant and extensively drug-resistant TB are mushrooming, fueled by the surge in AIDS and by health-care systems that have ignored the threat of TB for too long.
But it doesn't have to be this way. TB is an entirely preventable and treatable disease. And the drug-resistant strains beginning to emerge in Africa, Russia, China and India, say experts, are epidemics of our own making. Unlike HIV, the tubercle bacillus succumbs to powerful medications. But these drugs are not where they need to be, and when they are, spotty monitoring and poor health infrastructure make it hard to ensure that patients take their daily doses for the six months that are needed to eradicate the infection--all of which encourages drug-resistant strains to survive and keep the disease going. "We are still in denial about how bad this problem is and how much worse it's going to get," says Dr. Jim Kim, head of social medicine at Harvard Medical School.
DURBAN] Clinical trials of a new molecular technique have found it to be effective at quickly identifying multidrug-resistant tuberculosis (MDR-TB) in resource-poor settings.
As a result, the WHO has endorsed the use of the test in all countries with MDR-TB.
South Africa's National Health Laboratory Service and Medical Research Council (MRC), and the Foundation for Innovative Diagnostics (FIND) collaborated to test 30,000 patients suspected to have MDR-TB in South Africa between 2007 and 2008. They used both the rapid test and conventional testing.
They announced the results at the opening of the 2008 South African Tuberculosis conference in Durban this week (1 July).
The test uses polymerase chain reaction (PCR) technology to amplify Mycobacterium tuberculosis DNA and look for genetic mutations that cause resistance to drugs.
It is the first of its kind to be used against TB and the first new tool for TB in 50 years, says Martie van der Walt, acting director of the TB Epidemiology and Intervention Research Unit at the MRC.
The new TB test yielded results on 92 per cent of all samples compared with about three-quarters (77.5 per cent) of samples tested by conventional methods. It takes between eight hours and two days to get a result, compared to six to eight weeks for conventional testing.
Patients who receive appropriate drugs sooner minimise their risk of acquiring additional drug resistance, van der Walt told SciDev.Net. Earlier diagnosis also cuts the chance of infecting others.
Seventeen countries will receive the tests over the next four years through the WHO Stop TB Partnership's Global Drug Facility. FIND and the WHO's Global Laboratory Initiative will help countries build the capacity — such as laboratory equipment and trained staff — to carry out tests based on PCR techniques.
However it is clear that this initiative goes only so far in meeting the medical needs. In addition, several further issues are also of concern:
The tests are problematic for ‘smear negative’ TB patients
The new diagnostic method is based on the DNA analysis of resistant mycobacterium tuberculosis in sputum samples. But many TB patients are either unable to produce sputum or are sputum negative and the WHO does not recommend this new technology for use in smear negative patients. This is problematic in that for instance up to 50% of TB patients co- infected with HIV are sputum negative. Similarly patient suffering from extra pulmonary TB will not produce TB bacterium in their sputum. Since in some places, up to 80% of TB patients are co-infected with HIV, this means the test will be of restricted use in high burden HIV countries.
The test will not be available in the most peripheral settings
The new testing method can only be processed in well equipped laboratory conditions, requiring at least three different rooms, constant power supply, refrigeration facilities and very well trained staff – unavailable in the remotest settings. This kind of testing can only be carried out in laboratories at a regional level. This means that many of those with TB cannot be reached through implementation of the new tests.
The test is still expensive
At present, the cost of testing for MDR TB stands at around 34USD. The new test, after training and equipment costs are included, is offered at 20 USD which is still far too high for most health systems and individuals in developing countries. At present the tests are offered at this price only to South Africa and unless things change, this leaves the remaining 15 countries with a much larger bill. Price reductions must be made available across the board for all countries wishing to use this new technology
Still need for culture and drug-sensitivity testing
Another drawback to the test is that while it can rapidly give a yes-no answer as to whether the patient is multi-drug resistant or not, it cannot give more detailed information on the drug resistance status of the patient. To be able to exclude extremely drug resistant TB (XDR TB), which would require further adaptation to the already complex and toxic MDR-TB-treatment, culture techniques and performance of DST have still to be in place.
Furthermore, culture must still be employed in order to follow-up on patients and monitor whether they are responding to treatment as the new technique cannot give the answer whether the bacilli detected are still alive or not.
Therefore, the new technique may be able to reduce the numbers of cultures performed but it cannot replace it, which will also have an impact on the total costs for the health system.
Laboratory failings are not the key factor
WHO and its partners suggest that it is mainly the lack of laboratory capacity that is responsible for the enrollment of only 2 % of patients in need for effective MDR-TB care. As explained above, this is certainly not the single most important obstacle: Highly complex treatment regimens, lack of effective 2nd line drugs, trained staff and infrastructure, diagnostic and treatment costs that are still far too high - these are just some additional examples why effective MDR-TB care is still severely restricted
Need for many and varied fronts in battle against TB
The medical needs for tackling drug resistant TB are many and urgent. TB is a public health emergency and demands a multi-faceted, co-ordinated response on many fronts including ramping up overall funding for TB drugs and diagnostic research, stimulating trials and pushing on drug development.
While these new testing methods/techniques should be welcomed as a useful additional weapon in our battle against TB, with its limitations, it can only remain one part of the solution.
*The iniatives have been launched by WHO, the Stop TB Partnership, UNITAID and the Foundation for Innovative New Diagnostics (FIND).
Speaker's case provoked a flurry of media attention and public outrage. During hearings, Representative Bennie Thompson (D-MS), chair of the House Homeland Security Committee, exclaimed, "We've dodged a bullet. When are we going to stop dodging bullets and start protecting Americans?"1 The implication was clear: tuberculosis carriers threaten the nation. Like terrorists, they must be thwarted by enhanced security measures, including the vigorous application of isolation and quarantine. Lost in the debate was the recognition of legal checks on the use of compulsory isolation and quarantine as well as the importance of such checks to protect the public health.
