Every Day is TB Day

By Bryan Schaaf on Friday, March 27, 2009.

World TB Day was on March 24.  If this were a blog about HIV/AIDS, I could write about the progress that Haiti and the rest of the world is making.  However, this is a blog on tuberculosis and a fight we are losing.  More than two billion people, one third of the world’s total population, are infected with TB bacilli, the microbes that cause TB.  People living with HIV are at greater risk.  For Haiti, much more remains to be done.

 

The statistics above were released as part of the 13th annual report on global control of tuberculosis, produced by the World Health Organization (WHO) in a series that started in 1997.  The 196 countries and territories that reported data in 2008 account for 99.6% of the world’s estimated number of TB cases and 99.7% of the world’s population.

 

First, the global picture.  Although a cure for TB has existed for more than half a century, it is one of three leading causes of deaths worldwide due to infectious diseases.  A total of 1.77 million people died from TB in 2007 (including 456 000 people with HIV), equal to about 4,800 deaths a day.  In 2007, there were 9.27 million new TB cases of which 80% were in just 22 countries. Per capita, the global TB incidence rate is falling, but the rate of decline is very slow - less than 1%.  TB thrives on poverty and instability, disproportionately affecting the poorest of the poor.  In the United States, on the other hand, TB rates reached a record low in 2008.  Even here though TB affected our most vulnerable - minority and immigrant populations.

 

Alarmingly, there were an estimated 511,000 new cases of multi-drug resistant TB – hard to treat, expensive to cure.   Extensively drug resistant TB, even more difficult to treat, has also been documented in more than 50 countries.

 

I had known about tuberculosis before living Haiti, but did not really understand how devastating it was before visiting the Partners in Health Hospital.  I remember asking if I needed a mask to enter the TB ward.  The reality is that if one is well nourished and has a healthy immune system, TB is not easy to contract.  Unfortunately, that is not the world we live in.  Many individuals in Haiti are sick, malnourished, sharing sub-standard shelter, or have compromised immune systems from HIV/AIDS or other conditions.  I distinctly recall meeting a man named Isaac who had needed surgery to remove on of his lungs, which TB had destroyed.  Isaac was the kind of person who never hurt anyone in his life, but when it comes to infectious diseases, that doesn't matter.

 

Courtesy of USAID, here is a summary of TB in Haiti.   Haiti has the highest per capita TB burden in the Latin America and Caribbean region.  After HIV/AIDS, TB is the country’s greatest infectious cause of mortality in both youth and adults (5,400 deaths in 2006).  Haiti is among the eight priority countries identified by the Pan American Health Organization for TB control in the region.

 

According to the World Health Organization’s (WHO’s) 2008 Global Tuberculosis Control Report, Haiti had and estimated 28,290 new TB cases in 2006. Of these, 44 percent were new pulmonary sputum smear-positive (SS+) cases.  Although Haiti falls short of the WHO targets of 70 percent case detection and 85 percent treatment success rates, the DOTS (directly observed treatment, short course) case detection rate is 55 percent, up from 22 percent in 1998.

 

The DOTS treatment success rate is 81 percent and has remained stable at an average of 78 percent over the last five years. DOTS coverage is estimated at 91 percent, up from 55 percent in 2004, but in some highly dense metropolitan settings, such as areas in Port-au-Prince, coverage can be as low as 13 percent.  The most populated department in Haiti, Ouest (West), has 34 percent of the country’s population but only 25 percent coverage.

 

Since 1998, the Ministry of Health (MOH) has supported the DOTS strategy in order to strengthen the national TB program, the Programme National de Lutte contre la Tuberculose (PNLT), and approved national guidelines and norms for TB control in 2002. However, the program lacks political and financial support from the government, and there is a lack of skilled technical human resources at the central level of the PNLT.  A major problem in combating TB is that co-infection with HIV can run as high as 30 percent in some urban areas.  Conversely, 20 percent of HIV-positive adults in Haiti are infected with TB. Strong stigma and cultural barriers attached to TB also interfere with case detection and adherence to treatment.  Multidrug-resistant (MDR) TB has increased from 1.4 percent in 2004 to 1.9 percent in 2006.  In partnership with three USAID-supported nongovernmental organizations, the MOH has taken steps to implement DOTS clinics in all 10 geographical departments in Haiti.

 

Between 2003 and 2005, USAID funds for TB programming in Haiti averaged $1.8 million per year.  USAID’s approach in Haiti complements the priorities of the PNLT.  The major areas of USAID activities reinforce TB-HIV/AIDS program building within the national DOTS program and establish links between TB and HIV services in order to continue to increase case detection and improve treatment completion rates.  Through the Santé pour le Développement et la Stabilité d’Haïti Project, USAID provides a continuum of care for co-infected patients based on the national norms.

 

Three Haitian non-governmental organizations (NGOs) receive support through this project: International Child Care/ Anti-Tuberculosis Crusade (ICC/CAT); Center for Health Development (CDS); and CARE.  This new integrated community care and support project supports the provision of TB detection and limited DOTS treatment services in clinics and communities nationwide, serving approximately 50 percent of the Haitian population. In the past, the Tuberculosis Coalition for Technical Assistance had also supported the PNLT with technical assistance. 

 

In the face of political turmoil and socioeconomic instability, TB control in Haiti has progressed in recent years. USAID support has led to improvements in TB control  The international community provides significant support for TB control in Haiti. Other partners include the Haitian Study Group on Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), Partners in Health, Management Sciences for Health, and the U.S. CDC. In 2003, the Global Fund awarded Haiti $14.6 million for TB control and prevention. NOTE: You can find much more recent Global Fund information on Haiti here.

