In-depth: TB and HIV: Deadly allies

GLOBAL: Fatal ‘extensively-resistant’ tuberculosis spreads

Photo: Charles Akena/IRIN
A patient in Uganda shows her daily dose of TB medication (file photo)
DAKAR, 24 March 2009 (IRIN) - Over the past three years, the number of countries reporting cases of extensively drug resistant tuberculosis (XDR-TB)- essentially untreatable in the developing world- has grown by almost 25 percent to reach 55 countries, as of 2009 World TB Day.

The World Health Organization (WHO) estimates about five percent of newly diagnosed cases of tuberculosis (TB) every year is multi-drug resistant (MDR-TB); of these cases, some 60,000 infections are of the fatal, almost impossible to treat variety.

“The news is not good,” said the director of WHO’s “Stop TB Partnership,” Mario Raviglione. “If the world does not move, we are in deep trouble.”

Any type of multi-drug resistance is highly lethal in HIV patients, who are susceptible to developing full-blown TB infections because of their weak immune systems. WHO studies show fatality rates of more than 90 percent in HIV patients infected with XDR-TB.

But the extensive drug resistant strain is deadly for even non-HIV patients. “This form of tuberculosis is resistant to almost all effective anti-TB drugs,” said the WHO tuberculosis director.

TB bacteria usually attack the lungs and spread through the air from one person to another; crowded, economically-destitute areas are fertile places for quick transmission, according to health workers.

Spotty information

Raviglione told IRIN that only about three percent of those infected with XDR-TB – the most extreme form of multi-drug resistance - will receive high-quality, timely care capable of curing the infection. While some medical studies have shown that countries with strong health systems can treat up to 60 percent of XDR-TB infections, Raviglione told IRIN most countries reporting such highly resistant bacteria do not have the human or laboratory resources to provide early, accurate diagnoses.

“Reliable information is limited to developed countries. In Africa we have little grasp [of the extent of XDR-TB infection],” said Raviglione. “The vast majority of affected countries do not have the means to put together proper surveys. These countries may simply not be reporting XDR-TB.”

55 countries with XDR-TB as of March 2009
Only 6 countries in Africa submitted data for latest TB report
9.2 million new cases, 2007
5% of those cases are multi-drug resistant
1.7 million deaths, 2007
Source: WHO
If 60,000 are infected with XDR-TB every year, Raviglione estimates more than 40,000 will not be cured and will continue to spread the highly-resistant bacteria further.

Based on WHO’s 2009 Tuberculosis report, more than half a million new multi-drug resistant cases were reported in 2007. Resistance develops when people improperly follow the required six-month medication treatment, or when they are infected by someone with MDR-TB. India, China and the Russian Federation topped the list of reporting countries for MDR-TB cases in 2007.

One strike

In Burkina Faso, 26-year-old Herman Zombré told IRIN he stopped taking medication one month after his diagnosis in November 2008. “My employer did not want to give me time off [to take daily a dose at health clinic].” To ensure compliance, health centres often require patients take their medication under health worker surveillance.

In March, health staff managed to find Zombré and resume his treatment. Head of the nursing division at the government’s Centre of Tuberculosis Control, Augustin Darankoum, told IRIN health staff try to track down all patients who stop coming. “When Zombré stopped coming, we went to look for him. Before a patient starts treatment, we take down all his information and one of our staff is sent to accompany him home so we can know our patients’ homes.”

Darankoum said it is not medication that turns people away from treatment, but the lack of money for transport for daily medical visits. “To help patients, we help cover fuel costs and phone cards so they can contact us in emergencies.”

But it comes down to daily vigilance, said the nurse. “If we do not see a patient by 11 AM, we call them. And then we look for them,” Darankoum told IRIN. “We cannot leave them out walking around- they will [develop complications] and infect others who will also inherit those complications.”

There are 4,000 people being treated for tuberculosis in Burkina Faso, according to the government.

Two strikes

WHO’s TB director Raviglione told IRIN governments can ill-afford to wait to rein in tuberculosis before it morphs into resistant forms. “We cannot stave off multi-drug resistant TB through national control programmes alone.” WHO’s director said non-existent labs, lack of inspection control and diagnostics, and poor treatment adherence have increased occurrences of multi-drug resistant TB, which require more regional and international cooperation to eliminate.

When asked whether XDR-TB, which accounted for less than one percent of the world’s new tuberculosis cases in 2007, can qualify as a public health danger, Raviglione said there are parts of the world where up to 19 percent of TB cases are classified as extensively-resistant. “It is not too late to react,” he said. “But I will be honest- it is already very late in some places. The situation is not evolving in a favourable way.”

WHO estimates 1.7 million people died from TB infections in 2007, while 9.2 million were newly infected.

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