Although the terms are often used interchangeably, public health practice distinguishes between isolation, which applies to someone, such as Speaker, who is known to be contagious, and quarantine, which applies to not-yet-ill people who or goods that may have been exposed to a disease. The undertaking of both isolation and quarantine may be voluntary or compelled by law. Although tuberculosis is more commonly addressed by isolation than by quarantine, thousands were quarantined in their homes and other facilities in Asia and Canada during the 2003 severe acute respiratory syndrome (SARS) outbreak. The use of quarantine has also been widely discussed in connection with a possible influenza pandemic, although federal plans note that it may have limited efficacy for so highly contagious a disease.
Both the states and the federal government have the authority, in appropriate cases, to compel isolation and quarantine. The states derive their authority from their police power, the sovereign authority they retain under the Constitution. Although the federal government lacks a general police power, it has long used its authority for regulating international and interstate commerce to quarantine interstate or international travelers or commerce. Today, Section 361 of the Public Health Service Act authorizes the Department of Health and Human Services (which acts through the CDC) to apprehend, detain, and forcibly examine persons to prevent certain communicable diseases (specified by the President) from entering the country or traveling across state lines. Tuberculosis and types of influenza with pandemic potential are among the listed diseases.
Traditionally, courts have interpreted the authority of the states and the federal government broadly, giving great deference to public health officials. Still, even broad authority is not unfettered. Detained persons have a right to a court review of their detention's legality. Moreover, constitutional guarantees of equal protection and due process must be respected.
These safeguards are critical because the power to impose isolation and quarantine can be and historically often has been used in an abusive and discriminatory manner. For example, when bubonic plague struck San Francisco in 1900, the board of health imposed a quarantine drawn to include the homes of Chinese Americans but exclude the homes and businesses of white residents. A federal court found the quarantine unconstitutional. Although blatantly discriminatory measures may be unlikely today, studies of New York City's use of isolation orders for tuberculosis in the 1990s show that more than 90% of the people detained were nonwhite and more than 60% were homeless.2 Although these figures may reflect the democracy of noncompliant patients with tuberculosis in New York City at that time, the fact that the most potent public health tool was used primarily against marginalized, nonwhite persons underscores the need for legal oversight — if only so that affected communities can be assured of the absence of discrimination.
In recent decades, courts have clarified the legal rights of patients with tuberculosis who are subject to compulsory isolation. Drawing an analogy between isolation orders and civil commitment for mental illness, courts have affirmed that patients who are isolated by law have many procedural due-process rights, including the right to counsel and a hearing before an independent decision maker. States must also provide "clear and convincing" evidence that isolation is necessary to prevent a significant risk of harm to others. Most important, some courts have held that isolation must be the least restrictive alternative for preventing such a risk. If the government can protect public health without relying on involuntary detention, it must and should do so.
Many important questions remain. First, courts have not decided how long someone may be held before a hearing is offered or what procedures are necessary in the event of a mass quarantine. Courts have also not yet decided what probability of risk justifies short-term or long-term detention. Nor have they clarified what evidence is needed to determine that a person is or may be infectious or how infectious a person must be to justify isolation. Most critical, courts have not explained what must be shown to conclude that a patient is noncompliant so that detention is the least restrictive alternative. In tuberculosis cases, courts have upheld detention when a patient has failed, like Speaker, to follow medical advice. But they have not considered how forcefully that advice must be given or what, if anything, the government has to do to facilitate compliance. Thus it is unclear whether the CDC was required to provide Speaker with a safe way home in order to consider him noncompliant and requiring detention.
However, in this post-9/11, post-SARS era, public health officials often feel compelled to exercise compulsory powers. Hence in 2005, the CDC published proposed regulations calling for an expanded role for isolation and quarantine without ensuring all the individual rights courts have required.5 These regulations, which are still under review by the CDC, would authorize short-term provisional quarantines without any hearing for up to 3 business days. Persons subject to nonprovisional quarantine would be entitled to a hearing, but no lawyer would be provided and there would not be an independent decision maker. Moreover, the CDC would be able to isolate people without showing that they posed a significant risk to others or that isolation was the least restrictive alternative.
A lab technician holds up a
sputum sample containing
blood
Photo credit: Gary Hampton/The Global Fund
The good people at scidev.net have started up an entire new, very helpful section on their website devoted exclusively to tuberculosis - which can be reached - here.
The introduction:
TUBERCULOSIS: INTRODUCTION
When the World Health Organization announced in 1993 that tuberculosis (TB) should be treated as a global emergency, the international community's response was slow and uncoordinated.
Although initial progress has since been made in controlling the disease, the emergence of a deadly HIV–TB co-infection epidemic and extensively drug-resistant strains of TB means that a more serious and aggressive strategy is essential to fight the world's second biggest infectious disease.
Practical action
What needs to be done? More research is undoubtedly necessary. Understanding the social factors deterring people from seeking diagnosis or treatment, removing the barriers to accessing care, and devising new strategies to diagnose TB in children and HIV/AIDS patients are key priorities.
When the genome of the bacterium that causes TB has been sequenced, researchers will be able to look for ways to defeat it. Understanding immunity to the disease may also help researchers who have so far been frustrated in efforts to develop a new, long-lasting vaccine.
But there are practical measures that can be implemented using existing knowledge: integrating TB and HIV efforts — especially in sub-Saharan Africa — and strengthening health systems are just two examples.
Two-thirds of TB cases could be detected with existing diagnostic methods if only these techniques were widely and effectively implemented. These measures will need tremendous national commitment as well as international support and guidance.
Need for information
Just as important as these actions is the need for accurate information. This means not only training healthcare workers to understand the growing challenges of TB, but also educating the wider population to dispel any lingering myths about TB and combat the stigma associated with this disease. Raising awareness of the increased risk of TB infection for people with HIV and helping people know when they might be at risk of having latent or 'hidden' TB, are also key.
