by Fran Blandy,
Cape Town, 24 Mar 2009 - Hospitalising patients suffering from Multiple Drug Resistant (MDR) and Extremely Drug Resistant (XDR) TB in order to isolate them from their crowded communities has often proved disastrous in South Africa.
Bored, depressed and ravaged by the treatment, which causes daily nausea and leaves 20 percent deaf, patients escape from the hospitals and abandon treatment, which encourages drug-resistance in the disease.
Floating above the top of the white mask stretching across her face, Lydia Pinzie's dark brown eyes are spirited and alert, despite nearly three years on toxic tuberculosis treatment.
Some white, some grubby, some askew, some comically large over the faces of toddlers; the sea of masks in the waiting room at a South African TB clinic harbour an often deadly drug resistant form of the virus.
SITEKI, 24 March 2009 (PLUSNEWS) - Kwanele Dlamini's motorbike can carry him to most rural homesteads in the eastern Lubombo Region of Swaziland, but he has to get off and walk the final rocky stretch to Solomon Ndwandwe's property and then duck a barbed-wire fence.
Ndwandwe, 58, approaches with slow, careful steps from a small plot of sweet potatoes, planted when he still had the strength for such things, and the two men seat themselves on the step in front of the house.
Dlamini is one of two tuberculosis (TB) medication adherence officers working on motorcycles out of the Good Shepherd Hospital in Siteki, the region's main referral facility. He is here to find out why Ndwandwe missed his last appointment at the hospital and what he can do to help him restart his treatment.
SITEKI, 25 March 2009 (PLUSNEWS) - Siphiwe*, 14, has not been to school for two years but can still fit into her uniform. She has a strain of tuberculosis (TB) that is resistant to most first-line drugs and can take two years or more to treat, but she stopped taking her medication four months ago.
She is reluctant to give a reason, saying only that the tablets were "becoming bitter", but there are a number of possible explanations. She had already endured six months of walking to her local clinic in Siteki in Swaziland's eastern Lubombo Region to receive painful daily injections, and was swallowing 11 pills a day, including antiretroviral (ARV) drugs to control her HIV infection.
TB patients who are resistant to two or more first-line drugs are managed by Swaziland's National TB Programme in Manzini, about 60 kilometres away, which meant that Siphiwe and her aunt, who is also her caregiver, had to beg and borrow money from neighbours to have bus fare for her monthly appointments.
There was also the daily struggle to find food to take with her pills, and the three-kilometre walk to collect water. Her aunt is blind, so these tasks fell to Siphiwe, despite her obvious difficulty in breathing and persistent cough.
"I tried talking to her about taking her pills," said her aunt, "but sometimes she was taking them without food and it made her sick."
by Gillian Wong,
Beijing, 30 Mar 2009 - The Beijing Chest Hospital was packed with people on a recent weekday morning. In the waiting area, Wang Chong, a migrant worker who has been fighting tuberculosis for several months, was facing a dilemma: Does he continue treatment that has already cost him more than $5,000 or stop before his savings are wiped out?
It's not only his health at stake. If Wang stops treatment prematurely, his tuberculosis is likely to morph into one of the new, hardier strains that resist the drugs he has been using and that pose a growing threat to global public health. Countries as diverse as China, Russia and South Africa are vulnerable, and the new strains have also appeared in the United States.
DURBAN, 1 April 2009 (PLUSNEWS) - Several years ago, the World Health Organization (WHO) identified the three most important ways of reducing the risk of tuberculosis (TB) in people living with HIV, who are highly susceptible to the airborne disease.
The strategy, called the "3 I's", includes "Improving TB infection control", "Intensifying efforts to diagnose TB cases", and "Isoniazid for six months" - giving HIV-infected patients six months of Isoniazid, a first-line TB drug, as a preventive therapy.
