James Moratti
Chapter on Tuberculosis
Sections
2.) Risk groups:
3.) Treatment
What is Tuberculosis?
Tuberculosis has
been around since the beginning of known history. The earliest evidence of tuberculosis in humans is from a
neolithic grave near Heidelberg, Germany.
This grave dates back to 5000BC.
Examinations of the spines of mummies and of tomb paintings from 4000BC
confirm TB as a common disease in Egypt, and skeletal remains in Italy from the
same date show TB in the spine (28).
Around
2500 BC - 1500 BC, TB was fully established in the mainland of Europe, but the
earliest evidence of the disease in Britain comes from graves dating from the
Roman occupation (55 BC - 800 AD). By
the mid 17th century, one in five deaths in London - as recorded in the Bills
of Mortality - were due to TB, known as consumption at that time. TB soon became an epidemic in Britain and in
major cities in the USA and Europe (28).
It became known as the "White Plague.”
The estimation of
the worldwide TB death rate was 7 million per year, and the worldwide pulmonary
TB rate was 50 million per year by the turn of the 19th
century. London and New York were two
of the worst affected cities worldwide.
This led to the fear that by the end of the 19th century, European
civilization might be destroyed. At the turn of
the twentieth century, more than 80% of the population in the United States was
infected before age 20.
Then in 1882 in Germany, Dr. Robert
Koch discovered the bacterium that was the cause of TB, and in 1931 in France,
Drs. Calmette and Guerin discovered Bacillus Calmett-Guerin (BCG) - a 'tamed'
living bacterium. In 1952 at Seaview Hospital in New York, a new wonder drug
called 'Isoniazid' was used to treat TB, and the centuries-long losing war
against TB began to be a winning war.
Tuberculosis or TB for short comes from
the bacterium Mycobacterium tuberculosis.
This bacterium can attack any part of the human body, but in most
incidents, it attacks the lungs. The
disease that attacks the lungs is known as pulmonary TB. It was at one time the leading cause of
death in the United States (2). Nearly
a third of the world's population is infected with tuberculosis (TB). TB kills almost 8,000 people a day, which
adds up to about 3 million people each year (1). Of those deaths, 100,000 were children. Worldwide some 2 billion people are affected with TB with an
estimated 10 to 15 million people in the United States infected with without
displaying symptoms (3).
Tuberculosis resurged in the mid-1980's
in the United States, which brought greater attention to the disease. The increasing number of cases has been
caused by the high risk for the disease among immune-suppressed persons, in
particular those infected with human immunodeficiency virus (HIV) (1). Drug resistant strains of this deadly
disease have also contributed to many problems with the spread of the disease
(1). Humans, because of the incomplete
treatment of patients that have the disease, have created these drug resistant
strains. The outbreaks of TB have
occurred in homeless shelters, hospitals, correctional institutions, nursing
homes, and residential care facilities for AIDS patients (1). Before these outbreaks, the United States
had become complacent with TB because the number of cases was so low that
funding for TB had continually decreased.
Because of these outbreaks and new versions of the disease, there has
been increased funding for tuberculosis research, prevention, and
treatment. This has allowed for a
steady decline in the number of persons with TB since the first outbreaks, but
TB is still a major problem. In 2000
alone, more then 16,000 cases were reported (2). TB disproportionately affects minorities: 54% of active TB cases
in 1999 were among African-American and Hispanic people, with an additional 20%
of TB cases found in Asians (3).
Tuberculosis is an airborne virus that is spread though the air
from person to person. This bacterium
is put into the air when an infected individual with pulmonary tuberculosis or
tuberculosis of the throat coughs (2).
It usually takes lengthy contact with someone with active TB before a
person can become infected (3). On
average, a person will have a 50% chance of becoming infected with tuberculosis
if they spend eight hours a day for six months or 24 hours a day for two months
working or living with someone with active TB (3). However, people with TB who have been treated with appropriate
drugs for at least two weeks are no longer contagious (3).
