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Tuberculosis: Breaking the Deadlock
October 19, 2005
To mark the 36th conference held by the International Union against tuberculosis and respiratory diseases, Doctors Without Borders/Médecins Sans Frontières (MSF) organized a seminar on October 20 under the banner: "Tuberculosis: we can do more."
Head of MSF's tuberculosis unit,
What remarks can be made about tuberculosis and the methods being used to treat it?
The situation at the moment is very worrying because we've reached a brick wall. Each year, two million people die from the disease and nine million newly infected people are reported, more than 95 percent of them in poor countries. MSF therefore faces a precarious situation when it comes to treating people with tuberculosis. In 2004, 16,500 people began treatment in one of our programs. Our medical staff face constant challenges on a daily basis: obsolete and inefficient methods of diagnosis and treatment prevent us from effectively detecting and treating the disease.
The AIDS pandemic has enlarged the problem: 12 million infected by the AIDS virus also suffer from tuberculosis (this is known as co-infection). However, the diagnostic test currently available (the microscopic examination of sputum, lung fluid) does not work in the majority of people living with HIV/AIDS and on the whole only allows us to detect less than half of the cases of tuberculosis, with the risk that millions of people are left untreated. What's more, multidrug-resistant tuberculosis treatment is not only very long and costly; it also causes numerous undesirable side effects and remains largely ineffective as the number of cases increases.
MSF is thus launching a call for help on this front: it's of the utmost urgency that research and development is aimed at innovative solutions in the diagnosis and treatment of tuberculosis.
Why does the diagnostic test pose a problem?
The most frequently used diagnostic method—the microscopic examination of sputum—is over 120 years old and only allows for the diagnosis of between 45 and 60 percent of patients. It's not adapted to either the diagnosis of HIV-positive patients or that of children (who can't produce sputum). Other methods such as cultures and drug-resistance tests may exist but these are sophisticated techniques that are difficult to implement in developing countries where 95% of sufferers live.
What we lack is an easy-to-use diagnostic tool capable of providing rapid results, which can be used by any technician or health worker without the need for a sophisticated laboratory. Our teams are working closely with experts towards this goal but it appears that research and development is not investing sufficient resources in this direction.
Why is treating tuberculosis so complicated?
The current treatment of tuberculosis is based on drugs conceived over forty years ago. Patients are often required to ingest a large number of tablets, which adds to the difficulty of the treatment. To alleviate this, MSF is pushing for the implementation of "fixed-dose combinations"—which combine four drugs in one tablet—the quality of which has been certified by the World Health Organization (WHO). We use this treatment in the majority of our programs though it is not always included in the national protocols in the countries we operate in.
The other inherent difficulty is the duration of the treatment: between six and eight months. During this long period, the strategy recommended by the WHO urges patients to attend a health facility every day to take their treatment or to do so under the supervision of a volunteer in the community. Known as DOT, or directly observed therapy, treatment of this kind is undermined by a lack of human resources and tends to ignore treatment education and patients' responsibility for their own disease.
However, with the knowledge gained from our AIDS programs, we know that patients are capable of adhering to long and complex treatments without DOT, provided they're correctly informed and supported, and that they play an active role in their treatment. In MSF tuberculosis treatment programs, we offer certain patients the choice of attending a consultation only once a month where they receive their medicine for the following month combined with a strong adherence counseling educational component. A new approach to adherence is required.
What particular difficulties does HIV/AIDS-tuberculosis co-infection cause?
Tuberculosis and AIDS form a lethal duo. A third of the 40 million people who are HIV positive—close to 12 million people—are co-infected with tuberculosis and HIV/AIDS. Tuberculosis is the first opportunistic infection that strikes people suffering from HIV/AIDS and is also the leading cause of death in HIV-positive patients in Africa. Left untreated, 90 percent of tuberculosis patients die within a few months of contracting the disease.
Treating the two pathologies is a real challenge in terms of both diagnosis and treatment. It's currently impossible to diagnose tuberculosis in the majority of HIV-positive patients with diagnosis methods available in the field (essentially microscopic examination). It's vitally important that a new method of diagnosis be made available so that sufferers can begin treatment as soon as possible. In addition, information on the detection of AIDS in tuberculosis patients and tuberculosis in HIV-positive patients is also a priority. Finally, another area that needs to be developed is an integrated treatment of the two pathologies that incorporates patient care. Under this approach, people suffering from co-infection receive proper care and are monitored for both pathologies within the confines of a single health facility.
In what way is the emergence of the multidrug-resistant form of tuberculosis worrying?
Several factors cause the emergence of drug-resistant bacteria, chief among these are inadequate or incomplete treatment, or the use of poor quality drugs. Treating people suffering from multidrug -resistant tuberculosis is a terrible ordeal for both the sufferers and the people caring for them.
The treatment lasts two years and can lead to side effects that are particularly hard to cope with. The cost—as much as $15,000 per patient—is very high, and in some cases, represents some 200 times the cost of normal tuberculosis treatment. The supply of drugs is both complex and inconsistent. In some MSF programs, it can take up to a year for an order to reach the field.
Our medical teams face extreme difficulties in treating the increasingly large number of patients. In certain regions such as Central Asia (Kazakhstan, Uzbekistan), nearly a quarter of sufferers show multidrug-resistant forms of tuberculosis. According to WHO estimates, there are currently two million people affected by multidrug resistance, only a small proportion of which have access to existing treatments. Cases of multidrug resistance have also been detected in other developing countries, many of which have a high prevalence of HIV. MSF is thus launching a virtual call for help: without new treatments and an effective supply, multidrug-resistant tuberculosis will not be contained.