The approach was widely recognized as effective and feasible, and incorporated into a number of national TB policies, yet TB - the most common and life-threatening opportunistic infection in people living with HIV - claimed the lives of an estimated 230,000 HIV-positive people in 2008, according to WHO.
by Editorial, The Lancet
UK, 03 Apr 2009 - Tuberculosis is a preventable and treatable disease that thrives amid poverty and weak health systems. For these reasons, the shortcomings and challenges in WHO's 13th annual report Global Tuberculosis Control 2009, released on March 24, make sombre reading.
Tuberculosis incidence has declined since 2004, but only by less than 1% per year. Case detection is stagnant. Despite progress in several regions, the Stop TB Partnership target of a 50% reduction in 1990 prevalence and mortality by 2015 will not be met. More worrying is the synergy of tuberculosis and HIV/AIDS co-infection in sub-Saharan Africa, and the growth of multidrug-resistant tuberculosis (MDR-TB) and extensively drug-resistant strains (XDR-TB) in eastern Europe: two factors that complicate treatment and threaten to increase fatality rates.
by Becky Debens,
SCRIP World Pharmaceutical News
UK, 08 Apr 2009 - Drug-resistant tuberculosis is a "time-bomb" waiting to explode into a global epidemic, World Health Organization director-general Dr Margaret Chan warned last week.
Speaking at the WHO's ministerial meeting for high TB burden countries in Beijing, China, on preventing the spread of multi- and extensively drug-resistant TB (M/XDR-TB), Dr Chan said the "potentially explosive situation" meant new plans of action were urgently required in TB-endemic countries.
The meeting, attended by ministers and representatives from 27 high-burden countries, including China, Ethiopia, India, Nigeria, Russia, Pakistan, South Africa and Ukraine, discussed the threat of drug-resistant TB and studied actions to prevent and manage the disease.
by Katie McQue,
SCRIP World Pharmaceutical News
UK, 20 Apr 2009 - Multiple drug-resistant tuberculosis is rife in the former Soviet Union and parts of Southeast Asia, and efforts to fight resistance are inadequate, a study partly funded by Lilly of the worldwide prevalence of drug-resistant tuberculosis has revealed.
The report, published online in The Lancet on April 16th, found the highest resistant rate in Azerbaijan, with 22.3% of new treatment-naïve TB cases classified as multiple drug resistant (MDR).
Moldovia's MDR rates were the second highest, at 19.4%, followed by Ukraine, with a rate of 16%. Countries in the Americas, western and central Europe and Africa reported the lowest prevalence of MDR TB.
The epidemiology survey was conducted by the World Health Organisation's Global Project on Anti-tuberculosis Resistance, which gathered data from more than 90,000 patients in 83 countries between 2002 and 2007. Where possible, data for HIV status and resistance to second line drugs were also obtained.
"The countries of the former Soviet Union are facing a serious and widespread epidemic with the highest prevalence of MDR tuberculosis ever reported in 13 years of data collection. Almost half of all tuberculosis cases in countries of the former Soviet Union are resistant to at least one drug and one in five cases are MDR," said study author Dr Abigail Wright of the WHO. "In this region, MDR-tuberculosis cases have more extensive resistance patterns and the highest rate of XDR (extensively drug-resistant) tuberculosis."
The study called for anti-tuberculosis efforts to be accelerated and backed by strong political commitment in order to quash the growing epidemic.
"Outliers were identified in all regions, suggesting a prevalence of MDR tuberculosis is linked to the performance of national tuberculosis control programmes," added Dr Wright.
In 2000, the WHO implemented a directly observed therapy short course (DOTS); however, a WHO study published shortly after found that the strategy would not control multiple drug resistance in countries with widespread resistance.
DOTS consists of the administration of short-course chemotherapy regimens with first-line drugs under direct observation. New cases of TB receive an initial phase of treatment with four drugs (isoniazid, rifampicin, pyrazinamide and streptomycin or ethambutol) for two months under strict direct observation, followed by a continuation phase with rifampicin and isoniazid for four months.
"We know how to prevent the emergence of drug resistance: consistent use of good, basic tuberculosis control. The bad news is that this measure is not being done in affected countries," said Dr Martien Borgdorff, executive director of the KNVC Tuberculosis foundation, in The Lancet's commentary article.
