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A Toronto hospital is treating several cases of extensively drug resistant tuberculosis, with one of the patients being held in isolation under court order, the doctor overseeing the treatment said Mon 22 Jan 2007.
Public health experts fear the dangerous strain of tuberculosis, which is susceptible to very few of the anti-tuberculosis medications normally used to treat TB, is a global health crisis in the making. Dr. Monica Avendano, the physician in charge of the tuberculosis service at West Park Healthcare Centre, said since 2004, her unit has treated 5 or 6 patients with XDR TB, as it is called. All the patients were either infected abroad or infected by a family member who picked up the highly resistant strain elsewhere, she said.
"Currently, I am treating 3," said Avendano. "All of them have a previous history of tuberculosis that was not well managed."
Multi-drug resistant TB and the more difficult extensively drug resistant TB can arise one of 2 ways. A person with tuberculosis can fail to take all their medication, as in the case of the "not-well managed" patients to which Avendano referred. This spotty treatment allows the bacterium to survive the assault of the drugs and develop resistance to them. Or a person can be infected by contact with a person sick with XDR TB. Two of the cases Avendano has treated fall into this latter category.
"Both of the cases are young women who went to their country of origin to look after their ailing grandmothers. And the ailing grandmothers gave them TB. And it was XDR TB," she said.
She did not identify the countries involved. XDR TB has been found in a number of places, including China, South Africa, and many republics of the former Soviet Union. It is believed to have spread, still at low levels, from these jurisdictions to developed countries.
The Public Health Agency of Canada currently doesn't know the scope of the problem in this country. The last time Canadian TB statistics were gathered, the provinces and territories were not asked to report XDR TB cases. The TB statistics for 2006 -- which will be reported sometime in 2007 -- will include XDR TB figures, agency spokesperson Alain Desroches said in an e-mail.
Where such cases arise, they are treated in isolation, either with the consent of the patient or with the help of the courts. "All provinces and territories will use their public health legislation if necessary to ensure treatment of XDR TB," said Dr. Edward Ellis, manager of tuberculosis prevention and control with the public health agency. "With TB, in my experience, there's never a problem getting a court order if necessary. And nobody stands there saying: 'Oh, no, let them go.'"
Avendano said treatment with alternative drug regimes is effective, but it can take months of in-hospital care. Even then, it's not clear whether these patients -- who will be required to be seen on an ongoing basis -- are cured for life. That's because the strain hasn't been around long enough, and the treatment regime being used is too new to gauge its long-term efficacy.
http://thechronicleherald.ca/Canada/554590.html
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ProMED thanks Mary Marshall for this posting. A relevant discussion on the XDR problem in tuberculosis can be found at: CDC: Emergence of _Mycobacterium tuberculosis_ with Extensive Resistance to 2nd-Line Drugs --- Worldwide, 2000-2004. 2006;55: 301-305. Parts of the report are found below:
"17 690 isolates from the period 2000-2004 were tested for susceptibility to at least 3 of the 6 2nd line drugs (SLD) classes. Of these, 11 939 were from South Korea, of which 1298 (11 percent) were multidrug-resistant (MDR, defined as resistance to at least isoniazid and rifampin). From the other Global Supranational TB Reference Laboratory (SRLs), 2222 (39 percent) of 5751 isolates were MDR.
Of the 3520 MDR isolates, 347 (10 percent) were XDR (defined as cases in persons with TB whose isolates were resistant to isoniazid and rifampin and at least 3 of the 6 main classes of SLDs (aminoglycosides, polypeptides, fluoroquinolones, thioamides, cycloserine, and para-aminosalicyclic acid), including 200 (15 percent) of 1298 from South Korea and 147 (7 percent) of 2222 from other SRLs. The drug-susceptibility testing results were tabulated by year and geographic region (on the basis of the country of origin of the isolates) (Table 1; for table, see original URL. - Mod.LL).
XDR TB was identified in all regions but was most common in South Korea (n = 200; 15 percent of all MDR TB isolates) and countries of eastern Europe/western Asia (Armenia, Azerbaijan, Czech Republic, Republic of Georgia, and Russia, n = 55; 14 percent of all MDR TB isolates). The total number and proportion of XDR TB isolates observed worldwide (excluding South Korea) increased from 14 (5 percent of MDR TB isolates) in 2000 to 34 (7 percent of MDR TB isolates) in 2004. Year-specific proportions were stratified by geographic region. Increasing proportions of XDR TB were found among isolates from countries of eastern Europe/western Asia (n = 5 [9 percent] in 2000; n = 11 [17 percent] in 2003) and the group of industrialized nations (Australia, Belgium, Canada, France, Germany, Ireland, Japan, Portugal, Spain, UK, and USA, n = 3 [3 percent] in 2000; n = 25 [11 percent] in 2004).