The most common version of TB is
pulmonary tuberculosis, which affects the lungs. The initial symptoms of pulmonary TB are easily confused with
those of other diseases. An infected
person may at first feel vaguely unwell or develop a cough (29). At the same time, a small amount of greenish
or yellow sputum may be coughed up when the person gets up in the morning. In time, more sputum is produced that is
streaked with blood. Persons with
pulmonary TB will not run a high fever, but they often will have a low-grade
fever (29). The patient often loses
interest in food and may lose weight.
In some cases, the patient experiences chest pain. If the disease is allowed to escape from the
lungs into the chest cavity (pneumothorax) or if the fluid collects in the
pleural space (pleural effusion), the patient may then have difficulty
breathing. The TB bacilli may travel
from the lungs to lymph nodes in the sides and back of the neck. Infection in these areas can break through
the skin and discharge pus. Before the
development of effective antibiotics, many patients became chronically ill with
increasingly severe lung symptoms (29).
They lost a great deal of weight and developed a wasted appearance. Hence TB was referred to as the White
Plague. This outcome is uncommon
today--at least where modern treatment methods are available.
A new form of TB has emerged recently,
called MDR-TB. MDR-TB is caused by
inconsistent or partial treatment, which may happen for a number of
reasons. These reasons include when
patients do not take their full course of drug treatment, when doctors and
health workers prescribe the wrong drugs or the wrong combination of drugs, or
when the drug supply is unreliable.
MDR-TB is very deadly and needs to be watched closely.
From
a public health perspective, poorly supervised and incomplete treatment of TB
is worse than no treatment at all. When
people fail to complete standard treatment regimens or are given the wrong
treatment, they may remain infectious and at the same time, they can develop
resistance to anti-TB drugs (25).
People then may become infected with the same drug-resistant strain. Drug-resistant TB is a lot more difficult
and much more expensive to treat and more likely to be fatal (25). In industrialized countries, TB treatment
costs around $2,000 per patient, but rises more than 100-fold to up to $250,000
per patient with MDR-TB (25).
Outbreaks
of MDR-TB in Western Europe, Asia, and the United States have been linked to a
single strain (the W strain), which originated in Peru (25). This strain in particular has been shown to
cause extremely high mortality in immune suppressed patients. Given that treatment of MDR-TB requires extensive
resources and can take up to two years of chemotherapy per patient, efforts
must be made to prevent the transmission of such strains. Focus should be placed to prevent the
emergence of MDR-TB (with DOTS) and to manage present MDR-TB cases in areas of
high prevalence. This combination
is the concept of DOTS-Plus
(25).
Tuberculosis in Developing Countries
While a cure for tuberculosis (TB) was developed more the 50
years ago, tuberculosis remains one of the world’s deadliest infectious
diseases. One-third of the world’s population is
infected with TB, and one-third
of HIV/AIDS patients have TB. TB
threatens the poorest and most marginalized groups. It disrupts the social fabric of the society and undermines gains
in economic development. Sadly, the
global resurgence of tuberculosis over the past few decades has been fuelled by decreasing
investments in public health systems, emerging drug resistance, and increasing
HIV/AIDS prevalence (13).
The World Health
Organization estimates that 80% of all TB cases are found in 22 countries.
The rates for
infection in 20 of these countries are:
|
Country |
Population |
All cases |
|
India |
1,008,937,000 |
1,856,000 |
|
China |
1,275,133,000 |
1,365,000 |
|
Indonesia |
212,092,000 |
595,000 |
|
Nigeria |
113,862,000 |
347,000 |
|
Bangladesh |
137,439,000 |
332,000 |
|
Ethiopia |
62,908,000 |
249,000 |
|
Philippines |
75,653,000 |
249,000 |
|
Pakistan |
141,256,000 |
247,000 |
|
South Africa |
43,309,000 |
228,000 |
|
Russian Federation |
145,491,000 |
193,000 |
|
DR of Congo |
50,948,000 |
163,000 |
|
Kenya |
30,669,000 |
149,000 |
|
Vietnam |
78,137,000 |
148,000 |
|
Tanzania |
35,119,000 |
126,000 |
|
Brazil |
170,406,000 |
116,000 |
|
Thailand |
62,806,000 |
88,000 |
|
Uganda |
23,300,000 |
82,000 |
|
Myanmar |
47,749,000 |
80,000 |
|
Mozambique |
18,292,000 |
79,000 |
|
Cambodia |
13,104,000 |
75,000 |
|
Global total |
6,053,531,000 |
8,735,000 |
(Zimbabwe and
Afghanistan are the two countries not listed in the chart.)