"This drug-resistant epidemic is being tackled with antiquated and inadequate diagnostics, drugs, and vaccines. Fortunately, progress is being made: rapid diagnostic tests are in late stages of development, three drug candidates with new mechanisms of action have recently shown positive results in trials, and six vaccines will be in human trials by the end of the year," Dr Borgdoff continued.
Potential antibiotics in the clinic include Bayer's moxifloxacin, with Phase III results expected next year. The drug is already approved for various skin and respiratory infections.
Tibotec is developing novel adenosome triphosphate (ATP) synthase inhibitor, diarylquinoline (TMC-207), which promisingly displayed bactericidal activity of a similar magnitude to rifampicin and isoniazid in Phase II. The company says an NDA filing is expected by 2010.
The Japanese firm Otsuka also has a Phase II candidate, OPC-67683 – an oral mycolic acid synthesis inhibitor (scripnews.com, December 1st, 2006). The US FDA awarded it orphan status for pulmonary tuberculosis in 2007.
Montreal, 15 Sep 2009 - Tuberculosis is a global threat that affects more than 10 million people each year. Working with colleagues in the United States and France, Dr. Dick Menzies of the Research Institute of the McGill University Health Centre (RI-MUHC) has placed current tuberculosis treatment guidelines under the microscope in a new study. The team's conclusions, published today in two separate articles in the journal PLoS Medicine, recommend that the World Health Organization (WHO) must review and adjust its guidelines for fighting the disease.
"Our first study is a systematic review and meta-analysis of 57 studies, involving more than 20,000 patients from around the world," says Dr. Menzies. "It demonstrates that the treatment period should be extended for people affected by the active form of tuberculosis for the first time. Specifically, the study recommends that these patients should be treated with Rifampin for six months, instead of two months; the additional four months will help maximize the medication's effectiveness."
In the second article, the researchers assess guidelines for patients who have been treated but not cured. "Currently, these patients receive a cocktail of drugs over the course of eight months, which can result in drug resistance and a failure to cure in up to 45 per cent of cases," says Dr. Menzies. "More studies are needed to determine the optimal strategy. However, we believe that it is essential – indeed, of critical importance – to thoroughly review these guidelines."
"Our challenge as researchers is to put into place the most effective strategies for the treatment of tuberculosis, to determine the optimal length for courses of treatment so as to avoid relapse, and to formulate more effective combinations of drugs in order to avoid drug resistance," Dr. Menzies adds. The two studies will allow the WHO to review and update its directives for the treatment of tuberculosis, thereby benefiting the global community.
Dr. Dick Menzies is the Director of Respiratory Medicine at the MUHC and a researcher in the Respiratory Health Axis and Health Outcomes Axis at the Research Institute of the MUHC. He is also a Full Professor in the Departments of Medicine and Epidemiology, Biostatistics & Occupational Health in the Faculty of Medicine of McGill University.
This article was co-authored by Dr. Dick Menzies, Dr. Andrea Benedetti, Dr. Anita Paydar, Dr. Ian Martin and Dr. Madhukar Pai from the RI-MUHC, Dr. Sarah Royce from the University of California at San Francisco, San Francisco, USA, Dr. Andrew Vernon from the Centres for Disease Control and Prevention, Atlanta, USA Dr. Christian Lienhardt from the International Union against Tuberculosis and Lung Diseases and Institut de Recherche pour le Développement, Paris, France and Dr. William Burman, from the Denver Public Health, Denver, Colorado, USA
This study was funded by the World Health Organization (WHO). The Canadian Institutes of Health Research and the Fonds de la recherche en santé du Québec (FRSQ) provided salary support for some authors.
Guangzhou, 06 Jan 2010 - China, saddled with the world's second largest tuberculosis burden after India, is fighting an uphill battle against drug-resistant forms of the disease which will only drain the country's health budget.
Drug-resistant TB, far more expensive to treat, emerges when patients fail to follow treatment regimens and take substandard drugs or stop treatment too early.
