Virulent New Strain of TB Raising Fears of Pandemic
Pastor Dale Morgan
Virulent New Strain of TB Raising Fears of Pandemic*
Bug Is Resistant to Most Available Drugs
By Peter Finn
Washington Post Foreign Service
Thursday, May 3, 2007; A01
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.