USA national TB surveillance data included 169 654 patients with drug-susceptibility testing results. During 1993-2004, a total of 2689 (1.6 percent) MDR TB cases were identified, of which 1814 (67 percent) had results reported for 3 or more SLD classes. Of these, 74 (4.1 percent) had resistance to 3 or more SLD classes and thus met the criteria for XDR TB. Despite an overall decline in MDR TB incidence in the USA, the proportion of XDR TB increased slightly, from 37 (3.9 percent) of 944 cases during 1993-1996 to 20 (4.1 percent) of 489 during 1997-2000, to 17 (4.5 percent) of 381 in 2001-2004 (chi-square test for trend = 0.20; p = 0.66). During 1993-2002, patients with XDR TB were 64 percent more likely to die during treatment (relative risk [RR] = 1.6; 95 percent confidence interval [CI] = 1.2-2.2) than patients with MDR TB.
Among 605 MDR TB patients in Latvia who initiated therapy during 2000-2002, 115 (19 percent) had XDR TB. The proportion with XDR TB increased from 30 (15 percent) of 204 in 2000, to 46 (21 percent) of 215 in 2001, to 39 (21 percent) of 186 in 2002 (chi-square test for trend = 2.57; p = 0.11). Patients with XDR were 54 percent more likely to die or have treatment failure (RR = 1.5; CI = 1.1-2.2)." - Mod.LL
Patricia A. Doyle DVM, PhD,
Bus Admin, Tropical Agricultural Economics,
Univ of West Indies.
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Go with God and in Good Health
Medical ethics and other experts say tough isolation measures, involuntary if need be, are justified to contain very deadly, highly-contagious and drug-resistant mutant strains of tuberculosis and to prevent "a potentially explosive international health crisis" brewing most dangerously in South Africa.
They warn that new variations of the disease now defeat many of the world's existing drugs and "the forced isolation and confinement of XDR-TB ( extensively drug resistant tuberculosis ) and MDR-TB ( multiple drug resistant tuberculosis ) infected individuals may be a proportionate response in defined situations given the extreme risk posed."
Writing in the peer-reviewed online journal PLoS Medicine, co-authors Ross Upshur, MD, Director of the University of Toronto Joint Centre for Bioethics, and South Africa-based HIV-AIDS experts Jerome Amir Singh and Nesri Padayatchi, MD, say the world community urgently needs to help isolate and contain the threat.
"The South African government's initial lethargic reaction to the crisis and uncertainty amongst South African health professionals concerning the ethical, social and human rights implications of effectively tackling this outbreak highlights the need to address these issues as a matter of urgency lest doubt and inaction spawns a full-blown XDR-TB epidemic in South Africa and beyond," the paper says.
The World Health Organization ( WHO ) announced Sept. 1, 2006 that yet another deadly new strain of extensively drug resistant tuberculosis ( XDR-TB ) had been detected in Tugela Ferry, a rural town in KwaZulu-Natal ( KZN ) province, epicenter of South Africa's HIV / AIDS epidemic. Eight days later, the WHO urged a response to the outbreak akin to recent global efforts to control SARS and bird flu.
The new strain in September appeared within a year of a study showing 221 of 544 TB patients in KNZ province had multi-drug resistant tuberculosis ( unresponsive, at a minimum, to front-line drugs rifampicin and isoniazid ). Among the 221 cases, 53 were extensively drug resistant - i.e. resistant to rifampicin and isoniazid and to three or more of the six potential second line drug options.
Of the 53 XDR-TB patients, 44 were tested for HIV; all were infected with that disease too. The median survival from the time of sputum specimen collection was just 16 days for 52 of the 53 infected individuals, including six health workers and those reportedly taking anti-retroviral drugs.
"Such a fatality rate for XDR-TB, especially within such a relatively short period of time, is unprecedented anywhere in the world," the authors warn.
