TUBERCULOSIS EXPLODING IN EUROPE
WHO Roadmap to Contain Rise of Drug-Resistant TB in Europe
By Becky McCall M.SC., from Medscape Medical News
An action plan to combat the alarming rise in the incidence of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis (TB) in Europe was announced by the WHO Regional Office for Europe today. It is the first WHO region to develop an MDR-TB and XDR-TB action plan.
The Consolidated Action Plan to Prevent and Combat Multidrug and Extensively Drug-Resistant Tuberculosis 2011-2015 was announced by Ogtay Gozalov, MD, key author of the Action Plan and medical officer WHO/EURO, and Lucica Ditiu, MD, executive secretary, Stop TB Partnership.
Dr. Gozalov told Medscape Medical News that the main aims of the action plan were to strengthen and intensify efforts to address the alarming problem of MDR-TB and XDR-TB in the region. “We want to grant universal access to prevention, diagnosis and treatment; we want to prevent further emergence of MDR-TB; and we want to diagnose at least 85% of all estimated cases and successfully treat 75% of them.”
In comparison to other regions worldwide, Europe has been particularly badly hit by MDR-TB. The WHO European Region is estimated to harbor 18.4% of the global burden of MDR-TB, or 81,000 cases. It also contains the top 15 countries in the world with the highest proportion of MDR-TB among newly diagnosed and previously treated cases. The Russian Federation has an estimated MDR-TB incidence of 38,000, and Ukraine and Uzbekistan have the second highest incidence, with 8700 cases each.
Furthermore, costs associated with drug treatment of MDR-TB in the European region amount to US$6000 per patient over 2 years. “Diagnosis and hospitalization of patients costs even more. In the developed world, if you look at the entire package for an MDR-TB patient, it can be up to US$200-$300,000 per case. These are huge costs for society,” pointed out Dr. Ditiu.
Dr. Gozalov explained that if the Action Plan is fully implemented, then 225,000 MDR-TB cases would be diagnosed, and 127,000 of these would be treated by 2015, interrupting transmission. “By treating, we will avert around 250,000 new MDR-TB and 13,000 XDR-TB cases and this should save US$12 billion overall for the 53 member states,” he added. The Action Plan will cost an estimated US$5 billion.
According to Dr. Ditiu, MDR-TB and XDR-TB have increased substantially because of poor disease management by healthcare staff, inappropriate combinations or poor quality of drugs, lack of patient adherence to treatment, or contact with patients without adequate infection control measures in place.
She explained that the Action Plan was inclusive of medical and social issues in tackling the roots of TB. “Importantly it addresses the rights and involvement of civil societies and communities of health workers. Normal TB needs to be contained if we are to control MDR-TB; it is the mistakes 15 years ago that have led us to where we are today. I certainly hope we will not be here in another 15 years time trying to contain XDR-TB in the same way.”
The plan also addresses an urgent need for more effective drugs and vaccines. Dr. Ditiu said that new drugs in development should reduce the length of treatment from approximately 6 months to 4 months but they are unlikely to have a significant effect on MDR-TB treatment regimens. “Each country needs to put their heads together in the research effort, as is called for in this Action Plan.”
New treatments aside, Dr. Gozalov stressed that the initial problem lies with diagnosis and access to tests. He referred to WHO diagnostic guidelines, adding that technology has made the diagnostic process much quicker but that access was essential.
“About a year ago, WHO approved a revolutionary new diagnostic test [Xpert MTB/RIF, co-developed by Cepheid, Inc., and Foundation for Innovative New Diagnostics], which takes 90 minutes to determine whether it is TB or not TB and also whether it is resistant to rifampin. This test is supported by the Action Plan to ensure access to all TB suspects.”
Adding to the discussion on how to find and diagnose new cases, Dr. Ditiu stressed that work with communities and civil societies needs to be enhanced in a way similar to that seen with HIV. “There aren’t so many [nongovernment organizations] or patient groups addressing TB, particularly in Eastern Europe, so it will be a challenge to push the boundaries to discover new cases. This plan is a change in thinking because development of the Action Plan involved a lot of input from communities and civil societies from the start.”
The Consolidated Plan has been developed in consultation with representatives from the 53 European member states. A detailed assessment of existing interventions for MDR-TB and XDR-TB was conducted. Input from member states, a 3-day workshop for regional members, and finally feedback from a public consultation all contributed to the final plan. It is being submitted for endorsement by the WHO Regional Committee for Europe at its 61st session in Baku, Azerbaijan, this week. If accepted, it will be rolled out by member states, and monitoring and evaluation will be conducted and assessed against milestones at each Regional Committee annual meeting for the course of the Action Plan.
The Centers for Disease Control and Prevention has a TB elimination plan for the United States. TB incidence is declining in the United States, with 2005 figures showing a case rate of 4.8 per 100,000.
Dr. Pinna says:
When I was a medical student at the University of Bologna in Italy, I studied Infectious Diseases as all medical students do.
I was surprised at the emphasis that the professors laid on the study of Tuberculosis. We had to study the micro-organism in extreme detail: What did it look like? How did it grow? Where did it grow? Who could be exposed to infection? What were the symptoms of infection? And an endless series of mini-topics concerning treatment and re-treatment.
We had patients in our hospitals that were being treated for Tuberculosis and we talked to them and examined them. We took every precaution during our conversations and examinations.
When I returned from Bologna to take more training in an American hospital the first test given to me was a test for Tuberculosis. I was grossly Positive!
That finding set off a series of x ray examinations and blood examinations and also a required treatment for six months. All the exams were negative, but every new hospital that employed me wanted to see the x-rays and blood tests. This all came about because I came too close to a patient with Tuberculosis.
The importance of this personal story is that contagion is very very high. An inhalation of breath from an infected person will trigger the disease.
Today, in Europe, people from the entire world are moving about incessantly.
Tuberculosis, especially Drug Resistant Tuberculosis, is rising rapidly.
Tuberculosis can kill some people quickly. Others may be incapacitated and others simply have a strong allergic reaction. Tuberculosis in intertwined with the history of Europe. Many famous people died of Tuberculosis.
If you live in Europe be very cautious when you travel and meet others. An infection with this micro-organism may take you to a different planet.
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