 

What does the world need to win the fight against TB?  First and foremost, we must have a vaccine.  There are over 50 tuberculosis vaccines being tested, but this is a very long and very expensive process.  We also need better drugs - it is unacceptable that treatment should last well over six months.   We also need better diagnostics so we can learn as soon as possible who needs to be treated.  Above all, we need the long term will to see this struggle through.

 

Thanks for reading. We welcome your thoughts.

 

Bryan 

 

 

Haiti and DR Hold Bi-National TB Workshop (7/31/2014)

IOM this week supported the Haitian Ministry of Health and the National Anti-Tuberculosis Program by organizing and facilitating the second bi-national workshop on tuberculosis (TB). The event, held this week in Port-au-Prince, was attended by the Haitian Minister of Health, delegations from Haiti and the Dominican Republic, and representatives from IOM and the World Health Organization (WHO). The purpose of the workshop was to develop a joint plan to reduce the incidence of TB on both sides of the island, with a special focus on vulnerable populations, including the migrant population. Migrant health is a major challenge in the Caribbean region. The growing mobility of workers between Haiti and the Dominican Republic makes the need to reinforce the prevention and treatment of TB a priority.
Multi-drug resistant tuberculosis, to which migrant and internally displaced populations are particularly vulnerable, is also a growing cause of concern on the island. "IOM will work closely with the Ministry of Health, WHO and bi-national partners to support the implementation of this joint plan and to advocate for the promotion of migrant health through TB and HIV programs, particularly in the border areas," said Kristin Parco, IOM's health program manager in Haiti.
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Since the January 2010 earthquake, IOM has worked in close collaboration with the Ministry of Public Health and Population to address priority health issues and improve access to healthcare for internally displaced persons (IDPs). IOM integrates TB and HIV detection and response in its health interventions in camps and assisted voluntary return and reintegration (AVRR) programming. IOM also builds capacities of medical personnel and community health agents in screening, referral and treatment of TB, as well as sensitization and health education. "IOM will continue to offer technical support to the Haitian and Dominican governments. Migrant integration in national policies is essential for an effective and inclusive fight against tuberculosis," said IOM Haiti Chief of Mission, Gregoire Goodstein.
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On the occasion of the World Health Assembly held in Geneva in May 2014, IOM, in support of Resolution 61.17 on migrant health, highlighted the need to reinforce collaboration between countries to fight tuberculosis, the second leading cause of death from an infectious disease worldwide. At the global level, IOM has substantial experience in TB screening among refugee, IDP and migrant populations. IOM is a member in the Stop TB Partnership and the Global Fund and implements TB-related projects in South-East Asia, the Middle East, South America and Africa.

Architect Goes After TB in Haiti (NPR - 6/28/2011)

By Eliza Barclay
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A nonprofit group hopes this winning home design will help prevent tuberculosis transmission with better ventilation. When it comes to beating tuberculosis, the focus is usually on better drugs and tests and, maybe someday, a vaccine. But what about building better homes for people at risk of catching the infection? That's what Peter Williams, a Jamaican-born architect and a visiting scholar in the Healthy Infrastructure Research Centre at the University College London, is doing with a little group he founded called ARCHIVE (Architecture for Health in Vulnerable Environments). The New York-based nonprofit wants to use one basic need – housing – to help satisfy another – health. Williams has worked all over the world, and he's seen a lot of overcrowded slums in his day — places where TB bacteria, which travel by air, can have a field day, jumping from person to person in tight, badly ventilated spaces. Good ventilation, according to the National Institute of Allergy and Infectious Diseases, is the most important way to prevent TB transmission anywhere.
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Williams tells Shots he realized early on that the state of your home can have a direct impact on your health. As a child in Kingston, Jamaica, he saw his father succumb to an illness from a rodent that crawled in through their home's patchy flooring. Since then he says he's realized there's an untapped opportunity to get architects and planners to join forces with epidemiologists and doctors around housing and health. ARCHIVE's first project is in the town of Saint-Marc in Haiti, a country with a big TB problem (306 cases per 100,000 people in 2007, according to the World Health Organization) as well as an urgent need for new housing. At particular risk are people there with HIV, for whom coinfection with TB would be especially devastating. ARCHIVE wasn't sure how the homes should be designed, so it put out a call for designs. Some 1,600 people from around the world in diverse teams – architects, engineers, physicians and immunologists among them — submitted ideas, which were winnowed down to 20 finalists.
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Construction of the five winning prototypes began in June in Haiti. When they're finished in about three months, the locals will test them out, and then ARCHIVE will choose one to replicate for 20 members of the community. What makes these houses so special? They use stacked ventilation with perforated walls to maintain continuous airflow. They also have less indoor humidity and better access to sunlight. Breathe House, the winning prototype, was designed by architects and their students from the U.S. and U.K., and comes with a user's guide for easy construction with mostly local materials. ARCHIVE will have to foot the bill for the homes, which, even at $50,000 a pop, are still totally out of reach for most Haitians. So one has to wonder whether this is a realistic solution to a nationwide epidemic of tuberculosis.