They note that South Africa is among the world's fastest growing tourist destinations, home to millions of migrant labourers, with ports and roads servicing several African countries.
"Cumulatively, these factors make for a potentially explosive international health crisis. The threat to regional and global public health is thus clear and further underlined by reports that XDR-TB is now considered endemic to KZN ... reported in at least 39 hospitals throughout the province and in other parts of the country."
South African XDR-TB cases numbered 300 on Dec. 1, 2006 and at least 30 new cases of XDR-TB are now reportedly detected each month in KZN alone, according to the paper.
XDR-TB diagnoses to date ( which require specialized laboratory facilities ) "likely represent a small proportion of the true extent of the problem. The number of persons harbouring latent infections is unknown ( and likely unknowable at present )," they add.
Factors fuelling the outbreak
Isolated cases of XDR-TB are documented in other regions and countries, including Canada. However, the situation in South Africa represents "the world's first recognized instance of extensive transmission of MDR- and XDR-TB," says Dr. Upshur. "Isolated cases do not so clearly raise the host of public health issues we discuss."
According to the paper, "factors that facilitate the spread of tuberculosis are well known and abundantly present in sub-Saharan Africa. Alongside inadequate health care systems response, poverty and global inequity contribute to the worsening of the global TB situation."
Low TB cure rates ( only about half of South Africa's adult patients are cured each year, compared with 80% in countries with better resources ) and the HIV epidemic have contributed to South Africa's MDR- and XDR-TB outbreak, the authors say. Underlying factors include:
These same patients "typically utilize public transport, and seek or continue ... employment. In so doing, they pose a significant public health risk to their families, co-workers, local community, and the wider public," the paper says.
Impoverished TB patients clearly need "some form of incentive and encouragement ... to enter and remain in the health system, although admittedly, their confinement could conceivably be indefinite or until they die."
The authors say South Africa urgently needs to:
Human rights, ethics and XDR-TB containment
The paper says South African officials have raised human rights concerns in dealing with the country's outbreaks but concede forcible treatment may be a viable option.
"An important question that we must come to terms with is the extent to which judicially-sanctioned restrictive measures should be employed to bring about control of what could develop into a lethal global pandemic," the authors say. "Ultimately in such crises, the interests of public health must prevail over the rights of the individual."
Other questions include what do with suspected TB sufferers for weeks while they await test results and about the conditions and duration of clinical surveillance once a case is confirmed. Ideally, confirmed cases "should be isolated in an acute admissions setting," the authors say, adding that XDR-TB patients should be quarantined separately from MDR-TB "as the latter is potentially curable."
WHO guidelines recommend that ambulatory MDR-TB patients refrain from mixing with the general public but offer no advice should voluntary measures fail. Just such a situation arose last Sept. 12, for example, when a Johannesburg XDR-TB patient refused hospitalization and discharged herself. Although forcibly hospitalized five days later, "it's unknown how many people she may have infected in the months between her sputum sample being taken and her eventual diagnosis in September 2006, and before she was traced after her self-discharge."
The authors say involuntary restrictive measures "may increase disincentives to seek care. However, if due care is taken to provide for the rights and needs of those so detained and therapeutic goals are kept paramount, such measures could play an important role of containing XDR-TB before it spreads more generally in the population globally."
"We would not argue for forcible treatment of MDR-TB or XDR-TB patients, simply restriction of mobility rights of such individuals," the authors say, adding that detained patients need appropriate legal council, given the uncertainty of the duration of restrictions. They also raise the possibility of independent tribunals to oversee the process.
The paper says authorities have "a strong reciprocal obligation" to support isolated patients with humane and decent living conditions.
"In fact, the restriction of their liberties is more for a collective good than for their own. Thus every effort must be made to ensure conditions of living that preserve dignity," the authors say. The duty of patients not to infect others can only be expected if the community shares the burdens involved.
New TB threat could derail HIV/AIDS efforts
"XDR-TB is a serious global health threat with the potential to derail the global efforts to contain HIV/AIDS, as broadly disseminated XDR-TB will prove to be a much more serious public health threat owing to its mode of transmission," says JCB Director Ross Upshur.
"The emergence of XDR-TB is also an uncomfortable reminder of the failure of health systems to control problems at a tractable scale. If, in the recent past, TB were to have been adequately managed when it was completely drug sensitive, we would not be in such a dire situation as is currently the case. This failure rests upon us all. We should begin to contemplate the response when we move to the predictable next phase: completely drug resistant tuberculosis ( CDR-TB )."
