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Virulent New Strain of TB Raising
Fears of Pandemic
Peter Finn
Washington
Post
Thursday May 03, 2007
MOSCOW -- A virulent strain of tuberculosis resistant to most
available drugs is surfacing around the globe, raising fears of
a pandemic that could devastate efforts to contain TB and prove
deadly to people with immune-deficiency diseases such as HIV-AIDS.
Known formally as extensively drug-resistant TB, or XDR-TB, the
strain has been detected in 37 countries. It arises when the bacterium
that causes TB mutates because antibiotics used to combat it are
carelessly administered by poorly trained doctors or patients don't
take their full course of medication. Rather than being killed by
the drugs, the microbe builds up resistance to them.
At least 50 percent of those who contract this strain of TB will
die of it, according to medical experts. In trying to stop the spread
of the disease, which can be transmitted through coughing, spitting
or even speaking, health officials have imposed sometimes extreme
controls on infected people.
Robert Daniels, a 27-year-old dual Russian-U.S. citizen, underwent
months of treatment for TB in Russia, where he often led a homeless
existence. After telling people he was feeling better, he flew from
Moscow to New York on Jan. 14 last year, then on to Phoenix.
In fact, his disease had not disappeared. The microbe causing it
had mutated, apparently helped by his failure to complete a drug
regimen in Russia. Weeks after arriving in Phoenix, Daniels was
again coughing, feeling weak and losing weight.
Doctors in Phoenix diagnosed his illness as the new resistant strain
of TB. Daniels again failed to follow doctors' orders, authorities
say. So health officials got a court order, and he was locked up
in the prison wing of a Phoenix hospital, where he has spent the
past nine months in hermetically sealed isolation.
"It's not right," Daniels said in a telephone interview.
"I'm not a criminal."
Daniels has become a case study in the bleak choices society faces
in dealing with the new strain and attempting to balance protection
of individual rights with protection of the public.
Evidence of TB has been found in ancient skeletons and mummified
remains. From the 17th century to the 20th, it was a major killer
in the United States and Europe, taking the lives of such notable
people as the poet John Keats, the composer Frédéric
Chopin, the writer Stephen Crane and the actress Vivien Leigh.
Even in the antibiotics age, TB has remained a scourge in poorer
countries and communities. Today, one in three people globally is
estimated to be infected with dormant TB, according to the World
Health Organization (WHO). Most will never get sick, but in one
in 10 cases the bacterium becomes active when the host's immune
system is compromised. Worldwide, an estimated 1.7 million people
die every year of the disease.
Two events last year alerted the medical community to a frightening
new version of the disease. The Centers for Disease Control and
Prevention, drawing on a survey of TB labs on six continents, reported
that the prevalence of the super strain of TB increased from 3 percent
of patients to 11 percent between 2000 and 2004. It reached 15 percent
in South Korea and 19 percent in Latvia. There are no statistics
yet about the new strain in Russia, China or Africa, areas with
major TB populations .
In the United States, 13,767 TB cases were recorded in 2006, the
lowest rate of infection since reporting began in 1953. A retrospective
analysis by the CDC found 49 cases of the new strain in the country
since 1993.
The CDC survey was followed by a report from Yale University researchers
that the superbug had raged through a rural hospital in South Africa
in 2005 and early 2006, killing 52 of 53 who contracted it, including
six health care workers. The victims, apparently infected by airborne
transmission of the virus, died on average just 16 days after diagnosis;
most of them also had HIV.
"We have to come to grips with this quickly," said Vladislav
Yerokhin, director of the Central Tuberculosis Research Institute
in Moscow. "This is not just a threat for TB patients. This
is a serious threat for the general population."
Russia has become a petri dish for drug resistance.
After the fall of the Soviet Union in 1991, rising poverty and
a disintegrating medical system unleashed a TB epidemic in Russia
and other post-communist countries. In 2005, the number of newly
diagnosed cases in Russia reached 119,226, and 32,148 people died
of the disease, according to the Ministry of Health and Social Development.
Up to 70 percent of TB patients in Russia are homeless, unemployed,
in prison, former prisoners or alcohol abusers; 30 percent or more
of patients break off their treatment, boosting resistance to anti-TB
drugs.