USAID Statement on 2011 World TB Day

World Tuberculosis Day is to call attention to the devastation the disease causes and to mobilize action to combat it. Between 1990 and 2009, deaths from TB declined 35 percent and prevalence decreased 14 percent. This is in large part due to global effort, large scale implementation of the DOTS strategy and involvement/engagement of public, private and community sectors. TB has always been the signature disease of the urban poor. In a world that is urbanizing at a rate of 200,000 (people) every day, we must fight TB now before it becomes an unparalleled global killer. The frightening growth of drug-resistant strains of TB—some of which cannot be treated—make the case for combating the disease even more compelling.
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Through President Obama’s Global Health Initiative, the United States is making major investments to prevent and control TB where the burden of the disease is highest. The United States Agency for International Development (USAID) is working in 40 countries with national TB control programs to deliver high-quality services to find and treat TB earlier to prevent the spread of the disease and the development of drug resistance. The programs are improving access and the quality of services in the public, private and community sectors.
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U.S. Government TB Strategy: In 2008, U.S. Congress passed the Tom Lantos and Henry J. Hyde United States Global Leadership Against HIV/AIDS, Tuberculosis, and Malaria Reauthorization Act, supporting an increase in TB funding over a five-year period. The Act requests the development of a U.S. Government (USG) global TB strategy. In May 2009, President Obama announced the Global Health Initiative (GHI), which adopts an integrated approach to fighting diseases, improving health, and strengthening health systems. The TB strategy describes how the USG will contribute to the goals to control TB, which are included in the Lantos-Hyde Reauthorization Act, as part of the broader GHI. The USG TB strategy was developed in consultation with all relevant USG partners including USAID, Centers for Disease Control and Prevention and the National Institutes of Health within the U.S. Department of Health and Human Services, U.S. Department of Defense, and the Office of the U.S. Global AIDS Coordinator. More TB related resources are available at: http://www.usaid.gov/our_work/global_health/id/tuberculosis/news/tbday_2...

Examining TB in Haiti (BBC -8/13/2010)

UNAIDS Executive Director calls for 'serious attention to TB'

3/24/2010
Kaiser Family Foundation
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In a statement marking World Tuberculosis Day, UNAIDS Executive Director Michel Sidibe "warned Wednesday that double infections of HIV and TB could become the next new epidemic," the Associated Press reports. Sidibe said, "I'm calling for serious attention to TB, and serious attention to TB-HIV co-infection" (Corder, 3/24).
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"Left unchecked TB and drug resistant TB - which knows no borders - could spread and become an even more severe global health threat," Sidibe said in a statement. "The world has already committed to reducing new TB cases and deaths under Millennium Development Goal 6. However, I call on the HIV community to go one step further: We must commit to halving TB deaths in people living with HIV by 2015" (3/24).
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Also on Wednesday, the Global Fund to Fight AIDS, Tuberculosis and Malaria Executive Director Michel Kazatchkine "said he hoped to win pledges of up to $20 billion over the next three years from national governments, but he was concerned that the global economic meltdown could make rich countries scale back their contributions," according to the AP. Kazatchkine's announcement comes ahead of an October 5 meeting, to be held at the U.N. headquarters, when donors will pledge funding for the next three-year period (3/24).
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Almost 30 donors are meeting March 24-25 in The Hague "to review global heath progress and assess funding needs for the period 2011-2013," according to a Global Fund press release (3/24). According to the AP, Kazatchkine "said the [Global Fund] also aims to reduce the prevalence of tuberculosis to 124 out of every 100,000 people in 2015, from 164 now, although he said the world was 'clearly off track' in its fight against drug-resistant tuberculosis" (3/24).
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TB In South-East Asia, Prisons Worldwide
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Also on Wednesday, the WHO's Regional Office for South-East Asia released a report detailing tuberculosis control in the region, VOA News reports (Herman, 3/24).
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The report (.pdf) said the disease is "one of the most serious health and developmental problems in the South-East Asia Region of WHO," which includes 11 countries. Each year, there are 3.2 million new TB cases in the region and approximately half a million deaths, according to the report. "The region accounts for over a third of the global TB burden. ... Of the 3.6 million people living with HIV in the region, roughly half are estimated to be co-infected with TB," the report notes (3/24).
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WHO officials are concerned about the spread of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) in the region, VOA News reports. Jai Narain, WHO's regional director of communicable diseases, said effective TB control programs can stop the spread of difficult to treat strains. "The emergence of drug-resistant TB is also a reflection of the quality of TB control programs. MDR [multi-drug resistant] levels are indeed reversible once we have good quality TB control programs," Narain said.