This spotlight offers the simple facts and figures about TB but also delves into more complex issues — in particular, the obstacles confronting mandatory quarantine of patients with drug-resistant TB, the problem of overlapping HIV and TB epidemics and the clinical challenges for drug development. For those wanting to read further, the spotlight also offers a comprehensive summary of websites and key reports.
Nearly one third of the global population - i.e. two billion people - is infected with mycobacterium tuberculosis and at risk of developing the disease. More than eight million people develop active tuberculosis (TB) every year, and about two million die.
More than 90% of the global TB cases and deaths occur in the developing world where 75% off cases are in the most economically productive group (15-54 years). An adult with TB loses an average of three to four months (annually) of work time. This results in the loss of 20-30% of annual household income and if the patient dies of TB, and average of 15 years of lost income. In addition to the devastating economic costs, TB imposes indirect negative consequences - children leave school because of their parents' tubecuolsis, and women abandoned by their families as a result of the disease.
Coinfection with human immunodeficiency virus 9HIV) significantly increases the risk of developing TB. Countries with high prevelance of HIV, particularly those in sub-sharan Africa, have witnessed a profound increase in the number of TB cases, with reported incidence rates increasing two to three fold in the 1990's.
At the same time, multi-drug resistance which is caused by poorly managed TB treatment, is a growing problem of serious concern in many countries around the world.".
"REASONS FOR THE GLOBAL TB BURDEN:
The main reasons for the increasing burdne of TB globally are:
- Poverty and the widening gap between rich and poor in various populations, eg. developing countries, disenfranchised urban populations in developed countries.
- Neglect of the disease (inadequate case detection, diagnosis and cure)
-Collapse of the health infrastructure in countries experiencing severe economic crisis and civil unrest.
The impact of the HIV pandemic.
TREATMENT:
"The most cost-effective public health measure for the control of tuberculosis is identification and cure of infectious TB cases, i.e. patients with smear positive (the TB bacillus visible through a microscope in a sputum sample) pulmonary TB. Nevertheless, NTP's (National Treatment Programs) provide the identification and cure for all patients with TB. These guidelines cover the treatment of patients, both adults and children, with smear positive pulmonary TB, smear negative pulmonary TB and extrapulmonary TB.
Treatment of TB is the cornerstone of any NTP. The modern treatment strategy is based on standardized short-course chemotherapy regimens and proper case management to ensure completion of treatment and cure. Standardized treatment is a component of the TB control control policy package, set out in the WHO's expanded framework for effective tuberculosis control, and of the internationally recommended strategy for TB control known as DOTS. Success of the treatment strategy depends on the commitment to the policy package in its entirety. The emphasis is on placing the patient at the centre of TB control activities, the health system begin responsible for facilitaiting access to treatment and ensuring drug intake.
The DOTS strategy provides the TB patient withg all the necessary requirements for cure.".
"The essentails needed to control TB, based on diagnosis and treatment of infectious cases and incorporating the essentail management tools, were developed and packaged as the DOTS strategy in the early 1990's.
Countries applying DOTS on a wide scale have witnessed remarkable results. Transmission has declined in several countries; in Peru, for example, incidence has dropped by approxiamtely 6% per year over the last decade. Mortality has fallen: in China some 30 000 deaths have been averted each year in districts implementing DOTS. Drug resistance has decreased: in New York in the 1990's the revelance of TB drug resistance fell by 75% following intensive interventions to improve pateint management and TB transmission.".
"What determines a case definition?
-Site of disease.
-Bacteriology
-Severity of TB disease
-History of previous treatment of TB.
CASE DEFINITIONS:
-Tuberculosis suspect: Any person who presents with symptoms or signs suggestive of TB, in particular cough of long duration.
- Case of tuberculosis: A patient in whom TB has been bacteriologically confirmed by a clinician.
- Definite case of tuberculosis: A pateint with postive culutre for mycobacterium tuberculosis complex. (In countries where culture is not routinely available, a patient with two putum smears positive for acide fast bacilli (AFB) is alos considered a definite case.".
TREATMENT REGIMENS:
"Treamtent regimens have an initial(or intensive) pahse pasting 2 months and a continuation phase lasting 4 to 6 months. During the intial phase, normally consisting of isoniazide, rifampicin, pyrazinamide and ethambutol, the tubercol bacilli are killed rapidly. Infectious patients quickly become non-infectious (within appoximately two weeks); symptoms abate. The vast majority of patients with sputum smear-positive TB become smear-negative within two months. During the continuation pahse, fewer drugs are necessary but for a longer time. The sterilizing effect of the drugs eliminates the remaining bacilli and prevents subsequent relapse.".
MANAGEMENT OF CHRONIC AND MULTI-DRUG RESISTANT CASES:
"CHRONIC: A patient with TB who is sputum-postive at the end of the standard re-treatment regimen with essential anti-tuberculosis drugs.
MDR-TB: A patient who has active tuberculosis with bacilli resistant at least to both rifampicin and isoniazid.
Chronic cases and MDR-TB cases are noy synonymous. MDR-TB can rarely be observed in new cases; it is mosre frequent in re-treatment cases, expecially in faliure cases. MDR-TB is one of the main cuases of faliure to a Category 1 (see above) treatment regimen in patients treated under strict observation.
Chronic patients probably have MDR-TB because they have proviously received at least two full course of treatment with essential antituberculosis drugs. The aim of treatment of chronic and MDR-TB cases are similar to those of all cases with TB. However, MDR-TB patients respond poorly to short-course chemotherapy and need to be treated intensively and for up to 24 months with a regimen based on reserve antituberculosis drugs.
Multi-drug resistant TB is a major cause of a faliure for the individual pateints concerned. Management of chronic cases becomes an objective for an NTP when the DOTS strategy is fully implemented. Full implementation of DOTS is the best prevention against chronic disease and extension of MDR-TB.".