Reference for this
section:
1.) http://www2.state.tn.us/health/ceds/TB/introduction.htm
2.) http://www.foh.dhhs.gov/public/nycu/worldtbday2003.asp
3.) http://www.niaid.nih.gov/newsroom/tbday02/tbglance.htm
10.) http://www.avert.org/tuberc.htm
13.) http://www.usaid.gov/pop_health/id/tuberculosis/burden.html
25.) http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html
28.) http://www.ukcoalition.org/HIV___TB/History_of_TB/history_of_tb.html
29. http://www.hendrickhealth.org/healthy/001409.htm
Risk Groups
People
at higher risk of having active TB than the general population include poor and
homeless people; Aboriginal Americans; individuals born in countries reporting
high TB rates; alcoholics and injection drug users; elderly people (especially
single men); individuals co-infected with HIV and tuberculosis; health care
workers; refugees; and prisoners.
TB is widespread and contagious, making
everyone at risk. A potentially fatal
infectious disease in one person is a threat to everyone’s survival (27). During 1995, examples of TB infection and
sickness appeared throughout parts of the world that at one time were
considered safe from this disease (27).
For instance in Minneapolis, a person with TB infected 41 people in a
neighborhood bar. A postal worker in
Tampa, Florida, was carrying TB bacilli as well as the mail! In Western Canada, a health care worker gave
TB to 100 other people (27). In recent
years, outbreaks of TB in wealthy countries have been investigated in
discotheques, churches, subways, schools, airplanes, courtrooms, and even on a
riverboat casino.
All these groups have something in
common. They have either lifestyle
conditions, living conditions or physical conditions that lead to a weakened
immune system or greater contact with the disease. These conditions combined lead to a much greater risk in contracting
tuberculosis and getting the active version of it. It is best to try to limit the risks that these people have in
order to help stop the spread of this very deadly but also curable disease.
Aboriginal Americans, poor people, and homeless people have much
in common. First, they live in very bad
conditions. They live in destitute
areas with widespread disease, leading to a greater risk in contacting any
disease. At the same time, they tend to
have bad diets and unhealthy life styles.
These factors are combined with a low income and lack of adequate health
insurance. These individuals are less
likely to take the drugs in full though, and at the same time they are less
likely to have adequate insurance to cover other health problems that could
weaken their immune systems. They do
not have enough resources to protect themselves form the diseases.
The same goes for the elderly, who may have weakened immune
systems and may be poor and living in poor conditions. In addition, some elderly live in communal
living areas such as nursing homes.
These places help spread disease because of the close proximity to
others. More than
one-fourth of the nearly 23,000 cases of TB reported in the United States in
1995 developed in people above age 65, while elderly people are only
approaching one-fifth of the population (29).
Many elderly patients developed the infection when they were younger and
the disease was more widespread. The aging
process itself weakens the body's immune system, which is then less able to
ward off the disease. Finally, bacteria
that have lain dormant for some time in elderly persons may be reactivated and
cause illness.
