Saturday, June 02, 2007

XDR-TB Blues

Tuberculosis has a strange history. It is an ancient disease: Hippocrates long ago identified phthisis, the Greek term for tuberculosis, as the most widespread disease of his day, and over the centuries the disease has killed millions. But it is also curable. Albert Schatz, a graduate student at Rutgers, isolated the antibiotic Streptomycin in 1943, which has proved effective against tuberculosis in treatment programs around the world.
Ideally, that should have been the end of TB's story as a major source of mortality. It has not turned out that way.

Effective treatment of TB requires taking the current drugs of choice (Rifampicin and Isoniazid) for a number of months, which patients are not always able to do, particularly in resource-poor countries, where drug supply chains, availability of health workers, funding of tuberculosis programs, and even the drugs themselves may be unreliable. Treatment interruption is largely responsible for the worldwide rise of multidrug resistant or MDR-TB, and of extensively drug resistant or XDR-TB. The upsurge of drug resistance is obviously a step backwards: it evokes the pre-1943 days, the days before drug treatment, the days of sending patients to sanatoria for fresh air, and in the last resort, submitting them to ghastly surgical interventions.

The newspapers, television and blogs have been filled this week with the story of Andrew Speaker, the lawyer from Georgia who took an international flight from Prague to Montreal after having learned from the Centers for Disease Control and Prevention that he is suffering from XDR-TB. Despite his apparent low infectiousness (having tested negative on skin tests, not being symptomatic), despite the lack of one known case of contracted active TB within an aircraft, and despite physicians not expressly forbidding him to fly, Mr. Speaker is largely being treated as a kind of bioterrorist, a fugitive, or a 'rascal', as this talking head (Dr. William Schaffner) on CNN video refers to him. On another CNN fear-inducing clip, one of Speaker's fellow passengers talks about her concerns about getting TB and possibly tranmitting it to family members by 'eating and drinking with them.' The CNN anchor does nothing to correct the misconception. Meanwhile, every expert and his dog is lining up to justify strict quarantine. On a brighter note, NPR gives a nuanced view of the case and provides useful factoids to help prevent further stigmatization of TB patients.

Let's see how the other half -- in the southern hemisphere of our planet -- lives with XDR-TB. While Speaker was flown to a high-tech TB facility in Denver on private CDC jet, things look a bit different down in Brooklyn Chest Hospital in Cape Town, South Africa. There, XDR-TB patients can only get a hospital bed after many months, if at all, and MDR-TB patients fare no better. This means that there are many identified (and who knows how many unidentified) MDR and XDR-TB patients out and about in the Cape Town community. Whereas in America this would probably lead to mass hysteria, local health providers in South Africa take a pragmatic approach: since isolation is not feasible, these patients may have to be treated within community settings, and ways will have be devised to prevent them passing on infection to others.

"We need to now as a department and as a society come up with the best and most humane manner to care for untreatable infectious patients. Maybe put infection control measures in place at community level and do lots of health education so that patients can be with their families and loved ones," says Dr Marlene Poolman, Deputy Director for TB Control in the province.

Watching Andrew Speaker on Good Morning America is about as close as the vast majority of Americans are ever likely to get to an XDR-TB patient. Other countries can't radically separate healthy citizens from such 'rascals', because they don't have the resources. Still, Speaker is a victim just like any patient with drug-resistant TB: a victim of poorly funded and implemented primary TB programs around the world, the rich spawning ground of drug-resistant strains. Perhaps now that an affluent citizen of the North has been struck by a disease far more prevalent in the impoverished South, more attention will be paid to global TB control. Or maybe we will just speculate and sermonize about his rascally behavior.


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