MANAGERIAL PRINCIPLES:
"The main priority for TB control is the identification and cure of sputum smear-positive pulmonary TB cases. The decision to use regimens incorporating reserve antituberculosis drugs shoudl based on:
-The availability of financial resources for reserved drugs;
- The capacity of the NTP to maintain patients on regular treatment;
- Laboratories that can perfrom high quality drug susceptibility testing;
- Prevention of uncontrolled use of reserve drugs;
- Special registration of chronic and MDR-TB cases and expert commitees for decisions on treatment and monitoring;
- Special cohort analysis.".
"Without an effective organizational framework, such as the one suggested in the DOTS strategy and without knowledge of the operational requirements of treatment with reserve regimens, the chances of success will be minimal.
Treatment of chronic and MDR-TB cases with reserve drugs is more expensive and more toxic than treatment with essential drugs. Many programmes will therefore choose hospitalization, at least for the initial portion of therapy. However, hospitalization entails increased risk of nosocomial transmission of MDR-TB to both staff and patients, especially those infected with HIV. After tolerance of the drug regiemn has been ascertained and the patient's cooperation has been secured, the patient can be started on ambulatory treatment. Programmes with strong hom-based care cnetres may choose to have ambulatory treatment from the outset. Ambulatory treatment reduces the risk of MDR-TB transmission in hospitals, which often lack adequate infection control capacity.
Management of chronic and MDR-TB cases with reserve drugs can be done in different ways. If standardized regimens are used, feasibility of their administration under the aegis of the NTP is conditional on a strong NTP that is successfully applying the DOTS strategy. Advantages of standard regimens include potential reduction of costs compared with invidualized regimens, reduction of errors in prescrription, easier estimation of drug needs, purchasing, distribution, and monitoring, facilitation of staff training, and facilitation of a regular drug supply when patients move from one area to another.
Centres of excellence, to which patients are referred for treatment, could utilize individualized regimens tailored to the drug suscepibility pattern of the patient. Referral to such facilities may also be the best option for patients whose cooperation is not easy to chieve, such as individuals suffering alcoholism or drug dependance, prisoners, and homeless persons. Special efforts are needed to persuade such patients to somplete the long and arduous treatment regimens required. The advantages of individualized regimens include treatment according to the susceptibility pattern and, probably, higher cure rates. This approach may, however, be more costly than standardized regimens in terms of tthe drugs involved, n laboratory capability and in the training required to administer a variety of treatment regimens.
Use of standardized or individualized treatment regimens is currently the subject of operations studies to assess the feasibility and cost-effectiveness of using drugs under aegis the NTP in resource-limited countries. Evidence from Peru shows that the use of standardized regimens at the country level may be feasible and cost-effective.".
The treatment regimen should include at least 4 drugs , including an injectable agent and fluoroquine in the initial phase, and at least 3 of the most active and best-tolerated drugs in the continuation phase. And initial phse of at least 6 months should be followed by a continuation phase of 12-18 months.
While drug susceptibility testing may not be available in some resource-limited settings, all efforts shoudl be made to obtain an accurate essentail drug susceptibility testing profile of pateints failing short-course chemotherapy and of chronic disease in order to confirm the presence of MDR-TB. Programmes planning to implement the use of reserve drugs in a standardized regimen but unable to perform susceptibility testing should set up relationshops with suprnational laboratories until such facilities can be established locally.
Standradized regimens are the choice in settings where susceptibility testing of reserve drugs is not available. However, drug susceptibility testing is recommended in patients who fail the standardized regimen and, when possible, these cases should be referred to specialized centres for individualized treatment.
Use of regimens tailored to the susceptibility pattern of reserve drugs requires highly specialized laboratory and microbiological follow-up facilites that are not yet available in most resource-limited countries.".
"The management of chronic and MDR-TB cases require operational organization that allows integration with the NTP. An expert commitee of TB specialists, public health specialists and laboratory specialists should be appointed to screen requests from general health facilites for access to treatment with reserve drugs. The commitee could be national, or several regional commiteess can be constituted. This is very important, since cental level NTP staff do not usually have time to be looking into these issues - their most important priority is the management of new cases to prevent the development of chronic and MDR-TB.
A register of the chronic cases and MDR-TB identified should be created, for follow-up and treatment outcome and the end of treatment.
Some countries have created a special unit under the aegis of the NTP to coordinate meetins of the special commitee, for data management and analysis, to solve problems, to oversea delivery of reserve drugs and for other operational activites. This unit is an appendage of the NTP. The minimum persoanl requirements are a project coordinator (who respnds to the NTP manager), a nurse, a medical coordinator and a data manager.
Coordination with the laboratory is vital. Usually only one reference laboratory capable of susceptibility testing of essential drugs (to confirm MDR) is available. It is therefore important that the reference laboratory works in close coodination with the special unit.".
"A standardized re-treatment regimen should include at least 4 drugs never used by the patient, including an injectible (capreomycin, amikacin or kanamycin) and a fluoroquinolone. Treatment should be given daily and directly observed. Bacteriologoical results (smear and, if possible culute) should be monitored. Pyrazinamide and ethambutol can included in the regimen because of the lower probability or resistnace than to other essential drugs. However, in chronic cases that have received multpile treatments, using ethambutol and pyraziniamide, it is doubtful whether these drugs remain active, and including them may offer little advantage. And initial phase of at least 6 months should be followed by a continuation pahse of 12-18 months with at lest 3 of the most active and best tolerated drugs.
"If the results of susceptibility test for essentail and reserve drugs are available and the full range of reserve drugs is available, the treatment regimen may be tailored according the susceptibility pattern. Designing a regimen will depend on several factors, such as the drugs to which the strain of M. tuberculosis is resistant. The same principles - at least 4 drugs never used, including an injectable and fluroroquinilone, and an initial pahse of at least 6 months followed by a continuation phase of 12-18 months - apply.
Treatment regimens with reserve antituberculosis drugs remain much more expensive than regimens with essentail antituberculosis drugs. In countries with limited financial resources, health facilites and staff, the provision of regimens with reserve drugs may be an acceptible drains on resrouces. It would irrational for any country to divert resources to regimens with reserve drugs is a large proportion of new infectious cases remain untreated or ineffectively treated and short-course chemotherapy with drugs has not reached its full therapeutic potential. (italics mine) A large requirement for resrve drugs reflects porr-quliaty implmentation of short-course treatment.