Individuals co-infected with HIV and M. tuberculosis
Studies in Italy, Rwanda, Spain, the
USA and Zaire found that people who were infected with the bacteria that cause
TB and were also infected with HIV were 30-50 times more likely to develop
active tuberculosis than those without HIV (10). This is because of the weakened immune system of an HIV positive
person. This increases greatly the risk
of developing TB, and the development of active TB accelerates the progression
of the HIV disease itself towards full-blown AIDS (9). TB is the most common among the
opportunistic infections in people that have AIDS. It is very easy for people that have AIDS to get TB. Tuberculosis is the first manifestation of
AIDS in over fifty percent of all AIDS cases in the developing world (9). Tuberculosis is the leading killer worldwide
of people that have AIDS (9). Seventy percent of TB patients in developing countries
are infected with HIV (9). Up to half
of HIV-infected patients in Africa will develop TB and out of these, one in
three will die from it (9). By
the year 2005, sub-Saharan Africa could have more tuberculosis cases (3.4
million) than any other region in the world (9). Once HIV is introduced into a community where there are people
infected with the TB germ, the population faces parallel epidemics of AIDS and
TB (10). A long-standing annual decline
in TB cases ended abruptly in the United States in 1985, at the peak of the HIV
spread (10). Of all TB cases in Asia,
14% will be attributable to HIV by the end of the 1990s (10). Only 2% of all TB cases in Asia were
attributable to HIV at the start of that decade (10). This is not only a menace for those infected with HIV; TB can
also be spread through the air to HIV-negative people. Tuberculosis is the only major AIDS-related
opportunistic infection to pose this kind of risk (10).
Health Care Workers
The threat of health care workers contracting
tuberculosis is a growing concern. Even
though the greatest risk is for health care workers that have constant contact
with TB patients, it is still very important for all health care workers to
take measure to protect themselves from TB (6). The increasing threat caused by TB’s comeback leads to increasing
risk for health care workers.
According to the Occupational
Safety & Health Administration (SHE) of the United States, an estimated 5
million U.S. workers are exposed to TB in the course of their work (7). The risk of these workers as a result of
their contact with TB-infected persons may be as high as 10 times the general
population risk (7). Health care
workers are at high risk for many diseases because of their contact with many
patients that are sick. Often they do
not take the proper measures to protect themselves from these sicknesses.
The United States federal
government has deemed the danger of tuberculosis spread amongst health care
workers in the US to be so important that the Department of Labor has to
establish a set of guidelines that make health care facilities follow certain
guidelines when dealing with TB patients (6).
Once a TB patient has had his/her treatment started, he/she should be
immediately isolated in an acid Flash cacilli isolation room that must be
maintained in a negative pressure state and appropriately exhausted ventilation
(6). This facility should provide three
forms of air purification, including ventilation, high-efficiency particulate air
(HEPA) filtration, and ultraviolet germicidal irradiation (UVGI) (6). This ventilation and filtration should be
sufficient to remove most bacteria from the air, and the ultraviolet lighting
in the room should be sufficient to kill the remaining bacteria. Health cares workers entering such a room
must wear a respirator that has been NIOSH-certified (National Institute for
Occupational Safety and Health) (6).
Prisoners:
TB has been a recognized problem in prisons
worldwide. In recent years, there have
been marked increases in the number of cases reported in correctional
facilities in the United States (8). In
1993, the inmates of the New York State correctional system, for instance, had
8 times the TB rate of the entire state--139.3 per 100,000 compared to 21.7 per
100,000 (8). Another example is that in
one California state prison, the annual incidence rate of TB in 1991 was 184
cases per 100,000, which is more than 10 times the statewide annual incidence
rate for people not in prison (8). Some
studies have been used to show that there is a correlation between tuberculin
skin test positive rates and the length of time one has been in prison
(8). This therefore indicated that the
disease transmission most likely had occurred within the correctional facilities
(8). These prisoners are in close
contact with many other persons who could have sicknesses. Prisons are breading grounds for disease. Prisoners also get weakened systems because
of the diets they eat, the amount of sickness around them, and in many cases,
the lack of adequate health care.
The incidence of TB within
Russian prisoners is fifty-eight times higher then that of the rest of the
population (16). The death rate is also
29 times that of the rest of the population.
Russia has the world’s highest correction rate in the world. About ten percent of Russia’s prison
population, or 100,000 convicts, have TB (16).
About 5000 Russian prisoners die each year from TB (19). Part of the problem is that there are
massive funding problems with in the Russian Prison system. For instance, the funding problems are so
bad that only 4.5 cents prisoner is spent a day on food, (17). The problem in the Russian prisons adds to
the health problems of Russia as a whole with about 13,000 Russian Prisoners who
are possibly infected are released in to the general population every
year. The release of these prisoners
adds to the already poorly funded and over worked health care system of Russia.