Liu Zhongwu, a stonecutter working in southern China, for example, stopped taking his TB medication midway through a standard six-month course in 2007 because it was too costly.
"Even though one or two drugs were free, I had to pay 500 yuan ($73) a month for other drugs (to reduce side effects) and the side effects were bad, I suffered terrible gastric pain and had to stop work, I didn't even have energy to walk," said Liu.
It is precisely this sort of behavior that health experts are trying to stop because if the TB bacteria is not fully eliminated, it can mutate, resurge later and become resistant to the small arsenal of drugs that can fight the disease.
China has 4.5 million TB cases currently; and each year 1.4 million people fall ill with the disease. TB killed 160,000 people in China in 2008, according to the World Health Organization.
TB killed 1.8 million people across the world in 2008, or a person every 20 seconds. It is not only a scourge in poor countries but also in the West, where it has flared anew in the last 20 years because of AIDS, which weakens the immune system.
TB is also a big drain on China's health budget because of a high incidence of people with a drug-resistant strain of the disease, which is a lot harder and more expensive to treat.
In such cases, patients need to take drugs for up to two years and the worst type of TB, for which there is no cure, kills one out of every two patients.
"If there are more drug-resistant cases, the cost of TB treatment will rise by a lot, that's for sure. With drug resistance, we can't use first-line drugs and other drugs cost a lot more," said Lin Yan, director of the China office of the non-profit International Union Against TB and Lung Disease.
"When these patients infect others, the others will get drug-resistant TB. That increases the cost of treating that person and increases the chances of him not recovering."
Regular TB costs 1,000 yuan to treat in China but drug-resistant TB ranges from 100,000 to 300,000 yuan per person, said Zhong Qiu of China's TB Expert Consultative Committee.
China ranks second in the world with 112,000 drug-resistant TB cases in 2007, after India with 131,000. Russia has 43,000 cases, while South Africa has 16,000 and Bangladesh 15,000.
China spent $225 million on tackling TB in 2008, up from $98 million in 2002, according to WHO. These figures do not take into account what patients pay out of their pockets, typically between 47 and 62 percent of their hospital bills.
Drug-resistant TB made up 27.8 percent of all TB cases in China in 2000 versus five percent in advanced countries.
"There are many reasons for China's drug-resistant TB problem. Patients stop taking drugs when they feel better, maybe after a month. Some have no money for drugs if the treatment is not free and they don't even know this is a serious disease," said Lin.
"Some are so afraid of stigma they don't see a doctor, they just buy drugs over the counter."
IGNORANCE, POVERTY, STIGMA
TB affects mostly poor people, who typically live in places where healthcare is not easily accessible. Many patients pay not only for treatment but also transportation, and any chronic, long-term disease can bankrupt entire families.
Li Jiachuen, 45, quickly ran out of money and had to borrow from relatives and friends after he was diagnosed with TB.
"I don't take drugs now. I don't even have money to pay off my 20,000 yuan debt. I spent thousands of yuan on diagnosis and treatment and even more on transportation," Li said.
WHO recommends all TB treatment be free because the disease is a public health threat.
But in China, diagnosis and treatment is only free in specialist TB outpatient clinics. General hospitals, which have been self-financing since the 1990s, impose charges.
"TB is a political problem because it is infectious. It has societal impact, it is a threat to public health ... free treatment is very important," said Zhong, who also heads the Anti-TB Research Institute in China's southern Guangdong province.
The world's only TB vaccine is 100 years old and there has been no new TB drug for more than 40 years. But the resurgence of TB due to AIDS has forced the West back into TB research in the last 20 years and a string of experimental drugs and vaccines are now in the pipeline.
Chinese scientists are working on a new class of TB drugs based on an old drug called clofazimine, used in the past to treat leprosy, said Ann Ginsberg, chief medical officer of the TB Alliance, a US-based non-profit scientific group that pulls together partners to develop new TB drugs.
"They (scientists) found a very promising lead compound and we hope within the next six months ... it will come into formal pre-clinical development and get the formal animal and non human studies that are required to convince the regulators it can go onto people," said Ginsberg.