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XDR-TB cases have been detected in Bangladesh, India, Indonesia and Thailand, according to the news service (3/24). Though the report says "considerable progress continues to be made" in TB control in the region, other challenges, such as "uncertainties regarding sustainable financial and operational resources ... are slowing the planned expansion of interventions for TB-HIV and MDR-TB." It adds that more attention needs to be given to the "social, economic and behavioural determinants that impact TB" in order to successfully control the disease "in the longer term" (3/24).
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On Tuesday, the International Committee of the Red Cross (ICRC) said failure to control TB in prisons worldwide could hamper efforts to prevent the spread of drug-resistant strains of the disease, CNN reports. According to ICRC, prisons in developing countries are "perfect incubators for new variations of the airborne disease because of overcrowding, poor nutrition and inadequate health services," CNN writes. The organization – which has worked to curb TB in prisons in the Caucasus, Central Asia, Latin America and Africa – "points to the success of efforts to bring the disease under control in Azerbaijan where infected inmates are now treated in a centralized prison hospital in Baku and a similar program in neighboring Georgia."
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Nikoloz Sadradze, the head of ICRC's delegation in Baku, said: "When we started visiting prisons in Azerbaijan 15 years ago, we discovered that TB was killing around 300 inmates every year. By last year, the number of deaths had fallen to 20, thanks to prevention measures, improved screening and diagnosis, and medically supervised treatment and follow-up" (Hooper, 3/23).
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"Experience has shown that improved living conditions, including ample doses of fresh air and a diet of healthful foods, a heightened awareness of how TB spreads, and a better understanding by patients of the severe side effects that TB drugs cause, can make a big difference," according to an ICRC press release. "The ICRC also recommends that authorities implement the World Health Organization's TB control strategy, known as DOTS, which requires government commitment, regular supplies of medication and observed treatment" (3/22).
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Financial Times Examines TB Worldwide
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The Financial Times features a special series called "Combating Tuberculosis."
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In an overview article, the newspaper writes that "[t]oo many of the crude innovations which have saved lives for a century are still in use, when they should long ago have been superseded. And too few targets to reduce the burden of TB have been met. In much of the world, diagnostic techniques have barely changed: unreliable microscopic analysis and lengthy laboratory culture of germs."
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Mario Raviglione, head of TB at the WHO, remains "cautiously optimistic," according to the article. "36m people have been cured since 1995, detection is rising and since 2004 we have been flattening the curve of new cases per capita," Raviglione said. "Those are signs of success."
.
The article examines "promising experimental medicines [that] have begun advanced clinical trials in patients, and helped catalyse unprecedented co-operation with regulators," as well as other efforts, including "public-private partnerships in the search for new diagnostic techniques, vaccines and more affordable, practical and effective drugs."
.
The Financial Times writes that TB is the "orphan of the 'big three' killer infectious diseases, with less attention or funding than either HIV or malaria. ... The U.S. has its bespoke President's Emergency Plan for AIDS Relief and the President's Malaria Initiative, but TB is subsumed into more general projects" (Jack, 3/23).
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Summaries of other Financial Times stories in the series appear below.
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One of the stories focuses on drug-resistant strains of TB. "The delays and difficulties of the treatment help explain why multiple drug resistant or MDR-TB is increasingly prevalent, accounting for an estimated 440,000 cases in 2008, of which a tiny fraction are treated in line with best practice. Patients take four or five pills a day, supplemented by a daily injection – into alternate buttocks because it is so painful." The article also looks at the socio-economic and financial dimensions of drug-resistant TB (Jack, 3/23).
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"In recent years, faster, more effective [TB] diagnostics technology has been developed. However, the challenge is to ensure it can be used in developing countries where healthcare infrastructure is weak or non-existent but where most of the world's TB patients live," the Financial Times reports in a story examining diagnosing TB in resource-limited settings. The article reports on several developments aimed at expediting the invention and use of newer, more efficient diagnostic techniques (Murray, 3/23).
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The Kaiser Daily Global Health Policy Report is published by the Kaiser Family Foundation.