The Russian Prison system is a
breading ground for Multidrug resistant (MDR)-TB (defined as resistance to at
least INH and RIF) (18) . The
implementation of a DOTS program at Colony 33 in Mariinsk (initiated 1996;
fully implemented 1997) has resulted in TB cure rates increasing from a low of
36% to 62% and a treatment failure rate decreasing from 56% to 23% (18). The rate of TB cases that are resistant to
isoniazid, rifampin, and streptomycin has remained relatively stable (22.6% in
1997 to 18.9% more recently) (18). To
treat MDR-TB, second line agents must be used , there treatments are more expensive, less effective, and a
lot more toxic than the first line agents
In Tomsk, and there is some evidence that there is misuse of second line
agents. The misuse of second line
agents can lead to the development of resistance strands of TB, resulting in
incurable disease. The increasing rate
of MDR-TB among the Russian civilian population is very likely related to
MDR-TB in the prisons system. The MDR
rate among civilians was only 6% in 1997, and increased to 10% by 1998. There are likely dual epidemics of MDR-TB in
the civilian and prisons sectors, with both epidemics contributing to one
another. In the Colony 33 detention
center, 90% of prison detainees are from the local area. In the Tomsk prison, 63% of the MDR cohort is from the local area (18).
Refugees
In 1994, nearly 23
Million refugees had to flee their homes, and an additional 26 Million persons
were displaced worldwide. Refugees are
also highly at risk to get Tuberculosis with an estimated Half of
the world’s refugees infected
with TB (26). Conditions in refugee
camps are ideal for the spread of TB ,untreated TB can spread quickly in
crowded living arrangements, . In
addition, since they are on the move, it is difficult to treat them fully
because of the lengthy treatment regimen required by existing drugs. Each year, over 17,000 refugees get sick
with the disease. People who have been
displaced for other reasons-such that as of homeless people are also a very
great risk.
Reference for this section:
http://www.who.int/gtb/publications/tbrep_96/
6.) http://www.lungusa.org/occupational/tuberculosis
_workers.html
7.) http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13717
8.) http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm
9.) http://www.tbalert.org/news/tb_aids.htm
10.) http://www.avert.org/tuberc.htm
16.) http://www.worldpaper.com/2000/sept00/pumpyansky.html
18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1
19.) http://www.canadafirst.net/immi-kill/russian_tb_threatens_the_world.html
26.) http://www2.provlab.ab.ca/bugs/hlthprom/tbschnee.htm
27.) http://www.stoptb.4t.com/whystopTB.html
29. http://www.hendrickhealth.org/healthy/001409.htm
Treatment:
The World
Health Organization recommended treatment strategy for detection and cure of TB
is DOTS or Directly Observed Treatment, Short-course (4). DOTS is a combination of five different
elements: drug supplies, political commitment, microscopy services,
surveillance and monitoring systems and use of highly efficient regimes with
direct observation of treatment (4). In
directly observed therapy, a trained health care worker monitors the patient
taking each dose of anti-tuberculosis medication. When TB patients receive all medications as prescribed under a
program of DOTS, both patients and community benefit by response to therapy is
closely monitored, Patients complete therapy, Survival may improve in patients
infected with the human immunodeficiency virus (HIV), because DOTS ensures
treatment for TB, (15). DOTS is so
important because it helps to deter the spread and development of Drug
Resistant TB This is important the course of treatment for drug-resistant TB is
USD250, 000 and that of normal TB is about USD 2000 (25).
Although the DOT the strategy
promoted by the World Health Organization to control and treat tuberculosis
(TB) - has been widely accepted, many developing countries have been unable to
expand coverage as rapidly as needed and have failed to achieve the global
targets of detecting 70% of infectious cases and curing 85% of those detected
by the year 2000 (14) The major obstacles to expanding the TB control are
political, managerial, and financial, rather than technical (14).
