A New Defense in the Fight Against Tuberculosis

TUBERCULOSIS (TB) is man’s oldest infectious killer, and it remains such a serious health threat that the World Health Organization (WHO) compares it to a time bomb. “We are in a race against time,” warns a WHO report on TB. If man fails to defuse this bomb, he may one day face a drug-resistant disease that “spreads through the air, yet is virtually as incurable as AIDS.” The time has come, urges WHO, to wake up to TB’s devastating potential. “Everyone who breathes air, from Wall Street to the Great Wall . . . , needs to worry about this risk.”

An overstatement? Hardly. Just imagine how wide-awake the world would be if a disease threatened to rage out of control and erase the entire population of, say, Canada in ten years! Though this sounds like fiction, the threat is real. Worldwide, TB kills more people than AIDS, malaria, and tropical diseases combined: 8,000 persons each day. Some 20 million people now suffer from active TB, and some 30 million could die from it in the next ten years—a number larger than the population of Canada.—See the box “TB’s Global Grip,” on page 22.

Now the Good News

Today, however, there is hope. After ten years of testing, researchers have come up with a strategy that may reduce TB from being a killer on the loose to being a criminal under siege. Dr. Hiroshi Nakajima, former director-general of WHO, called this new strategy “one of the most important public health breakthroughs of this decade.” And Dr. Arata Kochi, director of the WHO Global TB Programme, says that it offers the first-ever chance to “reverse the TB epidemic.” The cause of all this excitement? A method called DOTS.

DOTS is an acronym for directly observed treatment, short-course. It is a health management system that can cure most TB patients in six to eight months without their spending a single day in the hospital. DOTS depends on five elements for its success. If any of the elements are missing, notes WHO, the ability to cure TB victims “slips through our fingers.” What are these elements?

● 1. Directly: The most dangerous TB case is the undiagnosed case. WHO thus stresses that first of all, health-care workers should direct their efforts to identifying the people in their community who suffer from contagious TB.

● 2. Observed: The second element of DOTS makes the health system—not the patient—responsible for achieving a cure. Health-care workers or trained volunteers, such as shopkeepers, teachers, or former TB patients, observe patients swallowing each dose of anti-TB medicines. “Patient observers” are crucial for success because a main reason why TB persists till today is that patients stop taking their medicines too soon. (See the box “Why on the Rise—Again?” on page 22.) After just a few weeks of medication, they start feeling better and stop taking their pills. Yet, the medication must be taken for six to eight months in order to rid the body of all TB bacilli.

● 3. Treatment: During these six to eight months, health workers monitor the results of the treatment and document the patients’ progress. In that way, they make sure that patients are fully cured and cannot pass the infection on to others.

● 4. Short-Course: Using the right combination and the right amount of anti-TB drugs, known as short-course chemotherapy, for the right length of time is the fourth element of the DOTS strategy. These combined drugs give a knockout punch to kill the TB bacilli.* The drugs must always be in supply so that treatment is never interrupted.

● 5. !: WHO expresses this fifth element of the DOTS strategy by means of an exclamation mark at the end of DOTS! It represents funding and sound policies. WHO urges health systems to secure financial commitment from governments and nongovernmental organizations and to make TB treatment part of the country’s existing health system.

Speaking of funding, the DOTS method appeals to policymakers holding the purse strings. The World Bank has ranked DOTS as “one of the most cost-effective interventions available in fighting . . . disease.” The total cost of using the strategy in poor countries, calculates WHO, is about $100 per patient. “This seldom amounts to more than 10 cents (U.S.) per capita in developing countries, which is affordable even in the worst economic conditions.” Low costs, however, do not rule out high payoffs.

How Well Does It Work?

WHO representatives announced in March 1997 that the limited use of the DOTS strategy was “causing the global TB epidemic to level off for the first time in decades.” “Where DOTS is used, cure rates nearly double.” DOTS pilot projects carried out in areas rife with TB already show that the strategy is working. Consider a few success stories cited by WHO.

In India “DOTS has been applied in demonstration areas covering over 12 million people. . . . Tuberculosis is now cured in 4 out of every 5 patients.” In a pilot program covering one million people in Bangladesh, “87 percent [of the TB patients] were cured.” On an Indonesian island, a DOTS project “is curing 9 out of 10 infectious patients.” In China, pilot projects were “a stunning success,” with a cure rate of 94 percent. In one South African city, “more than 80 percent [of the TB patients] are being successfully treated.” Recently, DOTS was also instituted in New York City, with impressive results.

The findings of field tests in several dozen countries, concludes Dr. Kochi, show that the strategy “can be used everywhere and can produce cure rates of 85 percent and more.”

No Boom—But Progress

With a treatment that can practically defeat one of man’s deadliest infectious killers easily and inexpensively, you would expect the DOTS strategy to be booming. “Yet,” says a WHO official, “surprisingly few countries are implementing WHO’s proven and cost-effective TB control strategy.” Indeed, at the beginning of 1996, only 34 countries had implemented the strategy nationwide.