UNAIDS Executive Director calls for 'serious attention to TB'

Kaiser Foundation
3/25/2010
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In a statement marking World Tuberculosis Day, UNAIDS Executive Director Michel Sidibe "warned Wednesday that double infections of HIV and TB could become the next new epidemic," the Associated Press reports. Sidibe said, "I'm calling for serious attention to TB, and serious attention to TB-HIV co-infection" (Corder, 3/24).
.
"Left unchecked TB and drug resistant TB - which knows no borders - could spread and become an even more severe global health threat," Sidibe said in a statement. "The world has already committed to reducing new TB cases and deaths under Millennium Development Goal 6. However, I call on the HIV community to go one step further: We must commit to halving TB deaths in people living with HIV by 2015" (3/24).
.
Also on Wednesday, the Global Fund to Fight AIDS, Tuberculosis and Malaria Executive Director Michel Kazatchkine "said he hoped to win pledges of up to $20 billion over the next three years from national governments, but he was concerned that the global economic meltdown could make rich countries scale back their contributions," according to the AP. Kazatchkine's announcement comes ahead of an October 5 meeting, to be held at the U.N. headquarters, when donors will pledge funding for the next three-year period (3/24).
.
Almost 30 donors are meeting March 24-25 in The Hague "to review global heath progress and assess funding needs for the period 2011-2013," according to a Global Fund press release (3/24). According to the AP, Kazatchkine "said the [Global Fund] also aims to reduce the prevalence of tuberculosis to 124 out of every 100,000 people in 2015, from 164 now, although he said the world was 'clearly off track' in its fight against drug-resistant tuberculosis" (3/24).
.
Also on Wednesday, the WHO's Regional Office for South-East Asia released a report detailing tuberculosis control in the region, VOA News reports (Herman, 3/24).The report (.pdf) said the disease is "one of the most serious health and developmental problems in the South-East Asia Region of WHO," which includes 11 countries. Each year, there are 3.2 million new TB cases in the region and approximately half a million deaths, according to the report. "The region accounts for over a third of the global TB burden. ... Of the 3.6 million people living with HIV in the region, roughly half are estimated to be co-infected with TB," the report notes (3/24).
.
WHO officials are concerned about the spread of multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) in the region, VOA News reports. Jai Narain, WHO's regional director of communicable diseases, said effective TB control programs can stop the spread of difficult to treat strains. "The emergence of drug-resistant TB is also a reflection of the quality of TB control programs. MDR [multi-drug resistant] levels are indeed reversible once we have good quality TB control programs," Narain said.
.
XDR-TB cases have been detected in Bangladesh, India, Indonesia and Thailand, according to the news service (3/24). Though the report says "considerable progress continues to be made" in TB control in the region, other challenges, such as "uncertainties regarding sustainable financial and operational resources ... are slowing the planned expansion of interventions for TB-HIV and MDR-TB." It adds that more attention needs to be given to the "social, economic and behavioural determinants that impact TB" in order to successfully control the disease "in the longer term" (3/24).
.
On Tuesday, the International Committee of the Red Cross (ICRC) said failure to control TB in prisons worldwide could hamper efforts to prevent the spread of drug-resistant strains of the disease, CNN reports. According to ICRC, prisons in developing countries are "perfect incubators for new variations of the airborne disease because of overcrowding, poor nutrition and inadequate health services," CNN writes. The organization - which has worked to curb TB in prisons in the Caucasus, Central Asia, Latin America and Africa - "points to the success of efforts to bring the disease under control in Azerbaijan where infected inmates are now treated in a centralized prison hospital in Baku and a similar program in neighboring Georgia."
.
Nikoloz Sadradze, the head of ICRC's delegation in Baku, said: "When we started visiting prisons in Azerbaijan 15 years ago, we discovered that TB was killing around 300 inmates every year. By last year, the number of deaths had fallen to 20, thanks to prevention measures, improved screening and diagnosis, and medically supervised treatment and follow-up" (Hooper, 3/23).
.
"Experience has shown that improved living conditions, including ample doses of fresh air and a diet of healthful foods, a heightened awareness of how TB spreads, and a better understanding by patients of the severe side effects that TB drugs cause, can make a big difference," according to an ICRC press release. "The ICRC also recommends that authorities implement the World Health Organization's TB control strategy, known as DOTS, which requires government commitment, regular supplies of medication and observed treatment" (3/22).
.
The Financial Times features a special series called "Combating Tuberculosis." In an overview article, the newspaper writes that "[t]oo many of the crude innovations which have saved lives for a century are still in use, when they should long ago have been superseded. And too few targets to reduce the burden of TB have been met. In much of the world, diagnostic techniques have barely changed: unreliable microscopic analysis and lengthy laboratory culture of germs."
.
Mario Raviglione, head of TB at the WHO, remains "cautiously optimistic," according to the article. "36m people have been cured since 1995, detection is rising and since 2004 we have been flattening the curve of new cases per capita," Raviglione said. "Those are signs of success."
.
The article examines "promising experimental medicines [that] have begun advanced clinical trials in patients, and helped catalyse unprecedented co-operation with regulators," as well as other efforts, including "public-private partnerships in the search for new diagnostic techniques, vaccines and more affordable, practical and effective drugs."
.
The Financial Times writes that TB is the "orphan of the 'big three' killer infectious diseases, with less attention or funding than either HIV or malaria. ... The U.S. has its bespoke President's Emergency Plan for AIDS Relief and the President's Malaria Initiative, but TB is subsumed into more general projects" (Jack, 3/23).
.
Summaries of other Financial Times stories in the series appear below.
.
One of the stories focuses on drug-resistant strains of TB. "The delays and difficulties of the treatment help explain why multiple drug resistant or MDR-TB is increasingly prevalent, accounting for an estimated 440,000 cases in 2008, of which a tiny fraction are treated in line with best practice. Patients take four or five pills a day, supplemented by a daily injection - into alternate buttocks because it is so painful." The article also looks at the socio-economic and financial dimensions of drug-resistant TB (Jack, 3/23).
.
"In recent years, faster, more effective [TB] diagnostics technology has been developed. However, the challenge is to ensure it can be used in developing countries where healthcare infrastructure is weak or non-existent but where most of the world's TB patients live," the Financial Times reports in a story examining diagnosing TB in resource-limited settings. The article reports on several developments aimed at expediting the invention and use of newer, more efficient diagnostic techniques (Murray, 3/23).
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Another Financial Times article looks at the South African government's plan to provide antiretroviral (ARV) drugs to "all TB/HIV co-infected patients." According to the newspaper, "Some 70 percent of people treated for TB in South Africa are also HIV-positive. The introduction of earlier-stage HIV treatment should help prevent those with latent TB from developing the full-blown disease" (O'Connor, 3/23). A second article about TB in South Africa reports on efforts by the health ministry toward "greater vigilance - and resources - to trace and treat every new case of [TB] infection." It also reports on efforts by other groups, such as the Anglo American mining group and the South African TB Vaccine Initiative, to control the disease (O'Connor, 3/23).
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The series includes an article about TB control in China. The newspaper writes: "China provides a demonstration of just how hard it is to tackle tuberculosis in the developing world. The country has many of the prerequisites for constructing an effective strategy for treatment and prevention. It has a relatively well-organised health system and a long history of aggressive action against infectious disease. ... Yet despite all these efforts, it still faces an uphill struggle to control the disease" (Dyer, 3/23).
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Another article reports on TB efforts in Brazil. "In its 2009 report on global TB control, Brazil ranks 14th on the World Health Organization's list of 22 countries that account for 80 percent of cases worldwide. The WHO estimates there were about 92,000 new cases in 2007 with an estimated incidence of 48 per 100,000 population." In addition, "TB is now the number one killer of people with HIV/AIDS in the country" (Wheatley, 3/23).