According to WHO the estimated costs
of the 22 high-burden countries range of US$ 700–900
million per year, this is excluding investment in new interventions that are
specifically designed to raise case detection and cure rates. It is also estimated that the existing
resource gap for TB control in the 22 most burdened countries is probably
between US$100-300 million a year; this is provided that current loans and aid
are sustained (14)
Now
patients with infectious TB have been identified using microscopy services,
health, community workers, and trained volunteers observe and record the
patients swallowing the full course of the correct dosage of anti-TB medicines
in which Treatment lasts six to eight months (4). The most common of the anti-TB drugs are isoniazid, rifampicin,
pyrazinamide, streptomycin and ethambutol.
After two months, spectrum smear testing is repeated. It is repeated to check the progress and
again it is repeated at the end of treatment.
The patient’s progress is recorded and documented thought out the
treatment and the outcome of the treatment is recorded (4).
One a six-month supply of drugs for DOTS treatments costs
as little as US $11 per patient per year in some parts of the world. The World Bank has ranked DOTS as the “most
cost-effective of all health interventions” (4). DOTS have a cure rate of up to 95 percent this is even in the
poorest of the poor countries (4). DOTS
helps to prevent new infections by curing the patients that are
infectious. It at the same time helps
to prevent the development of MDR-TB by ensuring the full course of treatment
is followed; it ensures this though directly observing the patients. Since DOTS has been introduced on a global
scale, millions of people have received effective cost affective
treatment. For instance, in half of
China the cure rates among new cases are 96 percent (4). Another example is that in Peru the
widespread use of DOTS for more than five years has led to the successful
treatment of 91 percent of cases.
All
22 of the high TB burdened countries, which bear 80 percent of the estimated
incident rates by the end of 1998, have adopted DOTS. This brings the total of 43 percent of the world’s population
that have access to DOTS, which is double what it was in 1995 (4). In addition, at the same time in 1998 21
percent of the TB patients received treatment under DOTS, which is also double
of what it, was in 1995 (4). With only
21 percent receiving treatment under DOTS, it really needs to be greatly expanded.
An example of a DOTS program in the
west is the NYC Department of Health & Mental Hygiene Tuberculosis Control
Program. Because of how TB treatment is
difficult and requires taking two or more medicines for at least 6 months. Most people have trouble remembering to take
their medicines, or they stop taking their medicines when they start to feel
better. When this happens, a person
with TB could get sick again, and the TB germs could become resistant to the
medicines. Because of this DOTS was envisioned
and this is why New York uses it to control the TB problem (15). Some benefits that patients get thou using
the DOT program in New York are Free TB medication, free tokens, food, and gift
certificates to fast food restaurants, free social services, frequent medical
checkups, and Help with transportation to and from clinics. In addition, this is provided free of charge
to all residents of New York (15). The
New York City program sets an example for the rest of the Developed and for the
developing world on how to set up a TB treatment plan, which is effective and
patient friendly.
An example for a program of TB
treatment in the Developing world is the TB Clubs in Ethiopia. In Ethiopia, a strategy to combat TB was to
set up though using peers as a support group to help others go though the TB
treatment (23). In exploring ways to
increase the TB treatment adherence and outcomes they created, these so called
TB clubs. These Clubs were established
by people who have TB and who live in the same geological area (23). The people meet each other while attending
outpatient appointments. Medical
officers and the Community support these groups. Each of these groups have between three and ten members, they
elect a leader of the club who ensures that the members attend the TB
Clinic. The leader also arranges the
weekly meetings and checks up on their progress. Members of these clubs support each other, share progress, and problems
and send members that are not progressing correctly onto the Clinic. The clubs with help from the community help
to identify persons in the community who are suspected to have TB and they
encourage these community members to be tested and to be treated.
What have these TB clubs
achieved? During the first six months
of the clubs in 1997, the clubs referred 181 people with suspected tuberculosis
for investigation, of which two-thirds were diagnosed as TB cases (23). They also identified 69% of all TB patients
and 76% of new sputum smear-positive pulmonary TB patients with smear-positive
sputum diagnosed in the district during the same six-month period (23). TB clubs have helped to increase community
awareness of the symptoms of TB and the need for treatment, Attendance at TB
clinics has also improved significantly and treatment success rates are higher
than in other parts of the country (23).
This TB club approach shows what can
be achieved - even in remote rural areas with limited resources and using a
long course of treatment - if TB patients are at the centre of TB control
efforts and if there is effective community involvement. This shows how important community support
is in a TB treatment program.
