[A2k] SUNS: Drug-resistant TB treatment barely succeeds

[Sangeeta]

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HEALTH: TREATING DRUG-RESISTANT TB, A LOSING BATTLE?

By Kanaga Raja, Geneva, 22 March 2007
South-North Development Monitor (SUNS) #6217, 23 March 2007

Multi-drug resistant and extensively drug-resistant tuberculosis are the tip
of an iceberg of failing strategies to curb tuberculosis, and the World
Health Organization needs to take the lead in developing new strategies
against the disease, the international medical humanitarian organization
Medecins Sans Frontieres (MSF) warned Thursday.

This grim warning from MSF comes even as the World Health Organization
released a report on Thursday in which it maintained that the global
tuberculosis (TB) epidemic had leveled off for the first time since the WHO
declared the disease a public health emergency in 1993.

The Global Tuberculosis Control Report 2007 of the WHO said that the
percentage of the world's population struck by TB peaked in 2004 and then
held steady in 2005.

The WHO however acknowledged that the spread of extensively drug-resistant
TB (XDR-TB) poses a serious threat to progress and could reverse recent
gains.

"We have a clear plan on how to control XDR-TB, but countries are moving far
too slowly on implementing this plan. Funding is an issue as well - it will
take an additional $650 million globally to implement control of both XDR-TB
and multi-drug-resistant TB (MDR-TB) in 2007 alone," said Dr Mario
Raviglione, Director of the WHO Stop TB Department.

"Beyond that, because of the threat of XDR-TB, research to identify new
diagnostics, drugs and vaccines is more vital than ever," the WHO official
added.

MSF released statistics on Thursday showing that even under optimised
conditions, treatment will succeed in barely more than half of patients with
multi-drug resistant tuberculosis (MDR-TB).

As insufficient research and development on new drugs and diagnostics has
left health staff without the right tools to treat the disease, some
patients will go on to develop extensively drug-resistant tuberculosis
(XDR-TB) regardless of the quality of care they are offered. The situation
is particularly alarming when treating people co-infected with TB and HIV,
said MSF.

"When resistance emerges to the major TB drugs, we're forced to go back to
using older less effective ones," said Dr. Jessica Adam, a doctor in MSF's
programme in Uzbekistan. "This means a much longer, much more expensive
treatment course that can cost up to $15,000, and especially relying on
drugs that are toxic: the side effects are simply horrible."

MSF said that since 1999, it has invested considerable resources, and
provided rigorous support to treat 570 patients with MDR-TB in Armenia,
Abkhazia, Georgia, Cambodia, Kenya, Thailand, Uganda, and Uzbekistan.

Despite these efforts, only 55% of these patients completed the 18-24 month
course of treatment. The remaining 45% died, did not improve on treatment,
or defaulted because of side effects, isolation, and other difficulties in
tolerating the treatment.

Diagnosing MDR-TB is also extremely difficult, said MSF. Most resource-poor
settings do not have access to the necessary sophisticated equipment. But
even in the best of settings that do, it can take up to eight weeks to get a
result. In patients co-infected with HIV who are already sick, such delays
can mean the difference between life and death.

"In places where we see a lot of HIV/AIDS, the risk of MDR-TB spreading like
wildfire is a terrifying, but all too likely prospect," said Dr. Liesbet
Ohler from MSF's programme in Mathare, a slum near Nairobi.

"Treating MDR-TB and HIV simultaneously is incredibly frustrating because of
drug interactions and the potential for many strong side effects, let alone
the number of pills patients have to take everyday. With the tools we have
today, we're fighting a losing battle."

Last year's XDR epidemic in South Africa sparked international concern about
the extent of the crisis and the urgency of finding solutions, MSF said,
stressing that concrete actions need to be taken now. The WHO needs to take
the lead to develop new strategies against the disease.

Despite the urgency of the situation, MSF said that current research efforts
are not keeping pace with the need for better tests, drugs and vaccines. An
analysis conducted by MSF of the TB research and development pipeline found
that none of the compounds under development today will be able to deliver
the drastically shorter treatment that is needed to curb the disease.

Similarly, the diagnostics under development will not be simple enough to
use in resource-limited settings and will not reliably detect the disease.
There is a critical funding gap for research and development for TB with
around $900 million needed annually but only $206 million being invested,
said MSF.

"MDR-TB, and now XDR-TB are the tip of an iceberg of failing strategies to
curb TB. We desperately need new tools and we need them now - we cannot just
sit and wait," said Dr. Tido von Schoen-Angerer, Director of MSF's Campaign
for Access to Essential Medicines.

"There is no quick ready-made solution, but that is not an excuse not to
act. One important step is to have all TB drugs in development tested in
trials with MDR patients: this would be a quicker way to see whether new
compounds are efficacious for patients with regular TB and give those with
MDR a chance for a better treatment. At the moment, only one company has
stated that it is planning to conduct an MDR trial while others sit on the
fence. WHO needs to ensure that these trials will happen," he added.

Meanwhile, according to the WHO Global Tuberculosis Control Report, the
global tuberculosis epidemic is leveling off, with the percentage of the
world's population struck by TB peaking in 2004 and holding steady in 2005.

The WHO said that although the rate at which people developed TB in 2005 was
level or even declined slightly compared to 2004, the actual number of TB
cases continued to rise slowly. The reason for this difference is that world
population is expanding.

The pace at which new TB cases developed in 2005, however, was slightly
lower than global population growth. The number of cases in 2005 was
8,787,000, up from 8,718 000 in 2004. An estimated 1.6 million people died
of the disease in 2005, 195,000 of them people living with HIV.

The WHO said that more than 90 million TB patients were reported to the
organization between 1980 and 2005.

The WHO report noted that facilities to diagnose and treat MDR-TB, including
XDR-TB are not widely available yet, and that the scale of the XDR-TB
problem globally is not yet known.

The WHO also highlighted an overall funding gap for TB control. Although
funds for TB control have risen substantially since 2002, reaching $2
billion, an additional $1.1 billion will be needed to meet the 2007 funding
requirements set by the Global Plan to Stop TB (2006-2015). A total of $56
billion - half of which should be funded by endemic countries and the other
half by donors - is needed for the 10-year plan, but current funding
commitments indicate a gap of at least $31 billion.

The WHO report also found that the WHO Regions of the Americas, South-East
Asia and the Western Pacific are now on track to meet their 2015 Global Plan
Targets (to halve 1990 TB case numbers and deaths from the disease by 2015);
while the African, Eastern Mediterranean and European regions are not.

The WHO said that its 2005 targets of 70% case detection and 85% cure were
narrowly missed globally: case detection was 60% and treatment success was
84%.


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