2010 World TB Message from USAID DIrector (3/24/2010)

http://www.usaid.gov/press/releases/2010/ps100324.html
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Video Message from USAID Administrator Rajiv Shah Launches New U.S. Government Global TB Strategy
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In a video message, USAID Administrator Rajiv Shah commemorated World Tuberculosis Day on March 24. Dr Shah spoke about the global TB burden and highlighted important steps the United States is taking to stop TB around the world through a new strategy. Dr Shah said: "Hi, my name is Raj Shah and I'm the Administrator for the U.S. Agency for international Development. I'm here to talk to you today about Tuberculosis because today is World TB Day.
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Tuberculosis is an infectious disease that claims nearly two million lives every year. It is second only to HIV/AIDS among infectious disease killers worldwide. More than 2 billion people, one-third of the world's population, are infected with the microbe that causes the disease, putting them at risk of developing TB in their lifetime. And TB is a disease of the poor, it's much more commonly found in developing countries. In fact, if you look here, 22 countries account for about 80% of the total global disease burden in tuberculosis. And you see many of the countries in Africa where HIV/AIDS prevalence is very high also have a significant problem with TB.
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Making matters worse, new forms of the disease are resistant to existing drugs. These multi-drug resistant strains of tuberculosis really threaten to undermine years of progress. And this table shows where multi-drug resistant TB is most likely to be found. But there's good news too. TB is a curable. Saving lives is simply a matter of early detection and appropriate treatment. In fact began learning about TB when I worked on a tuberculosis project in south India when I was in college. Since that time India has made great strides in controlling TB with a nation-wide program in part supported by the U.S. Agency for International Development.
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One useful tool has been the introduction of kits containing all of the drugs a patient needs to complete treatment. This is a picture of just the drugs that the patient is taking, and this is a simple kit that has 6 months worth of drugs required for treatment. And this simple innovation has really helped simply the treatment and has saved hundreds of thousands of lives. Traditional microscopy, which is over 100 years old, is how tuberculosis is usually detected, and we simply have to have a better way of doing that. The problem with this method is that it misses almost 50% of TB cases, and it is not sensitive enough in people living with HIV. Which is why we're investing significantly in tuberculosis research and a lot of this work is very exciting. Tests to more rapidly diagnose drug resistant tuberculosis have already been endorsed by the World Health Organization.
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Hopefully, a point-of-care rapid test will soon be available so we don't have to use traditional microscopy and we have an effective and efficient way to identify tuberculosis. Once TB is diagnosed, treatment must also be provided. We are working with the private sector to develop new drugs that could shorten the TB treatment from the current 6 month recommendation to four months or even less. That would make it easier and cheaper to help solve TB in patients who have the illness.
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As part of the President's Global Health Initiative, we are accelerating our programs to control TB. Working with our many partners, we believe it will be possible to halve the number of TB cases and deaths by 2015. In doing so, 14 million lives could be saved. In support of these global targets, I am pleased to release the U.S. Government's Global TB Strategy (pdf, 485kb). This is our blueprint for expanded treatment and control over the next five years. We will work in close partnerships with host nations to implement this strategy.
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We also need action at the community level. This photograph shows women in Tanzania. This woman is actually a TB patient who's been cured during an effective directly observed therapy course of treatment. She's now working other patients to help them go through the treatment and to help protect them from tuberculosis. For those you on the front lines fighting this disease, I applaud your commitment. And I pledge to communities around the world that USAID will continue to stand by you in the important fight against TB. Thank you.

New WHO Report Estimates 440,000 MDR-TB Cases (3/19/2010)

Kaiser Foundation
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There were an estimated 440,000 cases of multidrug-resistant tuberculosis (MDR-TB) around the world in 2008 – one-third of which were fatal, according to a new WHO report on drug-resistant TB, the Los Angeles Times reports (Maugh, 3/19). The WHO report, based on data from 2008, found that almost half of all drug-resistant TB cases were in China and India, Reuters reports (Fox, 3/18).
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According to the Associated Press, data was missing from some countries, creating a "gap in the global TB picture." The report said that with current data, it is "impossible at this time to conclude whether the (drug-resistant TB) epidemic worldwide is growing or shrinking," AP reports (Cheng, 3/18).
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The report still cautions against the spread of drug-resistant TB and notes that more must be done to achieve global control, the Guardian writes. "Countries face enormous hurdles in accelerating access to diagnostic and treatment services for drug-resistant TB, and previous efforts to address this epidemic have clearly been insufficient," the report said (Boseley, 3/18).
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According to a WHO press release, "There is an urgent need to obtain information, particularly from Africa and those high MDR-TB burden countries where data have never been reported: Bangladesh, Belarus, Kyrgyzstan, Pakistan and Nigeria." Based on data from the countries reporting, in some parts of the world, one in four TB cases are MDR, defined as "resistant to at least isoniazid and rifampicin, the most effective anti-TB drugs," according to the release. For instance, 28 percent of newly diagnosed TB patients in one region of northwestern Russia were found to have MDR-TB in 2008, the press release notes. "This is the highest level ever reported to WHO. Previously, the highest recorded level was 22% in Baku City, Azerbaijan, in 2007," it adds (3/18).
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Elsewhere – in "Orel, outside Moscow, and Tomsk in Siberia" – the WHO said there had been "a remarkable decline" in MDR-TB over the last five years due to implementation of control efforts, the U.N. News Centre writes. In addition, neighboring "Estonia and Latvia also reversed rates of the disease," according to the news service.
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"In Africa, estimates show 69,000 cases [of MDR-TB] emerged, the vast majority of which went undiagnosed," U.N. News Centre writes (3/18). A low percentage of MDR-TB cases are reported in Africa compared with other regions, "due in part to the limited laboratory capacity to conduct drug resistance surveys," according to the WHO press release (3/18).
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The AP writes: "Again citing missing data, the agency says 'it has not been possible to conclude whether an overall association between (drug-resistant) TB and HIV epidemics exists.' In Estonia, Latvia and Moldova, WHO said people infected with both HIV and TB were more likely to develop drug-resistant TB. But there is no information from many countries across Africa where the most people with HIV live" (3/18).
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The report said of extensively drug-resistant TB (XDR-TB) cases, defined as resistent to first- and second-line drugs: "No official estimates have been made on the number of XDR-TB cases, but there may be around 25,000 a year with most cases fatal," according to the WHO press release (3/18). "Not all countries have the surveillance systems to pick up cases of XDR-TB ... So far, 58 countries have confirmed at least one case of XDR-TB," the Guardian reports (3/18).
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"Funding needed for MDR-TB control in 2015 will be 16 times higher than what is currently available in 2010," according to the WHO press release, which highlighted the financial challenges associated with controlling its spread. "There is an urgent need to expand and accelerate in countries access to new, rapid technologies that can diagnose MDR-TB in two days rather than traditional methods which can take up to four months," the release said (3/18).