Even so, there is progress. Prior to 1993, when WHO declared a global TB emergency, only 1 out of every 50 TB patients received DOTS. Today that ratio is 1 out of every 10. Reportedly, in 1998 some 96 countries were using the DOTS strategy. If more countries rally around DOTS, the annual number of TB cases ‘will be cut in half in just a decade.’ Says Dr. Kochi: “We have a proven health care package which only needs to be used more widely.”

Since man has the knowledge and the tools to fight against TB successfully, the only thing that is lacking is the ‘people who will see that these medicines are put to use throughout the world.’ No wonder that in a publication directed to physicians and other health workers worldwide, WHO asks: “What are we all waiting for?”

[Footnote]

[Blurb on page 21]

Every second, someone on earth is infected with tuberculosis

[Blurb on page 21]

‘Lifesaving medicines sit on the shelf while millions die.’—Dr. Arata Kochi

[Blurb on page 23]

“The DOTS strategy will represent the most important public health breakthrough of this decade.”—WHO press release

[Box on page 22]

Why on the Rise—AGAIN?

The cure for tuberculosis (TB) was discovered more than four decades ago. Since then, over 120 million people have died of TB, and nearly 3 million more people will die this year. Why are so many people still dying from TB when there is a cure? For three main reasons: neglect, HIV/AIDS, and multidrug-resistant TB.

Neglect. The eyes of the world are focused on such infectious diseases as AIDS and Ebola. In 1995, however, for every person who died of Ebola, 12,000 died of TB. In fact, TB is so common in developing countries that people there have come to view the disease as a fact of life. Meanwhile, in the richer countries, TB has been allowed to spread even while effective medicines to cure it sit on the shelves. This global neglect has proved to be a fatal mistake. While the world’s concern about TB was weakening, the TB bacilli were growing stronger. Today they attack more people in more countries than ever before in human history.

HIV⁄AIDS. TB is a traveling companion of HIV and AIDS. When people become infected with HIV—which lowers their immunity—they are 30 times more likely to develop TB. No wonder that the current worldwide HIV epidemic has caused an increase in the number of TB patients as well! It is estimated that 266,000 HIV-positive people died from TB in 1997. “These are the men and women,” says Peter Piot, director of the Joint United Nations Programme on HIV/AIDS, “who didn’t benefit from the inexpensive anti-TB medicines they needed to cure their tuberculosis.”

Multidrug-Resistant TB. “Superbugs,” immune to man’s antibiotic arsenal, are the stuff of science fiction, but in the case of TB, they are rapidly becoming a fact. More than 50 million people may already be infected with multidrug-resistant (MDR) TB. Patients who stop taking their medicines after a few weeks because they feel better, because the drug supplies run out, or because the disease carries a social stigma do not kill all TB bacilli in their body. In one Asian country, for instance, 2 out of every 3 TB patients drop out of treatment early. When they become sick again, the disease may be harder to treat because the surviving bacteria fight back and triumph over every available anti-TB medicine. As a result, the patients end up with a type of TB that is incurable—for them and for whomever they may infect. And once this deadly MDR genie is out of the bottle , we are left with the grim question, Will man be able to put it back?

[Box on page 22]

TB’s Global Grip

The tuberculosis (TB) epidemic is growing more sizable, more expensive, and more deadly by the year. Reports gathered by the World Health Organization trace the spread of this silent killer. Here are some examples: “Pakistan has been losing the war against tuberculosis.” “Tuberculosis has returned to Thailand with a vengeance.” “Today, tuberculosis ranks among the leading causes of illness and death in Brazil.” “Tuberculosis has maintained a tenacious grip on Mexico’s people.” In Russia “the incidence of TB is rising sharply.” In Ethiopia “tuberculosis rages throughout the country.” “South Africa has one of the highest recorded incidence rates of TB in the world.”

Although 95 out of every 100 TB patients live in the world’s poorer countries, TB is tightening its grip on rich countries as well. The United States saw a sharp rise in reported TB cases during the early 1990’s. U.S. journalist Valery Gartseff notes that TB “has once more returned to haunt Americans.” Likewise, Dr. Jaap Broekmans, director of the Royal Netherlands TB Association, said recently that the TB epidemic has “begun to worsen in Eastern Europe and parts of Western Europe.” Not surprisingly, the journal Science, of August 22, 1997, states that “tuberculosis continues to be a major health threat.”

[Box on page 24]

TB Blueprint Discovered

Researchers recently succeeded in documenting the entire genetic blueprint of the tuberculosis (TB) bacterium. This feat marks “a new phase in the battle against one of mankind’s most successful predators,” says Dr. Douglas Young, of the Imperial College School of Medicine in London. The World Health Organization reports that this discovery “could prove invaluable to future research on anti-TB drugs and vaccines.”—The TB Treatment Observer, September 15, 1998.

[Pictures on page 23]

These combined drugs can kill the TB bacilli

[Credit Lines]

Photo supplied by WHO, Geneva

Photo: WHO/Thierry Falise

[Pictures on page 24]

It takes $100 to cure a patient

[Credit Lines]

Photo: WHO/Thierry Falise

Photo supplied by WHO, Geneva

[Picture Credit Lines on page 21]

Photo: WHO/Thierry Falise

Photo supplied by WHO, Geneva

Photo: WHO/Thierry Falise