It is possible to control the spread of
MDR-TB, but according to Atiel Pablo-Mendez who is from the Rockefeller
Foundation presented arguments that DOTS alone may be sufficient to control TB
globally. This has been effective in a
country like Peru (which has one of the best DOTS programs in the world and is
relatively small), would be equally successful in a larger country such as
India, where DOTS is not as widely used (18).
Although recent reports have noted so-called MDR-TB hotspots, the median
prevalence of MDR-TB globally is 1%, with eight countries reporting no MDR-TB. Rates of MDR-TB range from 14% in Estonia to
0% in France in the United States, the rate of MDR-TB has decreased from 1.6%
to 1.2%. It was stated that MDR-TB
outbreaks are often due to poor infection controls for instance in New York
City, Russian prisons) and that therefore improvement will occur when infection
control is improved, not just the institution of DOTS-Plus.
TB in New York City
New TB Cases MDR-TB
1992 3,811 441
1997 1,730 53
Change -55% -88%
Thus,
there was a greater decrease in MDR-TB rates than overall TB rates. There is a high correlation between
incomplete therapy and MDR-TB, as well as the treatment failure rates
(18). Thus, for the programs that have
low treatment success rates less then 60%), the preference would then be to
provide a better implementation of DOTS prior to implementing DOTS-Plus
program. For programs that have a
greater then 80% treatment success rate, use of DOTS-Plus could be considered.
Controlling MDR-TB through
DOTS-Plus: In settings where the prevalence of Multi- Drug Resistant -TB is
low, cure rates with DOTS can exceed 90%; thus DOTS alone will suffice in many
settings (18). However, in settings
with high rates of MDR-TB, cure rates of DOTS decreases to 40-60%. For instance, in Baku, Azerbaijan, the cure
rate using DOTS is 54% (18). In areas
with documented MDR-TB, cure rates have been found in a range from 6% (Ivanovo,
Russia) to 59% (Peru) (18). The common
objections to DOTS-Plus include the argument that DOTS alone was responsible
for the decrease in rates of TB and MDR-TB in New York City in the early 1990s,
the expense of DOTS-Plus, the lack of cost-effectiveness, and the difficulty in
implementing such treatment regimens (18).
MDR-TB in the United States: The
proportion of MDR-TB patients who died during therapy decreased from 41% in
1993 to 29% in 1996 (18). Patients with
MDR-TB were a lot more likely to die than those with non-MDR-TB. Among AIDS patients with MDR-TB, 69% died
during therapy, compared to the 27% of AIDS patients with non-MDR-TB. Among patients who did not die during
therapy, completion of therapy was less common in persons with MDR compared to
non-MDR-TB. This is leading to ways
that we need to improve treatment so that we do not have to worry about
increasing the rate of MDR-TB growth.
Implementing a strong cost-effective Tuberculosis treatment programs
such as DOTS, will help stop the Spread of MDR-TB
References for
this section:
4.) http://sprojects.mmi.mcgill.ca/tropmed/disease/tb/dots.htm
14.) http://www.who.int/gtb/policyrd/Dots_expansion/index.htm
15.) http://www.ci.nyc.ny.us/html/doh/html/tb/tb.html
18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1
20.) http://www.who.int/gtb/dots/index.htm
23.) http://www.who.int/gtb/policyra/commcae.htm
25.) http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html
References for the whole chapter.
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6.) Tuberculosis and Health Care Workers. American Lung Association.
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8.) Controlling TB In Correctional Institutions 1995. 7 Sept. 2002. Centers for
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<http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm>.
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10.) AIDS, HIV & Tuberculosis. AVERT.
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World Health Organization. <http://www.who.int/gtb/>.
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13.) The Global Burden of Tuberculosis (TB) .
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16.) Pumpyansky , Alexander. Russian prisoners incubate
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17.) <http://www.river.org/~chuck/byline/1990/04/angela041.html>
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19.) Schweimler , Daniel . World: Europe Russian TB
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21.) <http://www.aegis.com/newa/ads/2000/AD001853.html>
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