Furthermore, since there is poor toleranace to some other reserved drugs and their efficacy is limited, the best strategy to prevent chronic cases (and MDR-TB) is through full implementation of the DOTS strategy and standardized short-course regimens Category I and II.
Access to spcially priced, quality assured reserve drugs can be possible through the Green Light Commitee (GLC). In addition the GLC offers technical assistance a regular monitoring mechanism for projects. Programmes considering the use of reserve drugs should strongly conside using the GLC mechanism to help ensure that all parameters are in place to guarantee successful outcomes.".
Now, the reason I wrote all this down was to provide at least some sense of just how serious MDR-TB actaully is, and just how complicated tuberculosis treatment becomes when the stantdard treatment for Phases I-IV fails to work and the bacillus begins to becoe drug resistant. Son one imagine just how difficult it would be in so-called 'resource-limited', with prgrams which are already struggling to achieve the basics in primary care.".
So, just to sum up:
"MDR-TB describes strains of tuberculosis that are resistant to at least the two first line drugs - isoniazid and rifampicin. XDR-TB, or Extensive Drug Resistant TB (also referred to as Extreme Drug Resistance) is MDR-TB that is also resistant to three or more of the six classes of second-line drugs, as well.">
And remember, in many of these case the patient is also suffering from HIV.
From this Plos article by Jerome Amir Sing, Ross Upshur and Nesri Padayatchi entitled 'XDR in South Africa: No Time for Denial or Complacency' :
"On September 1, 2006 the World Health Organization (WHO) announced that a deadly new strain of extensively drug-resistant tuberculosis (XDR-TB) had been detected in Tugela Ferry, a rural town in the South African province of KwaZulu-Natal (KZN), the epicentre of South Africa's HIV/AIDS epidemic. Of the 544 patients studied in the area in 2005, 221 had multi-drug resistant tuberculosis (MDR-TB) that is, mycobacterium tuberculosis that is resistant to at least rifampicin and isoniazid. O fthese 221 cases, 53 were identified as XDR-TB i.e. MDR-TB pluse resistance to at least 3 of the 6 classess of second-line agents. This reportedly represents almost one sixth of all known XDR-TB cases reported world-wide. Of the 53, 44 were tested for HIV and all were HIV infected.".
Thus XDR-TB is "now considered endemic to KZN; with 30 new cases reported each month.".
"(D)iagnosed cases of XDR-TB likely represent a small proportion of the true extent of the problem.
"WHO urged a response to the outbreak akin to the recent global efforts to control SARS and Bird Flu.".
Is XDR-TB then just the latest evidence of the inadequate response of the 'global community' to the global tuberculosis crisis? Well despite the the fact that TB has been and was declared a global health emergency in 1993, there are those who are asserting just that.
"Mario Raviglione, Director of StopTB at the WHO, said the local, national and international response to the spread of XDR tuberculosis was too little too late. 'This is an absolute emergency', he told The Lancet. "It is the most urgent thing I have seen in my 15 years of working in tuberculosis: a highly resistant strain that is now killing HIV-positive people and is spreading very rapidly ... Nobody is moving fast enough.'. an appeal for $US 95 million made last October in Paris has met little response, he said.".
"In fact (the Plos article again), "it could be said that the emergence of MDR-TB itself is evidence of the systemic failiure of the Global Community to tackle a curable disease.".
Tuberculois, is 'recognized as a disease that preys upon social disadvantage', and what we are talking about here in another step along the road to 'nightmare scenario' that many have feared - namely a virtually untreatable TB, a global health disaster of unimaginable consequences and implications. And this is certainly what we were alludingg to in our initial essay when we discussed how a failiure to deal with such public health issues on a justice/moral/humanitarian level can inevitably push them towards becoming a public security issue. And this is indeed what is happening with regards to XDR-TB and the tough measures that are now being considered. And it is certainly the issue that has underlined the whole response to the Andrew Speaker story.
Again, the Plos article:
"Is there a role for involuntary detention?
"The successful containment of TB, MDR-TB, and XDR-TB in South Africa carries human rights and ethical implications. And important question that we must come to terms with is the extent to which judicially sanctioned restrictuve measures should be employed to control what could develop into a lethal global pandemic.
"Current WHO guidelines recognize that this strategy is not feasible in resource-constrained environments. WHO recommends that persons with MDR-TB voluntarily refrain from mixing with the general public and from those susceptible to infection, while they are infectious and in ambulatroy care. The document is silent on what steps to take should voluntary measures fail.
"The failiure rests upon us all. We should begin to contemplate the response when we move to the predictable next: completely drug resisitant tuberculosis.".
Wel.. Let the contemplation begin.
And let me take this moment to emphasize the words 'resource deprived enivronments' as a note for many future posts where we will attempt to break down the complete story with regards to the resources available to fight tuberculosis 'versus' the resources deemed necessary.
And for those interested (like myself) who may not know what tuberculosis is , and how it is treated and thus what MDR-TB, and XDR-TB are - a good primer might be the Wikipedia version, or one could consult the WHO fact sheet on tuberculosis.
FURTHERMORE:
The great Stephanie Nolen breaks down the storyof Tony Moll the South African doctor who first discovered the problem of XDR-TB in 'the rural town in the low hills of KwZulu-Natal province. 'A problem that some public health experts say may be the worst threat to humanity in the past half-century.'. But it will cost you $4.95. Canadian.
AND FURTHER STILL:
This just in: the WHO has now released its Global MDR-TB and XDR-TB
response Plan. Here is the Press Release. And here is The Plan . And here is The Fact Sheet for The Plan. I haven't had time to read these yet. But I will be definitely getting to them in the near future.
