_|XDR-TB CASE IN UK|_

[Giuseppe]

Hospital confirms first UK case of extreme drug-resistant tuberculosis

? Glasgow officials tracing Somali man's contacts
? Epidemic unlikely but case highlights disease's danger

Aidan Jones and Sarah Boseley - The Guardian, Friday March 21 2008

Doctors have diagnosed the first ever UK case of a virtually untreatable strain of tuberculosis, marking a further step in the disease's fightback against the antibiotics that once kept it in check. A man in his 30s is in isolation at a hospital in Glasgow and is being treated with a cocktail of antibiotics in an effort to control the extreme drug-resistant tuberculosis (XDR-TB), the Guardian has learnt.

A spokeswoman at Gartnavel general hospital confirmed the case and said health officers were tracing people who may have come into close contact with the man.

This is the first time a patient has been diagnosed and treated for XDR-TB in the UK.

The World Health Organisation has warned of the danger that XDR-TB poses because of the ease with which the airborne disease can travel in an era of mass migration and global travel.

Tuberculosis is spread only through close and prolonged contact with other people, such as in a family or among children in a school, so there is no suggestion that a single case could spark an epidemic.

The arrival of XDR-TB in the UK is, however, a warning of the need for greater vigilance against the disease.

"XDR-TB is an extremely serious form of TB," said Professor Peter Davis, a Liverpool consultant and secretary of TB Alert in the UK. "It is quite prevalent in other parts of the world. We have got to be aware of it." Drugs could contain the disease, but not cure it, he said. About half of those who were infected would survive.

Strains of TB which are resistant to the two main antibiotics used to treat it have been spreading across the globe and complicating treatment for some years. About 1% of the 8,497 cases reported in the UK in 2006 showed multiple drug resistance.

XDR-TB, however, is a new and still more alarming phenomenon, showing resistance to both first and second-line drugs. Treatment takes 12 to 18 months and costs more than ?100,000 a patient. An outbreak would place a huge financial burden on local health authorities.

The man, a Somali, was screened for infectious diseases on arrival at Heathrow in November last year. An X-ray revealed TB scars on his lungs, but the disease was not active. The patient, thought to have claimed political asylum, told doctors he had recently undergone a six-month course of treatment for TB and, following an immigration interview, he was allowed to travel to Scotland.

In January he was admitted to Gartnavel after the disease reactivated in his lungs. Cultures later revealed the XDR strain, and health officials were called to trace his close contacts to prevent an outbreak.

Dr Oliver Blatchford, a consultant at the Greater Glasgow and Clyde NHS public health unit, said: "XDR-TB is no more infectious than ordinary TB, but does require different treatment. The contacts of this case are being screened in the same way as ordinary TB contacts and will be monitored closely to ensure that any further cases are identified early and treated quickly."

XDR-TB first came to public attention in 2006, when a cluster of cases was reported in KwaZulu Natal in South Africa. All 53 patients were HIV-positive and 52 of them died within 25 days. Dr Paul Nunn, head of the WHO's TB resistance team, warned that the cases were "raising the spectre of something that we have been worried might happen for a decade - the possibility of virtually untreatable TB".

The WHO estimates there are 9m cases of TB in the world, with perhaps 2% being XDR-TB. A report in February found that 44 countries had experienced cases. Many cases will have been missed because the correct tests will not have been carried out when the patient failed to respond to treatment.

The 'White Death': An old threat returns
Tuberculosis, once known as the White Death, ceased to be a big threat to the UK after the discovery of antibiotics. But the disease that killed Keats and at least two of the Bront? sisters has appeared in a new, deadly form with the identification of a case that appears resistant to most known drugs.

The more usual multi-drug resistant form of TB is a strain that is now resistant to rifampicine and isoniazid, the standard antibiotics used to treat TB. But there are good second-line drugs - taken as a "cocktail" - that can cure it. Even ordinary TB requires a six-month course of antibiotics, and it is essential the course is completed. It has been patients' failure to adhere to treatment regimes that has allowed the drug resistance to develop.

The best that doctors can do for patients with the extreme XDR-TB form is to contain the disease. In some cases, the affected part of the lung can be cut out, but often the disease has spread too far.

Health Protection Agency figures show a small drop in UK TB cases.

