Drug-Resistant TB at Record Levels

A ward for tuberculosis and HIV patients in Juba Hospital in southern Sudan. (Lynsey Addario for The New York Times)

Feb. 26th. (NY Times) - Multiple-drug-resistant tuberculosis cases in parts of the former Soviet Union have reached the highest rates ever recorded and could soar even higher, spreading the bacterial disease elsewhere, the World Health Organisation said on Tuesday in releasing findings from the largest global survey of the problem. The highest rate was in Baku, the capital of Azerbaijan, where 22.3 percent of new tuberculosis cases were resistant to the standard anti-tuberculosis drug regimen during the survey period from 2002 to 2006. That exceeded the previous high of 14.2 percent, in Kazakhstan. Studies in China also suggest that multiple-drug-resistant TB is widespread in the inner Mongolia and Heilongjiang regions, W.H.O. said. The new survey, the first in four years, shows that earlier predictions were correct and that governments have lost control of tuberculosis in many areas. The reason, health officials say, is that countries have failed to invest enough to build, equip and staff the laboratories needed to detect the disease. The countries also failed to assure sufficient amounts of standard drugs and then to monitor patients to ensure that they complete a full course of therapy. Inadequate therapy often leads to development of multiple-drug-resistant strains of the tuberculosis bacterium. Drug-resistant tuberculosis, like drug-sensitive TB, can be transmitted from an infected individual to a noninfected person in droplets through coughing, sneezing, singing and other activities. The drug resistant form can take two years to treat with drugs that are 100 times more expensive than the first-line regimen, the health agency, a unit of the United Nations said. The survey also found alarmingly high rates in Moldova (19.4 percent), Donetsk in the Ukraine (16 percent), Tomsk Oblast in Russia (15 percent) and Tashkent in Uzbekistan (14.8 percent). Those levels surpassed the highest levels that nearly all experts once thought were possible, Dr. Mario C. Raviglione, who directs the health organization’s Stop Tuberculosis program, said in an interview. “We are seeing levels of multiple-drug-resistant TB that we never expected — 20 percent is a very high level,” Dr. Raviglione, said. The Global Plan to Stop TB is a road map for reducing by half TB prevalence and deaths by 2015 compared with 1990 levels.

When W.H.O. started a drug surveillance project in 1994, he said, “the general thinking was that multiple-drug-resistant TB would never be a real problem since it was felt to be confined to immunosuppressed patients.” A decade ago, when W.H.O. first received reports of 9 to 10 percent rates of multiple-drug-resistant TB in some areas, many scientists thought the figure was inaccurate due to a misclassification that mixed new, previously treated and chronic cases together. Experts also said higher rates were not possible, Dr. Raviglione said, but “we see now it is possible, it tells you they are really doing something wrong in places where this form of TB is spreading.” Overall, about one in 20 new cases of tuberculosis in the world is resistant to first line drugs, which translates into nearly 500,000 of the 9 million new tuberculosis cases that are detected each year, according to the W.H.O. survey, which involved 90,000 patients in 81 countries.

The World Health Organization says that there is a financial gap of $2.5 billion of the estimated $4.8 billion needed this year for overall TB control in low- and middle-income countries. For the first time, the survey included analysis of extensively drug-resistant tuberculosis, or XDR-TB, a virtually untreatable form of the respiratory disease because the causative bacteria are resistant to virtually all the most effective anti-TB drugs. XDR-TB has been reported in 45 countries, but because few countries have the necessary laboratories to detect it, the data were limited. The true extent of the problem remains unknown in some pockets of the world because only six countries in Africa, the region with the world’s highest incidence of TB, could provide drug resistance data for the report, Dr. Raviglione said. Other countries in the region could not conduct surveys because they lack the laboratory equipment and trained personnel needed to identify drug-resistant TB. Outbreaks of drug resistance are likely going undetected, Abigail Wright, the principal author of the W.H.O. report, said. Although the W.H.O. report highlights the extent of drug resistance, Dr. Raviglione said there were successes where governments invested in control measures. He cited the Baltic countries of Estonia and Latvia as “the model” because they were the drug resistant tuberculosis “hot spots” 13 years ago. Today, following a substantial investment and a sustained assault on multiple-drug-resistant TB, rates in these two countries are stabilizing and rates of new TB are falling.
By Lawrence K. Altman
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