This post marks the beginning of what we here at Global Health Nexus hope will be our extensive Tuberculosis Coverage. So however we do it, considering that we are now about three months past World TB day (March 24), we best get started.
Now initially I was planning to begin the journey of our coverage through a trio of stories, all of them illustrative in their own particular way of the issue of tuberculosis in our time. One quite scary, one historical, one hopeful.
First was the emergence last year of identifiable XDR-TB, an 'emergence' which continues to this day. Second is that this year marks the 125th anniversary of the discovery of the mycobacterium tuberculosis by the great Robert Koch. And the third would be the recent announcement by the WHO that "the tuberculosis epidemic has leveled off for the first time since the WHO declared a TB a public health emergency in 1993.".
But then, as I was planning all this, along came the bizzare, almost surreal case of Andrew Speaker, and all of a sudden tuberculosis, and in particular XDR-TB (extensively drug resistant tuberculosis) was everywhere, media-wise; all over the news.
Now, I have been in the planning and researching phase of a documentary about international tuberculosis control, off and on for over four years now (don't ask. And thusly, I have thought long and hard about TB imagery with all its baggage and meaning and stigma; and the best, and even what would be best - i.e. the 'proper' way to accurately cinematically portray tuberculosis in its contemporary context. And I had been well aware of the development, and certainly the potential development of XDR-TB, for some time. But even in light of all that I have to admit that when this Andrew Speaker story first broke, I avoided it like the plague (forgive me, I'm weak). I'm not sure why, I just did. I did follow it somewhat peripherally, but I didn't read the stories very carefully, and I certainly avoided it on the old TV. Perhaps its part of larger avoidance thing that I have going in my life, perhaps its because I knew that it would impact upon what I am trying to do here. As I said, I'm just not sure. But alas, I have face it now, and admit that not only is this Speaker thing unavoidable, it may even be an opportunity.
An opportunity you say? Why not.
I think we can take this Speaker Story as an opportunity to engage in some deconstruction (already, always) of not only this story itself, but of the way the mainstream media, in particular the mainstream, corporate American television media, (the popular agenda-setting mind of not only America, but so much of the world) not only deals, and has dealt with this story, but of the way, given its profound limitations, it handles, or more specifically (as with so many other stories) ignores, the larger issue of international tuberculosis control, and why.
So now, for our collective consideration, I would ask you to ponder and view the following references as a kind of rough architecture for a template through which we will try to comprehend this whole Andrew Speaker story:
First, there is this quote (once again) from Richard Appignansesi's and Chris Garrets's< ahref="http://tesugen.com/archives/05/03/pomo-for-beginners-2">Postmodernism for Beginners:
The crux of postmodernity is that there are 'two presents. One is a 'spectre' present, a Virtual Reality techno-media simulacram that makes the other 'real' present appear borderline, fugitive, elusive.
A de-materialization of the real is haunting us, making our opposition to it ineffectual. A typicle example of this is the Western world's media representation of a disaster - the relief of the mass famine in Ethiopia is stage-managed as a rock concert charity event. Tragedy is a momentary virtuality not 'really' permissable in postmodernity.
We know (or at least - it is asserted) from Susan Sontag, in her famous book Illness as Metaphor that we have a tendency as - what? A Culture?, People? - to think that Illness can (in fact) be a Metaphor; a representation, a symbol for something other than just itself. As she writes:
"Nothing is more punitive than to give a disease meaning - that meaning being invariably a moralistic one. Any important disease whose casualty is murky, and for which treatment is ineffectual, tends to be awash in significance.". ... "Epidemic diseases were a common figure for social disorder.".
And we know from Neil Postman that we are in fact Amusing Ourselves to Death - i.e. that we live in age where we get most of our information through television, which means, implicitly, that we can only think, popularly, publicly about things, stories, issues, the way television thinks about them; (The Media as Epistimology, the epistimology of television. Postman: "We do not see nature or intelligence or human motivation or ideology as 'it' is but only as our languages are. And our languages are our media. Our media are our metaphors. Our metaphors create the content of our culture.". And "Form excludes content").
However, I also think that the both of the last two references need to be be qualified:
Firstly, with regards to Postman, I think that an argument can be made concerning his views about television. Though television is indeed the most powerful and popular medium going, isn't it in fact, in and of itself, relatively neutral? That is to say - it is what is done with it no? At its best Television can be incredibly informative and even thrilling, at its worst it can feel like your precious short time on this earth is dripping away into an abyss of asinine, meaningless sludge, complete with a laughtrack. One thing we know for sure is that television must somehow be paid for. And though there are many Postmanian elements to consider when critically examining television, and certainly television news, I would submit that much of his argument has to do with the dominant corporate model imposed upon television in order to finance it, and profit from it, maybe even more than it is a criticism of just the medium itself. But I may be wrong.
Remember one of the basic arguments put forth in both the film and book < ahref="http://www.thecorporation.com/index.cfm">The Corporation:
"The corporation's legally defined mandate is to pursue relentlessly and without exception its won economic self-interest, regardless of the harrmful consequences to others.".
Its a very large question. And nothing is forcing you to watch. You can always turn it off. And at least now we have the Internet.
And secondly, with regards to Sontag, the pervasive 'metaphor' of and for tuberculosis which she describes in her book is of TB as represented primarily in books and opera from the nineteenth century, and even before. Romantic. Nihilistic. Doomed. . She writes:
"TB was a disease in the service of a romantic view of the world." ... "TB was represented as the spiritualizing of conciousness ..."However much the disease was dreaded, TB always had pathos(italics mine) . Like the mental patient today, the tubercular was considered quintessentially vulnerable, and full of self-destructive whims. Nineteenth, and early-twentieth-century physicians addressed themselves to coaxing their tubercular patients back to health.".
Ah, (sigh) Pucini's La Boheme:
But what happens when the 'treatment' for said disease - tuberculosis - is in fact - 'effectual', as opposed to 'non'. Would 'we' be remiss if we were perhaps to read some significance into it then? All Sontag's examples and allusions, are essentially, pre-bacillus. She doesn't tuberculosis in the Post-Kochian age.