The 8,497 cases notified to the agency last year were down by 0.7% on the previous year's total.

Sarah Boseley
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http://www.guardian.co.uk/society/2008/mar/21/health?gusrc=rss&feed=networkfront

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[Gert van der Hoek]

Re: _|XDR-TB CASE IN UK|_

Man diagnosed with first ever British case of 'untreatable' tuberculosis strain


By NICK McDERMOTT -

on 21st March 2008

A patient has been diagnosed with what is believed to be the first ever British case of a virtually untreatable strain of tuberculosis.

The man - believed to be a Somali in his 30s - is in isolation at a hospital and being treated with a broad spectrum of antibiotics in a bid to control the disease.

This is the first time a patient has been diagnosed and treated for the extreme drug-resistant XDR-TB strain, which could kill half of those infected.

TB drug resistance has been increasing in the UK, following a similar worldwide trend, with the World Health Organisation warning that more needs to be done to combat the disease.

Tuberculosis is an airborne disease which is spread though close contact with other people.

Professor Peter Davis, a Liverpool consultant and secretary of TB Alert in the UK said: "XDR-TB is an extremely serious form of TB. We are aware that it is quite prevalent in other parts of the world, Because our country is no longer separated from disease by the channel, we have got to be aware of it."

Reports claim the patient, thought to be an asylum seeker, was screened for infectious diseases on his arrival into the country last year.

Despite x-rays revealing TB scarring on his lungs, the disease was not thought to be active, and he was allowed to travel to Scotland.

But in January he was admitted to Gartnavel General Hospital in Glasgow with TB, and tests have now revealed he is suffering from the drug-resistant strain.

Health officials are now trying to contact his close contacts in a bid to prevent any further outbreaks of the disease.

A spokesman for Gartnavel General Hospital said last night: "We can confirm a case of drug-resistant tuberculosis is being treated at the hospital.

"We are in touch with all close contacts of the patient, and where appropriate they will be screened.

"The strain is not any more infectious than normal TB. he main concern is that it is resistant to antibiotics, which makes it much harder to treat."

A WHO spokesman said the first case of XDR-TB was reported in March 2006 after researchers discovered an emerging global threat of highly resistant TB strains.

Concerns were heightened six months later by a cluster of "virtually untreatable" XDR-TB cases in an area of South Africa with high prevalence of HIV.

All but one of the 53 patients died in an average of 25 days after samples were taken for drug resistance tests.

http://www.dailymail.co.uk/pages/live/articles/health/healthmain.html?in_article_id=541110&in_page_id=1774

[Giuseppe]

Re: _|XDR-TB CASE IN UK|_

PROMED moderator commentary on the Somali XDR-TB case:
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[This Somali political asylum seeker is reported to have recently
completed a 6-month course of treatment for tuberculosis before
arrival in the U.K.; he likely declared he was asymptomatic and had
only a pulmonary scar indicative of old tuberculosis when he was
permitted to enter the U.K. in November 2007.

The exact components of this patient's regimen are not stated, but should have included INH, rifampin, pyrazinamide (PZA) and ethambutol. The 6-month regimen is only designed to treat disease due to drug-susceptible strains of _Mycobacterium tuberculosis_, although initial resistance to INH does not compromise the outcome for this 4-drug regimen.

However, initial resistance to rifampin does compromise the outcome of the 6-month regimen. Susceptibility to PZA is also essential for the 6-month
regimen to be effective.

In all likelihood, this Somali patient had XDR-TB to begin with, was given the 6-month regimen inappropriately in the absence of drug-susceptibility testing, and was mistakenly assumed to have inactive disease when he entered the U.K. in November 2007 (which raises the issue of possible exposure of airplane passengers to XDR-TB).

He unlikely developed XDR-TB as a result of non-adherence to the 6-month treatment regimen when he relapsed only 2 months later.

Such non-adherence would not easily explain acquisition of resistance to the fluoroquinolones and at least one of the 3 injectable anti-tuberculosis drugs capreomycin, kanamycin, and amikacin.

Development of XDR-TB usually follows the inappropriate use of these 2nd-line drugs in a patient for whom 1st-line drugs are failing. Patients then spread the infection to close contacts, who acquire primary XDR tuberculosis
(<http://content.nejm.org/cgi/content/full/356/7/656>).

