Drug resistant TB - WHO report documents spread of MDRTB and the even more resistant XDR-TB in Africa and Eastern Europe

The underclasses of Islington are up in arms. The prospect of the Polish peasantry, rag rolling their salons and plastering their privies, the delightful prospect of elbowing the idle Iberians in favour of energetic (and oh so grateful) Estonian au pairs, who combine the muscular rustic virtues of a ruthless and energetic haus frau with faultless English, and Madonna-like qualities of child rearing is slipping from their grasp.

The taxpaying lumpen proletariat, fuelled by the intellectuals of Murdoch's press (Sun, Times) are now alerted to the consequences of extending the excesses of Europe, to the newly free, but still impoverished Eastern Europeans. Not only will this alien wedge steal your jobs as well as your washing, seduce your daughters, slaughter your children driving cars that are untaxed, uninsured and unsafe. Now the drawing rooms of middle England are alive to the prospect that the low paid peasantry will also bring, death, disease and decay.

Third world workers, Third world wages, that's fine, but we don't want your Third world diseases.

Consumption is good. Consumption is bad

Euroland is full of consumer junkies. Retail therapy works, not only for the air head, Jimmy Choo shod, surgically assisted la Perla chested, Harvey Nick chick flashing the plastic. It works for the City. Every time the hemline shoots up, the Sloane slick chick boots up, the GNP ticks up. I make, you consume the coal, the gas, the oil goes down. But, hey the Dow is up!

That's why they used to call Tuberculosis, consumption. It doesn't only consume the body's resources it wastes them, until there are none left.

Tuberculosis, curable but making a comeback.

Tuberculosis (TB) is caused by an infection, Mycobacterium tuberculosis a spore like bacteria that can lie dormant for years. It commonly affects the lung and lymph systems but can affect any part of the body. It was a disease of 19th Century cities, the worst being New York and London.

The World Health Organisation claim that one third of the world's population (2 billion) are infected and that annually 10 million will develop the active disease, and 3 million will die. General ill health, and poor nutrition will precipitate the condition and especially where the immune system is challenged through, alcohol, drug abuse, and most recently with Human Immunodeficiency Virus (HIV).

Multiple Drug Resistance TB

TB is routinely treated with daily doses of a range of proven and effective low cost drugs. Treatment is lengthy and demands regular daily intake. Unsupervised patients can discontinue treatment or restrict the number of drugs used which has led to the recent and rapid development of drug resistant strains and more worrying, so called multiple drug resistant strains (MDR TB). This is not only a 3rd World problem, where WHO's program of "daily observed treatment" (DOT) of supervised drug delivery has helped. It is also a problem in New York and California where the Federal Centre for Disease Control (CDC) report 7.7% of new cases in 2002 were resistant to isoniazid, the first line drug of choice. WHO estimates that 50 million people worldwide are infected with MDR TB.

MDR TB is now increasingly recognised as a hospital acquired infection, and outbreaks have occurred in Florida, New York and there have been two widely reported outbreaks in London hospitals.

Dr Arata Kochi, Director of Global TB Programmes for WHO, said in 2002, "When you become sick with MDB TB, you have an illness often impossible to cure and costing one hundred times more to treat than ordinary TB".

World Health Organisation publish new report on the spread of drug resistant TB

The World Health Organisation (WHO) have produced a new report this week (The WHO/IUATLD Global Project on Anti-tuberculosis drug resistance surveillance. Anti-tuberculosis drug resistance in the world: fourth global report. February, 2008 ) showing that nearly half a million new cases of MDR-TB emerged in 2006, about 5 % of all new TB cases. Data was collected from from 81 countries (and 2 regions of China) between 2002 and 2006 and represents over 35 percent of the global total of new TB cases recorded in that time.

China, India and the Russian Federation are thought to carry the largest MDR-TB burden, with China and India accounting for 50 percent of the global caseload.In developed western countries it still remains an isolated (but threatening) problem for example in Canada in 2005 there were only 23 MDRTB cases recorded.

Amongst patients newly diagnosed with TB the prevalence of MDR-TB ranged from 0% in several western European countries to 56% in Baku, the capital of Azerbaijan. Half of the cases of MDRTB amongst patients newly diagnosed with TB were in China, India and 7% of TB cases in the former Soviet Union.

Resistance to at least one TB drug ranged between 0% in some European countries and 86% in Tashkent, Uzbekistan. The place with the highest proportion of MDR-TB cases was also Tashkent (60%).