The great Robert Koch discovered the tubercle bacillus - the cause of the disease tuberculosis - in 1882, and then evolving out of the discovery of several antibiotics by Selman Waksman (he coined the term) - came the discovery of the first drug, the first successful drug - Streptomycin ( 'first isolated by Albert Schatz) - 'the first anitbiotic remedy', 'the first cure', for tuberculosis.
So the drugs which can treat and cure tuberculosis have been around since basically the early fifties, and yet, as the WHO points out, (and which we will continue to repeat often) two billion people - one third of the world's total population- are infected with TB bacilli, and one in every ten of those people will develop active TB in their lifetime. And in 2005, approximately 1.6 million people died of tuberculosis. 1.6 million people then - overwhelmingly poor, from overwhelmingly poor countries - dead from a curable disease. Do they die because the drugs don't work? Well, in the cases of MDR-TB and XDR-TB they may, but for the most part they die because they don't have access to the drugs, or because the systems are not in place to provide them with these drugs. (Though much is afoot to remedy this, as we have talked about in our earlier discussions about The Global Health Movement') And to treat tuberculosis you have to treat the people who have tuberculosis. And obviously, its incredibly complicated and incredibly difficult.
So in the face of all that one could make that argument that tuberculosis does become - in addition to being a moral imperative - a symbol, or symbolic of something. A metaphor for - what? Global inequality and an international inequality of health outcomes. Basically. System failure. System absence. Even moral failure. If this puts me in jeopardy of 'romantically' projecting a kind of 'social disorder on to a epidemic disease', as Sontag would say, in order to assert a political opinion than so be it. It is certainly a romance that I am prepared to live with.
But irregardless, this then, is the story. In all its depth of complexity concerning questions of politics, history, economics, class, global inequality, biology, medicine, epidemiology, sociology, race and even gender. 1.6 million people! But do the major networks cover it? No that I'm aware of. Is it because they are bad, ignorant people? Well I guess that's an open question - but I would submit that they don't cover it because they wouldn't be allowed to cover it. If they tried to cover it they would probably be fired. The system that they work for can't cover it - is incapable of covering it! They're Corporate. And the subject is basically Tragic.And tragedy just isn't profitable, thus impossible, unless approached through a narrative of redemption. Then it might be possible. When was the last time anyone watched Network News? Why, with every thing going on in the world, and with all their reach and resources, is that system incapable of ignoring:
Because they have no choice. They're Corporate. Its the cheapest, most efficient and undeniable way to maximize their quarterly profits which is their entire reason for being, and to which they are legally bound. And everybody else is doing it. They are a business first and foremost. Am I being completely cynical if I speculate that the fate of entire multi-billion dollar corporate media entities, and the careers of the people who run them, ultimately rest upon the weekend plans of maybe four, five young women in the United States. All of them white, and all of them very rich. (Paris, Lindsay, Britney and the Olsen Twins. Okay. Maybe Brad and Anjelina. Princes William and Harry. The late Anna Nicole Smith. Tom and Katie. And maybe O.J. Simpson. And maybe, perhaps even Osama bin Laden.) Probably. Okay, so I'm losing the script here a little bit. (though I don't think I am too far off) But you get my meaning. I think its that bad. And so thats why like my health care, as I prefer my broadcast news - public. (Incidentally, much thanks to the good people at CelebrityNews.com for their generous donation of that incredibly exclusive video. Anything for the cause.)
Fortunately , we here at Global Health Nexus don't have that problem. (Although, apparently, judging by what has just occurred, we still may.) But we will cop to an abiding interest, bordering on an obsession, as to when, why and how the larger, complex political tragedy of the world enters into the neurotic corporate controlled media of the West. How the Second Present, enters into and impacts upon The First Present. It is a theme to which I am sure we will return.
(**And just as an aside: Though not specifically about this, but still about the effects of this system, anyone interested in watching a great film about how 'Corporations' unknowingly and almost unconsciously ultimately 'killed' the music industry could and should take the opportunity to watch the great PBS Frontline documentary The Way the Music Died**)
I have digressed. (It happens) But it does brings us full circle back to the story of Andrew Speaker.
For those few of you who don't know the story I'll do my best. Andrew Speaker is an Atlanta attorney who knew that he had tuberculosis which he apparently picked up in Viet Nam, while he was doing some kind of charity work over there or something or other. What Mr. Speaker did not know, he says, was that he was ill with XDR-TB and that he was 'sputum positive' and was indeed infectious. ('sputum positive' means that the bacilli in his system would be visible in a sample of his sputum when viewed under a microscope, and it would also mean that he was in fact 'infectious' to other people around him. TB being an airborn virus.) Mr. Speaker was in fact in dialogue with officials with at the Center for Disease Control and Prevention about this very subject, and he insists that they told him that they were legally bound to tell him that he may be infectious, but that they privately assured him that he was not infectious and that it would be okay for him to go celebrate his wedding in Greece. This seems to be the central point. And to back it up Mr. Speaker's father and legal partner in fact, actuallytaped these very conversations. (Tapes that he has now played before a Congressional Commitee in order to prove their point, and obviously, as ammunition in the inevitable lawsuits to come.) So with this knowledge Mr. Speaker left with his fiance Sarah and family over to the Greek Isles for their wedding, only to learn later on when they were in Rome, through another conversation with the same officials at the CDC, that not only was he in fact infectious, but that he was in fact infectious with XDR-TB. CDC officials claiming that they got the official results of all his tests back, only while he was away in Rome. So Mr. Speaker and his new wife found themselves in Rome, and the only place that could save his life was apparently back in Denver. And so in a panic, he and his wife flew back to Montreal and then rented a car and drove over the border and down to Denver. A customs official at the American/Canadian border apparently knowing and seeing that Mr. Speaker was on some kind of HEALTHWATCH LIST or something, let them through anyway. And anyone who came into contact with Mr. Speaker at this time - including all his fellow passengers on that enclosed airspace of the plane - could now also be at risk. And then the story broke.