From a prior ProMED-mail post 20080228.0813, "according to the WHO survey, which involved 90 000 patients in 81 countries from 2002-2006, about one in 20 new cases of tuberculosis worldwide is multidrug-resistant (MDR).., or approximately 450 000 of the 9 million new tuberculosis cases that are detected each year."

In another international, retrospective survey of nearly 18 000 TB isolates collected from 2000 through 2004, 20 percent of samples were MDR-TB, and 10 percent of these (or 2 percent overall) were XDR-TB (MMWR Morb Mortal Wkly Rep 2006; 55(11):301-5, available at
<http://www.cdc.gov/MMWR/preview/mmwrhtml/mm5511a2.htm>).

Although XDR-TB is present throughout the world, the international survey suggested that it is most common in Asia and Eastern Europe.

Up to 25 percent of cases are reported to be XDR in some localities; e.g., Baku, the capital of Azerbaijan, and Papua New Guinea.

In fact, because of poor surveillance and lack of resistance testing, the frequency of MDR and XDR TB in many parts of the world is unknown and may be much higher than has been as yet reported.

Anti-TB drug-susceptibility testing should be performed on initial _Mycobacterium tuberculosis_ isolates from all TB patients.

Isolates obtained after relapse or apparent treatment failure should also be
tested for drug susceptibility.

As pointed out in the prior ProMED-mail post 20080228.0813, a recent study (Pillay M, Sturm AW. Clin Infect Dis. 2007; 45: 1409-14) postulated that the introduction of the 6-month directly observed therapy-based tuberculosis-control programs in the absence of susceptibility testing or drug resistance surveillance was instrumental in the development of XDR in a highly transmissible strain in KwaZulu Natal, South Africa. - Mod.ML]
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http://apex.oracle.com/pls/otn/f?p=2400:1001:1774798791397790::NO::F2400_P1001_BACK_PAGE,F2400_P1001_PUB_MAIL_ID:1000,71914

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[teederkee]

Re: _|XDR-TB CASE IN UK|_

Given that the course of treatment is 12-18 months, what are some jursidictions doing to ensure that the patients are maintaining their regimen? Over the years I have read about incarceration and detention, but that is very rare. Many of those who carry TB also fall under a demographic lest likely to maintain a strict regimen.

[kent nickell]

Re: _|XDR-TB CASE IN UK|_

Some support mechanisms such as nutritional support can be used... but very complicated and expensive as you can imagine..Interestingly some of the support mechanisms esp in prison environments can be so valuable that a cottage industry has developed to fake being positive for TB to get into a more favorable environment or better nutritional support etc Outside of prisons the problems seem to be more related to cultural and social support. A lot of patients are also HIV positive which also further complicates therapy with multiple medications...

The WHO together with the South African Medical Assn and the Norwegian Medical Assn has produced a free of charge web based self-learning program on Multi Drug Resistant Tuberculosis including treatment guidelines which can be found at http://lupin-nma.net/index.cfm?m=2&s...K126/intro.cfm It is in English but will soon be translated into French, Spanish, Chinese and Russian...

[Giuseppe]

Re: _|XDR-TB CASE IN UK|_

(...) Outside of prisons the problems seem to be more related to cultural and social support. A lot of patients are also HIV positive which also further complicates therapy with multiple medications...

...

I read with interest your note, and today I found this piece on BBC:
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Deadly TB strain sweeps Kyrgyz prisons

A drug-resistant and virtually untreatable form of tuberculosis is spreading from prisons in Kyrgyzstan to the general population.

The BBC's Geneva correspondent Imogen Foulkes travelled to Kyrgyzstan with the International Committee of the Red Cross (ICRC) to see why.

Overcrowding in Kyrgyz prisons helps spread tuberculosis
Colony 19 is a rundown, Soviet-era prison just outside Kyrgyzstan's capital Bishkek.

Four hundred prisoners live inside its crumbling walls. Conditions are cramped and dirty, there is little water or electricity.

But the worst threat here is invisible.

Dr Maxim Berdnikov is an infectious diseases doctor with the ICRC. His regular visits to Kyrgyz prisons have led to an alarming discovery.

"Levels of tuberculosis in Kyrgyzstan's prisons are the highest I have seen in my entire career," he says.