"Given the South African government's poor track record in dealing with the country's HIV/AIDS epidemic and what is at stake if it adopts a similar lethargic and denialist response to the country's XDR-TB outbreak, the international community must be vigilant in monitoring the government's response to this emerging crisis," says Dr. Padayatchi of Durban, Deputy Director of the Centre for AIDS Programme of Research in South Africa ( CAPRISA ).
"Containing XDR-TB and selected MDR-TB will require an interdisciplinary approach and the synergistic cooperation of all organs of the state, including, in particular, the judiciary, as well as various government departments. Moreover, the government should urgently consider devising strategies to control the disease amongst particularly high risk groups such as prisoners and migrant labourers, which might necessitate the involvement of prisoner advocacy groups and neighbouring countries, respectively."
Says JCB associate and co-author Jerome Singh of CAPRISA: "If WHO is sincere in calling for the XDR-TB outbreak in South Africa to be treated in the same light as SARS and bird flu, then global efforts to develop rapid diagnostic tests and novel treatment regimens must be stepped up. Poor countries need equipment to address these challenges - not just to diagnose and monitor the disease at hospitals but potentially at border posts and airports as well.
"The experience of Canada and other countries affected by SARS, including the way ethical and legal issues related to control measures were handled, could prove valuable in dealing with South Africa's XDR-TB outbreak."
University of Toronto Joint Centre for Bioethics
Innovative. Interdisciplinary. International. Improving health care through bioethics.
The JCB is a partnership among the University of Toronto and 15 health care organizations. It provides leadership in bioethics research, education, and clinical activities. Its vision is to be a model of interdisciplinary collaboration in order to create new knowledge and improve practices with respect to bioethics. The JCB does not advocate positions on specific issues, although its individual members may do so. For more information: www.utoronto.ca/jcb/
CAPRISA
The Centre for the AIDS Program of Research in South Africa was founded by the Universities of Natal, Cape Town, and the Western Cape, the Trustees of Columbia University, New York, and the National Institute for Communicable Diseases. The main goals of CAPRISA: research prevention and treatment of HIV/AIDS; build research infrastructure and capacity; and train more researchers in South Africa. For more information: www.caprisa.org
PLoS Medicine
PLoS Medicine is an open access, freely available international medical journal. It publishes original research that enhances our understanding of human health and disease, together with commentary and analysis of important global health issues. For more information: www.plosmedicine.org
From http://presszoom.com/story_123261.html
A man infected with an especially virulent strain of tuberculosis has spent eight months in a hospital jail ward under a court order and may be held until he dies.
Robert Daniels has not been charged with a crime, but the 27-year-old violated the rules of a voluntary quarantine, exposing others to a potentially deadly illness. Maricopa County public health officials got a court order to keep him locked up.
The TB strain Daniels has is so dangerous that he has never met his appointed lawyer, Robert Blecher, who describes the situation as "extremely unusual." Daniels' hospital room is designed so that air flows in, never out, to prevent the bacterium from spreading.
Daniels, who has dual citizenship in the U.S. and Russia, contracted "extreme multidrug resistant tuberculosis" while living in Russia, court records show. He was diagnosed two years ago in Russia, and said he came to Phoenix in January 2006 after being told drugs were hard to get and expensive.
Daniels went to a Phoenix hospital with respiratory problems in July 2006, and was sent to a Phoenix halfway house for indigent TB patients under a voluntary quarantine. He was ordered to continue treatment and wear a mask when he went out in public because the disease is spread by airborne contact.
Daniels stopped taking his medication and went unmasked to a restaurant, a convenience market and other stores, court records stated.
Robert England, Maricopa County's tuberculosis control officer, said in court filings that Daniels understands the rules, but "merely refuses to follow them." England applied for and received a "compulsory detention" order for Daniels, a legal tool used about once a year in Arizona.
Daniels, who has a wife and child in Russia, said in a telephone interview with The Arizona Republic that he didn't want to confuse people by wearing a mask and that doctors at Russian clinics where he was treated didn't even wear masks.
The Centers for Disease Control and Prevention reported there were 14,097 cases of TB in the United States last year. Just 15 were of the rare strain Daniels has. Prospects for his release are unclear. A 2006 medical assessment indicated the disease was mutating in Daniels.
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