Now I have no intention of casting any more opprobrious language in Mr. Speaker's direction than has already been cast. But I think obviously, he could have done everybody a favour and not flown over to Europe for his wedding. Until he knew for sure he could and should have just had his wedding in Denver; in the hospital even. He and his father (whose legal firm's website - The Speaker Law Firm - has as its motto, amazingly: 'Experience You Can Depend on') were obviously concerned enough about his health status as to actually tape their conversations with the CDC, so thus I find it hard to believe that they were totally oblivious to the gravity of his health situation. They could have thought beyond merely - 'are we covered here?' And furthermore it has now come to light that Mr. Speaker's Father-in-Law is a PHD and researcher in, what else?, tuberculosis at the CDC itself. So, granted, it is all pretty bizarre.
Perhaps my long, discursive point here is nothing other than to be amazed at the small twists of fate where an incredibly complex story (XDR-TB) with all its implications, which tells us so much about the state of the world we live in, a story that would not otherwise be covered by the major networks - is suddenly catapulted on to and into the embrace of those same networks in terms and definitions that were perfectly suited to their incredibly limited parameters of discourse: Mr. Speaker, white, American, lawyer, Southerner and his incredibly attractive blonde wife Sarah, suddenly sitting across from Diane Sawyer on Good Morning America while Diane does all that she can to milk the situation of all its potential weepy emotion, and cheap lazy moralizing while never once going beyond it to give at least a little bit of context. XDR-TB as an episode of Dr. Phil. Its actually quite amazing. Stunning even. But now, thanks to the glories of Youtube, you can watch it for yourself:
I guess my favourite quotes have to be the referring to Andrew Speaker as - 'Patient Zero', or 'The Man Behind The Mask' . The way Diane professes to wanting to get to 'his anger and his fears'. Mr Speaker himself talking about living in 'constant fear and anxiety' And that 'he wouldn't want anyone else to feel that way. Its awful.'. Indeed it is , and indeed it must be. When the subject arises about whether or not Mr. Speaker could have chartered a private plane to bring him back from Rome, Diane states that yes it would have cost a hundred thousand dollars and 'a hundred thousand dollars is a lot of money, but not impossible.'; a statement to which Mr Speaker stays silent. And then there is a heart-rendering interview with Mr. Speaker's wife Sarah - 'in sickness and in health', hasn't been able to kiss him etc. Amazingly it seems that they both have been reading blogs (help me) where they are constantly referred to as 'terrorists'. 'We are not terrorists', Mr Speaker says. We learn that that there are presently 14 000 people registered in the United States as having active tuberculosis.
Two other telling points I think emerge from this interview: The first has to do with the fact that when the Speakers were in Rome and they finally got the news that Mr. Speaker was infectious with XDR-TB, how they felt, as Americans, that their government had abandoned them - and thus that their government had some responsibility in helping them: 'Your government is just going to leave you there, and you are going to die?'. 'At least send a military plane or something.'. And the second point is the deeply ironic one about how much all of this Speaker business revolves around choice - choices he could have made, choices that he did make. choices the CDC made. Choice, agency, going to the essence of so many issues surrounding tuberculosis, since for the overwhelming majority of those who are actually ill - they basically have no choice. No choice in where they live, and certainly no choice with regards to health care.
"There is so much more to this than I would imagined before seeing this", says Diane's very cute Good Morning America co-host whom I have no idea what his name is.
Well, indeed there is Mr. Co-Host, and in the spirit of that statement we here at Global Health Nexus intend to stay on this story and give it as much depth as we can in the weeks and months ahead, for we indeed do think its quite important.
And we do genuinely wish the Speakers all the best. We don't think they're terrorists.
And now to finish off this little post/film festival, for your consideration:
And here is one last Youtube video . One that at least touchest on the fuller, more complex international story of emerging XDR-TB:
Oh my! Stop the presses!
UPDATE:New Diagnosis! Turns out that Andrew Speaker was misdiagnosed. Turns out, that he doesn't have XDR-TB at all, but MDR-TB. In a statement "Speaker says that he is "incredibly relieved that tests that show he doesn't have XDR-TB. He noted that his understanding is that he does not have - and has has never had - XDR-TB. Speaker also indicated that today's news doesn't change the attention tuberculosis has recently gotten in the media, given that tuberculosis is a serious global health problem." Hear hear Andrew. And good luck.
Or not so good. Turns out that a bunch of Canadian passengers on that same flight to Montreal are now going to sue him for US 1.3 million, collectively. From a legal standpoint then, good thing he flew to Canada, for only a bunch of Canadians, when given an opportunity like this would sue for a measly 1.3. Now word yet from Speaker whether or not he is going to CDC. Stay tuned.
FURTHER UPDATE: Andrew Speaker is < ahref="http://www.webmd.com/news/20070726/andrew-speaker-released-from-hospital">released from the hospital!:
July 26, 2007 -- Tuberculosis patient Andrew Speaker took an air ambulance back to Georgia today after being discharged at 6 a.m. today from a Denver hospital.
Speaker, an Atlanta lawyer, got eight weeks of treatment for multidrug-resistant tuberculosis (MDR TB) at Denver's National Jewish Medical and Research Center. On July 17, Speaker had lung surgery to remove a tennis-ball sized piece of his lung that was infected by tuberculosis.
"Treatment for Mr. Speaker went very well, and we were able to release him more quickly than we originally anticipated," says Gwen Huitt, MD, in a National Jewish Medical and Research Center news release.
Speaker's TB treatment isn't over yet. He'll keep taking antibiotics for two years, though his TB is no longer detectable and isn't contagious.
"Although we believe there are still a few tuberculosis bacteria in his lungs, ongoing antibiotic therapy should kill those. We expect him to return to a full and active life," says Huitt, who directs the Adult Infectious Disease Care Center at National Jewish Medical and Research Center.