Helping hands for tuberculosis patients and disabled people

3/12/2010
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The earthquake that struck Haiti two months ago has brought new challenges for people with disabilities and chronic illnesses. The Red Cross is supporting a tuberculosis sanatorium in Léogane and a rehabilitation centre for children with disabilities in Port-au-Prince. The earthquake has brought new challenges for hundreds of tuberculosis and HIV/AIDS patients being cared for by nuns in the Signeau sanatorium at Léogane, a port town some 30 kilometres west of Port-au-Prince.
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Several buildings in the hospital were badly damaged during the quake, and four patients died. Large cracks appeared in the walls of the laboratory, pharmacy and consulting rooms, rendering them unusable. With the help of a Swiss Red Cross delegate, the nuns from the order of the Little Sisters of Saint Theresa pulled hospital beds out into the open. As soon as possible, they set up donated tents for the 20 patients who had remained at the sanatorium, the others having fled in panic. The sisters also moved their own beds outside for safety.
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A nearby Canadian army unit helped level a suitable patch of land so that larger tents could be erected and kitted out as wards. The Swiss delegate and teams from the Spanish and Mexican Red Cross Societies installed water bladders, connected them up to water points and tap stands, and built latrines and showers. The Spanish team and the Haitian Red Cross arranged for a water truck to refill the bladders daily.
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Order has gradually been restored to the sanatorium. Outpatient consultations have resumed, and the tented hospital has admitted new patients. Those who fled after the quake have either returned or are coming back regularly to collect their medicine. "Our wish is to give patients the best service we possibly can," said Sister Chantal. "We want to continue doing so for as long as there are patients who need us."
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Haiti has one of the highest rates of multi-drug resistant tuberculosis in the Americas. According to the World Health Organization's 2009 Global Tuberculosis Control Report, there were over 29,000 new TB cases in Haiti in 2007 alone. The Signeau sanatorium is one of four specialist units supported by the ministry of health's national TB and HIV/AIDS programme. It is also the referral hospital of choice for several medical aid agencies and treats TB patients from Haiti's prisons.
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Although Signeau receives regular supplies of drugs for the treatment of both TB and HIV/AIDS, other basic medicines and dressing materials are in short supply. Since the earthquake, there has also been a shortage beds, and there are not enough tents to store supplies or house equipment from the now unsafe laboratory. The ICRC has provided the nuns with dressing and medical kits, tents and beds. At the same time, the organization is encouraging donors to continue to provide the hospital with basic medicines and dressing materials long-term.
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The St Germain rehabilitation centre normally cares for children with severe physical or mental disabilities. Its newest patients, however, are earthquake victims, and the centre is filling up with young amputees. Among them is five-year-old Michel, whose left leg had to be amputated after the family home collapsed in the quake. Michel's father brought him to St Germain to be fitted with an artificial leg, and for help to get him walking again.
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Michel is a lively little boy, and has already learned to stand on his tiny new leg. He was busy trundling around on a red and yellow plastic tricycle when the ICRC health team visited St Germain last week to deliver food, mattresses, sheets, mosquito nets and basic household items. Some of these goods, including one month's food rations, will be given to the families of 150 physically disabled children who will shortly be discharged to make room for the new arrivals. Without such help, the children's parents would have difficulty looking after them. The rest of the supplies will help care for and feed 100 mentally handicapped youngsters who have nowhere else to go.
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The assistance that Signeau and St Germain have received in recent days is part of the ICRC's response to the current emergency. However, the organization has been supporting medical facilities in prisons and shanty towns since it started working in Haiti in 1994, and that long-term support will continue. The ICRC also supports the work of the Haitian National Red Cross Society, which maintains first-aid posts and gets the sick and wounded to hospital in impoverished violence-prone areas of Port-au-Prince. In addition, the Haitian Red Cross plays a vital role in promoting preventive health care at community level.
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Working with facilities such as the Signeau sanatorium or the St Germain rehabilitation centre highlights the extraordinary dedication of the local responders who look after some of Haiti's most vulnerable and least-regarded communities. It is these Haitian helpers who will remain long after the country has overcome the effects of the earthquake.
With the exception of public UN sources, reproduction or redistribution of the above text, in whole, part or in any form, requires the prior consent of the original source.