Africa - a black hole where TB records are concerned

Although data from 33 countries not previously covered is included, there are huge gaps in recording the problem. Only 6 countries in Africa - the region with the highest incidence of TB in the world - were able to provide drug-resistance data. Other countries lack the laboratory or human resource capacity to detect drug-resistant TB.

It is estimated that as many as half of all adults in southern Africa carry a latent form of TB. People with HIV-compromised immune systems are 50 times more likely to develop active TB, but the sputum tests most commonly used to detect TB often fail to recognise it in HIV-infected patients.

In most HIV-positive patients with negative sputum test results, the most reliable way to diagnose TB is by culture testing sputum , requiring equipment, laboratories . and money. According to Dr Paul Nunn, co-ordinator of the WHO's TB/HIV and TB Drug Resistance Unit, other countries in Africa have "a very long way to go" before they have similar laboratory capacity. "There are a number of countries in Africa that do not have a single laboratory capable of testing a culture for drug resistance."

Based on the available data, the WHO estimates there were 66,700 MDR-TB cases in Africa in 2006. However, the survey was based on smear-positive TB cases.

The HIV / MDRTB co-infection problem

The authors note that in countries with high HIV prevalence, both the proportion of drug resistance among patients co-infected with HIV, and the extent of links between HIV and drug-resistant TB could have been under-represented in the survey.

Seven countries recorded drug resistance data and HIV status in Latvia and Ukraine, 2 countries where co-infection was recognised as a problem. TB/HIV patients were nearly twice as likely to have MDR-TB as HIV-negative patients.

Tuberculosis (TB) infections in Côte d'Ivoire increased 9 percent between 2006 (18,000 cases) and 2006,(21,000 cases) and almost 10 percent of the cases were multidrug resistant, according to new World Health Organization (WHO) and Ministry of Health data.

The co-infection of HIV and TB is one of the principal causes of the disease's spread in Côte d'Ivoire, the ministry said. It has calculated that 39 % of people infected with TB are also infected with HIV. TB and HIV together form a lethal combination, each speeding the other's progress.

Now we have an even deadlier variant - XDR-TB

For the first time, the survey also includes data on extensively drug-resistant (XDR) TB, a strain that is resistant to both first and second-line treatment. Forty-five countries reported at least one case of XDR-TB, but the true scale of the problem remains unclear because many countries still lack the equipment to test for resistance to second-line TB drugs.

Citing the deadly outbreak of XDR-TB in South Africa's KwaZulu-Natal Province in 2006, which mainly affected HIV-positive patients, the report warned:

"Detection of this outbreak was only possible because of the extensive laboratory infrastructure available in the country.

"It is likely that similar outbreaks of drug resistance, with associated high mortality, are taking place in other countries but currently going undetected due to insufficient laboratory capacity."

Paradoxically and for reasons unstated, South Africa was not one of the countries that contributed data to the WHO survey. Recent official figures show that nearly 6 % of 17,615 MDR-TB cases detected over a four-year period were extremely-drug resistant; 14 % of drug-resistant cases in KwaZulu-Natal Province were XDR.

Cynically it has been pointed out that the low incidence of MDR-TB in Africa is because some of the first-line TB drugs available in Europe and other parts of the world were only introduced recently in Africa - meaning that resistance has had less time to develop - and be identified.

The WHO report shows 7% of reported MDR-TB involved cases of the often untreatable XDR-TB, with cases recorded in 45 countries - Armenia 4% of MDR-TB cases involved XDR-TB, but the figure was 24% in Estonia. The authors mordantly note ... “evidence suggests that the association between HIV and MDR-TB may be more closely related to environmental factors such as transmission in congregate settings rather than biological factors…it indicates that improving infection control in…health care facilities and prisons may be one of the most critical components in addressing dual infection.” A long way round to say that the prisons of Eastern Europe are full of HIV cases where TB is increasingly untreatable - and for reasons of cost - untreated.

"TB drug resistance needs a frontal assault. If countries and the international community fail to address it aggressively now, we will lose this battle," said Dr Mario Raviglione, director of the WHO Stop TB Department.

"In addition to specifically confronting drug-resistant TB and saving lives, programmes worldwide must immediately improve their performance in diagnosing all TB cases rapidly and treating them until cured, which is the best way to prevent the development of drug resistance."

WHO estimate that $4.8 billion is needed for TB control in low- and middle-income countries in 2008, with $1 billion for MDR-TB and XDR-TB. But there is a $2.5 billion short-fall for general TB programmes and a $500 billion shortfall for MDR-TB and XDR-TB efforts.