"I've worked in the Caucasus, where TB is very prevalent too, but here it is higher. It is very worrying."

Today Dr Berdnikov is screening new arrivals for TB, but his equipment is poor - a 40-year-old truck, with X-ray equipment that is even older.

The young men lined up outside will have to wait several days at least before they know the results.

"I'm not worried," says Maxat. "I used to get screened at school, I'm sure my health is fine."

"Of course I'm not worried," adds Yevgeny, "I know I don't have TB."

Prison killer

That optimism is misplaced. Even if they do not have TB now, they stand a good chance of catching it in prison.

"It's really very dangerous for inmates arriving in this prison environment," says Dr Berdnikov.

"They've got a high chance of catching the disease even if they arrived here healthy."

The ICRC says Kyrgyz prisons have become breeding grounds for tuberculosis. Around 40% of screened prisoners are found to have TB, and over a third of those have the new, and highly dangerous, multi-drug resistant (MDR) variety.

TB is the leading cause of death in Kyrgyz prisons, and the rates of MDR TB are among the highest in the world.

There are many reasons for this - overcrowded, poorly ventilated prisons, malnourished prisoners, and, especially in the case of MDR TB, inefficient treatment.

"I got TB when I was in prison," recalls Damir.

"And I did get medicine for it. When I was released they said I was getting better and I would probably improve on my own, so I didn't need to take the pills anymore.

Frightening place

Instead of getting better, the interrupted treatment meant that Damir developed MDR TB.

Just a few months ago he was close to death, but now, thanks to a new project, he is one of a handful of prisoners who are being treated.

Most are sent to another prison, Colony 27, which is now reserved for TB patients.

It is a frightening place. Everyone, including guards, nurses, doctors, and visitors must wear protective masks.

A special treatment facility for prisoners with MDR TB opened just five months ago, with the support of the ICRC.

Now 49 MDR patients are being treated, but there is a long waiting list

"Treating MDR TB is highly complicated," Dr Berdnikov explains.

"It takes much longer, for at least two years patients have to take 20 pills a day. They are much more expensive than the drugs for normal TB, and they are toxic - patients often suffer severe side effects."

But there is not really an alternative.

"Patients with MDR TB need to be treated," continues Dr Berdnikov. "It's a death sentence, most of them will die without the drugs."

Money worries

Kyrgyzstan, however, has little money to treat anyone with TB, let alone prison inmates with the multi-drug resistant strain.

Its health service is only now trying to reform itself, following years of economic crisis after the collapse of the Soviet Union, and the abrupt end of financial support from Moscow.

TB rates among Kyrgyzstan's general population are already 10 times higher than in western Europe, and rates of MDR TB are increasing rapidly.

"The latest figures show that in Bishkek around 25% of all new TB cases are MDR," says Maxim Berdnikov.

"That's more than in Azerbaijan's capital, Baku, which the World Health Organisation recently highlighted as having the highest rates in the world."

'People migrate'

Dr Berdnikov's biggest headache is trying to keep track of his MDR TB patients once they are released from prison, and to make sure they still have access to medicine.

Of nine recently released, one has disappeared - no-one knows where he is, or whether he is continuing his treatment.

Kyrgystan's Soviet-era prisons are crumbling for lack of funds
"You know sometimes I feel it would be easier to keep them in prison," Dr Berdnikov says.

"But of course we can't do that, they are released when the sentence ends.

"But the problem is their priority then is looking for work to support their families. They travel in crowded buses, they go to crowded markets, and all the time they are spreading infection."

So while inside prison there is a waiting list for treatment for MDR TB, outside there is no guarantee that former inmates with MDR TB will get any treatment at all.

One problem is that many donor countries will not make money available for those who have committed crimes.

Maxim Berdnikov knows this. He has already tried pointing out that a teenager arriving in prison for stealing a chicken may receive a death sentence in the form of MDR TB.

Now he is appealing instead to fear. "People travel, they migrate. And you know Kyrgyzstan is not that far from the European Union. Many people from Kyrgyzstan go to Russia and then onwards.

"Who knows if one of them might bring the MDR TB strain with him?"


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http://news.bbc.co.uk/2/hi/asia-pacific/7307398.stm

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