In addition, Russia has an estimated 1 million people who are HIV-positive.
That is an explosive combination, according to Murray Feshbach,
an expert on Russian demography at the Woodrow Wilson International
Center for Scholars in Washington. "It's potentially catastrophic
for Russia," he said.
Today, South Africa is also a major TB infection zone. "The
pressure of TB is enormous in our setting, and the majority of AIDS-related
deaths are due to TB," said Gilles van Cutsem, medical coordinator
with Doctors Without Borders in Khayelitsha, a large township on
the edge of Cape Town, South Africa.
"People are wary about transmission within the community,
as well as within health structures, from patients to patients and
from patients to staff," van Cutsem said. "Considering
that a great proportion of the health staff is also HIV-positive,
this is even more of a concern."
Active TB bacteria are treated with four standard drugs. In most
cases, patients quickly become non-infectious and start to feel
better, although they are considered cured only after a full course
of treatment, lasting about six months.
By the 1980s, doctors had begun to notice that some patients were
resistant to these first-line drugs, particularly the two most potent
ones, isoniazid and rifampicin. Their condition was defined as multidrug-resistant
TB.
When the first line of drugs fail, doctors fall back on more expensive
ones that have toxic side effects but can cure the condition after
being used for 18 to 24 months. However, it is extremely difficult
to keep patients taking the drugs for such a long period.
The new strain, a step up in resistance from the multidrug-resistant
variety, has appeared more recently. An estimated 22,000 Russians
have TB that is resistant to drug therapy to some degree. An unknown
number of them have the new super strain.
If it is not contained, it will almost certainly mutate again into
a completely drug-resistant TB, according to Mario Raviglione, director
of WHO's Stop TB Department.
Some experts believe that may have already happened. Doctors reported
this year that a 49-year-old woman in Italy died after 625 days
of hospital treatment; all the drugs they tried failed.
The world is facing a return to the era before antibiotics when
the white plague, as TB was known, was often a death sentence, according
to Raviglione. The only treatment option then involved risky surgery
in which doctors collapsed or removed an infected lung or attempted
to cut out diseased tissue.
"We will be left with surgery and prayers," Raviglione
said. "It's a desperate situation."
New drugs are in the pipeline but still years away, and patient
non-cooperation could quickly undermine their effectiveness. "Monitoring
patients is not easy when you are talking about a man who drinks
a half a liter of vodka a day, or has no home or no family or no
job, or all of the above. Those are our TB patients, " said
Sergei Borisov, deputy director of the Phthisio-Pulmonary Institute
in Moscow.
Some doctors and medical ethicists have said that countries will
have to consider forced isolation of uncooperative patients, a public
health strategy that evokes the sanitariums of decades ago.
"We have to face the possibility that restrictive measures
may be necessary to control what could become a global pandemic,"
said Ross Upshur, director of the Joint Center for Bioethics at
the University of Toronto. "I'm not advocating detention as
a first resort," he added. "But if voluntary measures
fail, people do not have the right to infect others. At the same
time, people should be treated humanely, and they should have access
to counsel, and they shouldn't be placed in a prison setting."
Other experts say such an approach might merely drive the disease
underground and is impractical in poor countries.
"Forcing one uncooperative patient into isolation is fine,
or even 10 patients or 100 patients," Borisov said. "But
what about our situation in Russia, where 25 percent of the patients
are uncooperative? Are we going to lock up thousands of patients?
And where will we put them? Doctors cannot be prison guards."
Daniels, for instance, was often homeless when he was in Russia,
according to him and his wife, Alla Danielova, an English teacher.
Daniels said he bounced among friends' houses, partying and trying
to ignore the bloody sputum he was coughing up. "I knew I was
going to have to treat it, but I had other plans at that time,"
he said. "I didn't think it was a big deal. Now I know better."
Daniels acknowledged that he had visited a fast-food restaurant
and stores in Phoenix without a mask but denied that he had stopped
taking his medicine there. "That's a nasty lie," he said.
He said his condition is now improving. He has petitioned the court
to be moved out of the prison ward and, ultimately, released. But
last week a judge rejected his plea and ordered him to remain in
medical confinement.
INFOWARS:
BECAUSE THERE'S A WAR ON FOR YOUR MIND
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