Multi-Drug Resistant (MDR) Untreatable TB
Spreading Rapidly
©1997 The Associated Press

Update: An Airborne Killer Returns
A new strain of tuberculosis is set to hit Asia
By Catherine Shepherd

TUBERCULOSIS, or TB, was once romanticized as the "artist's disease" in the West. Wasted youth and wan complexions found their way into countless 19th-century poems, paintings and novels. Today, there is no such glamorization. According to a recent report by the World Health Organization (WHO), TB has re-emerged more powerful and more threatening than the outbreak that killed thousands last century. The report, entitled Anti-Tuberculosis Drug Resistance in the World, details the spread of a "super-strain" of TB-causing bacteria. Worse still, the area poised to be hit hardest by the disease is Asia.
Several factors contribute to the danger in the region. The first, perhaps ironically, is the widespread availability of medication. Tuberculosis sufferers in Asia have had access to common anti-TB drugs like isoniazid and rifampicin but have failed to take them properly or completely. This has allowed the organism responsible for TB, Mycobacterium tuberculosis, to mutate and build up resistance.
Secondly, the region has several hundred urban centers, where overcrowding and the constant movement of people can lead to a rapid spread of the disease. The third factor is a familiar one. "All of Asia is at high risk, but there is no greater risk than in Southeast Asia, because HIV is moving so quickly," says Kraig Klaudt, WHO's external advocacy officer. Tuberculosis spreads 30 times faster in AIDS patients than in people whose immune systems are intact.
Carried in sputum droplets, the bacteria are transmitted through the air. Even getting into a cab that was occupied by a TB patient three hours before can lead to infection. "There is nothing a person can do to not get TB," says Klaudt. "You can change your behavior to lower the risk of AIDS, but you cannot stop breathing."
When inhaled, the bacteria are drawn into the lungs where the tissues react to the invaders by coating them with cells -- much the same way an oyster coats a sand grain to form a pearl. The trouble is, these "pearls," or tubercles, grow larger and larger, and eventually prevent the lungs from doing their job. The first symptoms of infection are chest pain, loss of appetite, fever and night sweats. Secondary symptoms: coughing up blood and pus, and severe shortness of breath.
The only program that has been effective against tuberculosis is DOTS, or Directly Observed Treatment, Short-course. Healthcare workers under this program do not just hand out medication; rather, the patient is required to return to the clinic daily to be given the proper dose and is monitored for any adverse reactions.
But only 12% of TB patients were treated with DOTS this year. Because it is more costly and complicated to operate than simply dispensing pills, health officials have been slow to change from their old TB management programs. WHO is calling on governments to implement DOTS and urging citizens to make the same demand. After all, there is no defense against the disease, except treating the infected.

WASHINGTON "Hot zones" of untreatable tuberculosis are emerging around the world and threaten a global crisis, the World Health Organization warned Wednesday. A study of 50,000 patients in 35 nations found that a third of the countries have a form of TB resistant to multiple drugs. Untreatable cases account for 2 percent to 14 percent of the world total. That number is low, but WHO said lethal tuberculosis could spread rapidly because only one in 10 patients gets medical care appropriate to curb drug resistance.
"Hot zones" in India, Russia, Latvia, Estonia, the Dominican Republic, Argentina and the Ivory Coast have so much drug-resistant TB that it threatens to overwhelm local health systems, said the study by WHO and U.S. health officials.
"This study shows definitively, and for the first time, what we most feared but could not previously prove: Our world again faces the specter of incurable tuberculosis," said Dr. Michael Iseman, TB chief at the National Jewish Medical and Research Center in Denver, who reviewed the study. Drug-resistant TB "is on every continent, probably in every country," he said.
Tuberculosis is the world's top infectious killer. It is spread through coughing and sneezing and can be highly contagious -- the average patient infects 10 to 20 people a year.
The World Health Organization announced last spring that TB's global spread had finally leveled off, but the new study looks specifically at killer drug-resistant forms. The normal variety of tuberculosis often can be cured with a combination of four drugs taken for six to eight months.
But many patients, especially in poor countries, stop taking the drugs when they feel better or run out of money, which allows the TB still in their bodies to mutate so that one or more medicines no longer work. This "acquired drug resistance" is entirely preventable with proper care, WHO said.
These people also can spread drug-resistant (MDR) TB to new patients, a circumstance that gives patients what is called "primary drug resistance." The WHO study found spots where resistance to a single drug is alarmingly high -- It reached 100 percent of treated but not cured TB patients in Ivanovo Oblast, Russia, about 180 miles east of Moscow. These people can be treated with other drugs, but they're in danger because the TB germ must make just one more mutation to become multidrug resistant -- and lethal.
The study identified "hot zones" with multidrug-resistant TB at levels high enough to overwhelm local TB control programs: * India's Delhi state, where 13 percent of all TB patients are multidrug resistant. * Ivanovo Oblast, Russia, 7 percent. * Latvia, 22 percent. * Estonia, 12 percent. * Dominican Republic, 9 percent. * Argentina, 8 percent. * Ivory Coast, 5 percent.
Lowest levels of multidrug-resistant TB were no cases in Kenya, less than 1 percent in Australia and New Zealand and 2 percent in the United States. Levels of primary resistance, people who caught a resistant strain, to any drug ranged from 2 percent in the Czech Republic to 41 percent in the Dominican Republic.
WHO said that to stem the spread of untreatable TB, countries must invest in therapy called DOTS -- Directly Observed Treatment, Short-course. Health workers watch patients swallow their four TB drugs every day, then follow up to ensure they're cured or to identify drug resistance early. DOTS is the standard in industrialized countries and has cut drug resistance 85 percent in metropolitan areas such as New York City, WHO said. By LAURAN NEERGAARD, The Associated Press

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