Haiti Hospital’s Fight Against TB Falls to One Man (2/5/2010)

The New York Times
By IAN URBINA
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PORT-AU-PRINCE, Haiti — At a fly-infested clinic hastily erected alongside the rubble of the only tuberculosis sanatorium in this country, Pierre-Louis Monfort is a lonely man in a crowded room. Haiti has the highest tuberculosis rate in the Americas, and health experts say it is about to drastically increase.
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But amid the ramshackle remains of the hospital where the country’s most infected patients used to live, Mr. Monfort runs the clinic alone, facing a vastness of unmet need that is as clear as the desperation on the faces around the room. “I’m drowning,” said Mr. Monfort, 52, flanked by a line of people waiting for pills as he emptied a bedpan full of blood. All of the hospital’s 50 other nurses and 20 doctors died in the earthquake or have refused to return to work out of fear for the building’s safety or preoccupation with their own problems, he said. Mr. Monfort joked that the earthquake had earned him a promotion from a staff nurse at the sanatorium to its new executive director.
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In normal times, Haiti sees about 30,000 new cases of tuberculosis each year. Among infectious diseases, it is the country’s second most common killer, after AIDS, according to the World Health Organization. The situation has gone from bad to worse because the earthquake set off a dangerous diaspora. Most of the sanatorium’s several hundred surviving patients fled and are now living in the densely packed tent cities where experts say they are probably spreading the disease. Most of these patients have also stopped taking their daily regimen of pills, thereby heightening the chance that there will be an outbreak of a strain resistant to treatment, experts say.
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At the city’s General Hospital, Dr. Megan Coffee said, “This right here is what is going to be devastating in six months,” and she pointed to several tuberculosis patients thought to have a resistant strain of the disease who were quarantined in a fenced-off blue tent. “Someone needs to go and help Monfort, or we are all going to be in big trouble.”
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A further complication is that definitively diagnosing tuberculosis takes weeks. So doctors are instead left to rely on conspicuous symptoms like night sweats, severe coughing and weight loss. “But look around,” Dr. Coffee said. “Everyone is thin, everyone is coughing from the dust and everyone is sweating from the heat.”
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Dr. Richar D’Meza, the coordinator for tuberculosis for the Haitian Ministry of Health, said his office and the World Health Organization had begun stockpiling tuberculosis medicines. “We are very concerned about a resistant strain, but we are also getting ready,” he said, adding that he is assembling medical teams to begin entering tent camps to survey for the disease. “This will begin soon,” he said. “We will get help to these people soon.”
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For Mr. Monfort, it is not soon enough. He scavenges the rubble daily for medicines and needles. He sterilizes needles using bleach and then reuses the bleach to clean the floors. In his cramped clinic, eight of the sickest and most contagious patients lay on brown- and red-stained beds. He said he had lost count of how many more were sleeping in other pockets alongside the hospital. Hundreds come daily to pick up medicine. Outside the clinic, the air is thick with the sickening smell of rotting bodies. Occasionally a breeze carried a waft of char from small cooking fires nearby, offering a respite from the stench and the flies.
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Mr. Monfort began to explain that his biggest problem was a lack of food. Suddenly a huge crash shook the clinic. A patient screamed. Everyone stood still, eyes darting. A man outside yelled that another section of the hospital had collapsed. People looking for materials to build huts had pulled wood pilings from a section of the hospital roof, which then fell as the scavengers leapt to safety, the man said.
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Mr. Monfort looked to the ground silently as if the weight of his lonely responsibility had just come crashing down. “These people are dying and in pain here,” he said. “And no one seems to care.” The dire scene at Mr. Monfort’s clinic speaks to a larger concern: as hospitals and medical staff are overrun by people with acute conditions, patients who were previously getting treatment for cancer, H.I.V. and other chronic or infectious diseases have been pushed aside and no longer have access to care.
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At the Champ de Mars, Jean-Baptiste Renauld sat on a curb, one shoe missing, his blue polo shirt torn, his head cupped in his hands. “I have TB, and I am also supposed to get dialysis every other day,” he said, explaining that he was a doctor’s assistant before the earthquake and meticulous about his treatments. “I have not had dialysis in three weeks, and I feel my blood is rotting from inside.”
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Waving his hand over a sea of tents and tarpaulins, he added, “It is like this country.” Back at the clinic, Mr. Monfort struggled to fix an IV that had missed the vein and was painfully pumping fluids under a patient’s skin. Another ghost of a man hobbled to the doorway on crutches, moaning for help. “Please wait, please wait,” Mr. Monfort said in a tense whisper. The biggest source of stress, Mr. Monfort said, is that his three children and wife are living on the street because the earthquake
destroyed their home. His wife begs him daily to stay with them. Instead, unpaid and without a mask or gloves to wear, he walks to the sanatorium each day at 6 a.m. and stays until 8 p.m. when most of the patients drift to sleep.
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“Why don’t you just leave us to die?” asked Clervil Orange, 39. Mr. Monfort looked offended by the notion. But he did not answer and the question seemed to stick with him. The ancient Greek playwright Aeschylus once wrote that there was a type of suffering so intense that, even in our sleep, it bores into the heart until eventually, “in our own despair, against our will,” it taps into a terrible wisdom. After several minutes in silence, Mr. Monfort spoke of that wisdom. He referred to it as a “strange hope” that had sprung from the suffering of his patients and the loss and abandonment of his fellow staff members.
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“These people here are dying, but they keep me alive,” he said. “I know they are hurting more than me and not complaining. “So,” he said, handing another walk-in patient a packet of pills, “I must continue.”

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