Drug Resistant Tuberculosis

By Diana J. Choyce
Nov 08 - 14, 1999

The World Health Organization reports that 22 countries together account for 80 percent of TB

cases across the world. TB is the largest worldwide killer after cancer and heart disease, even though under normal circumstances it is fully curable. However many of these countries are developing as drug resistant "hot zones" including the Dominican Republic, India, the former Soviet Union, and Argentina. If solid procedures and help are not put into place soon, TB could make a devastating resurgence. As it stands now up to 2 million people die each year and another 8 million are infected.

"TB resistance was noted right after the first use of streptomycin in 1948. But other drugs became available in the 1950s and 1960s which made resistance to streptomycin a non-issue. In the 1970s and 1980s, there was a very effective multidrug regimen, so regulations relaxed. Then HIV came in. And these two factors combined to create an explosive problem with tuberculosis. Now we see multi-drug resistant cases. If a patient takes just one drug, or three or four but once in awhile, the resistant strains are selected. The patient can transmit that resistant strain to others" says Dr. Pablos-Mendez.

India has the highest TB rate at almost 2 million new cases per year and kills nearly 500,000 people each year.

Apparently bureaucratic delays and insufficient priority by the Indian government has made it virtually impossible to implement a plan devised by the World Health Organization(WHO), called the Revised National TB Control program (RNTCP). The World Bank released a loan to India in early 1997 for $142 million. According Dr Luelmo of the WHO, "one year later we don't have drugs that should take three to five months to purchase in the international market.'' The sad thing is that India does have the money and health resources to battle TB effectively. But its neighboring countries do not and they are the ones who stand to lose in the long run.

The main push of the WHO program is using health care workers and volunteers who observe and log that patients are taking proper doses of anti-TB drugs and noting when they are cured. In China the program has worked very well and covered over 50% of the population. The full treatment costs only $2000US per patient over the six month course. The most serious problem that has emerged is that patients do not complete a full course of treatment. In this case the patient not only continues carrying the disease but can develop a resistance which they pass on to others. Treatment of drug resistant cases can cost as high as $250,000 per patient. If this continues, TB could well return to the days when it was incurable.

Another "hot zone" of TB is in the Russian prison system. There are about 100,000 cases of active TB and nearly 40% of those cases are drug resistant. The danger in this is that 30,000 inmates with active TB are released each year and 400 prison guards have been found to also have the disease. "These epidemics are only briefly local," said Dr. Paul Farmer, a professor of social medicine at Harvard and author of the report on Russia.

"They will not remain within prisons; they will not remain within national borders."

Pakistan is counted among one of the 22 "hot zones" surveyed by WHO. According to an article in the Dawn early this year, Punjab Governor Shahid Hamid has said "the government is paying more attention on the preventive, curative and rehabilitative services to ensure better healthcare facilities to the citizens". Currently, we are spending 2.2 per cent of the GDP on education while only 0.8 per cent on health. No nation in recent years has been able to make any substantial progress without investing in human resources at levels far higher than the levels that we have in Pakistan at present," he said. The federal government intends to expand the Social Action Program Project (SAPP-I) while including nutrition, TB control and first referral level care. An International Conference on Tuberculosis and Chest Diseases is expected to be held from 5 Novenber - 7 November at the Pearl Continental Hotel in Lahore. It has been organized by the Pakistan Chest Society, Institute of Chest Medicine and Mayo Hospital, Lahore.

According to the Centers for Disease Control and Prevention, Tuberculosis accounts for more than 25 percent of preventable adult deaths in Pakistan. The international Inter Press Service reported earlier this year that TB kills more woman in Pakistan than all other maternal mortality. Researchers are saying that the reasons include lower detection rates, unreliable treatments, and higher illiteracy rates compared to men. There is also a stigma attached to the disease that may keep woman from seeking treatment.

However when all is said and done it is our children that will bear the burden of this disease. Whether by losing their mothers or catching the disease themselves. Children can be easily cured with proper attention and care. If they are treated early and if they are not infected by the drug resistant strains. This can only be achieved by providing the funds and the means needed for early detection, access to medical care, and persistent follow up on every case. Unlike other infectious diseases TB is both treatable and curable. Its up to us to make that happen.