H5N1

WHO: A narrowing health gap between rich and poor nations

WHO has issued a news release about its newly published World Health Statistics 2013: WHO statistics show narrowing health gap between countries with best and worst health status. Excerpt:

As the Millennium Development Goals (MDGs) approach the 2015 deadline, this year’s World Health Statistics shows the considerable progress made in reducing child and maternal deaths, improving nutrition and reducing deaths and illness from HIV infection, tuberculosis and malaria. 

“Intensive efforts to achieve the MDGs have clearly improved health for people all over the world,” says Dr Margaret Chan, Director-General of WHO. “But with less than 1000 days to go to reach the MDG deadline, it is timely to ask if these efforts have made a difference in reducing the unacceptable inequities between the richest and poorest countries.” 

This year, the World Health Statistics compares progress made by countries with the best health status and those with least-favourable health status at the MDG baseline year of 1990 and again two decades later. 

Impressive health progress for countries in lowest health status category 

It shows that, in absolute terms, countries in the lowest 25% category of health status have made impressive health progress. 

For example, the absolute gap in child mortality between the top and bottom countries was reduced from 171 deaths per 1000 live births in 1990 to 107 deaths per 1000 live births in 2011. Some countries that were among those with the world’s highest child mortality rates in 1990 – including Bangladesh, Bhutan, Lao People’s Democratic Republic, Madagascar, Nepal, Rwanda, Senegal and Timor-Leste – have improved child survival to such an extent that they no longer belong to that group. 

However, despite the fact that 27 countries have reached the MDG target already, the current rates of progress will not be sufficient to reach the global target of a two-thirds reduction in 1990 levels of child mortality by 2015.

China: Infectious diseases in Beijing last week

Via the Beijing Municipal Health Bureau, a Google translated report: The Weekly Epidemiological (2013.04.29-2013.05.05).

Situation of the Epidemics 　　

2013 Week 18 (2013, April 29 to May 5, 2011), the city reported a total of 1934 cases of legal infectious diseases, 4 patients died (viral hepatitis). B infectious diseases were reported in 12 of 516 cases, the number of reported cases among the top five diseases were diarrhea, tuberculosis, viral hepatitis, scarlet fever and syphilis. Class C infectious diseases were reported in 1418 cases, the number of reported cases among the top three diseases were hand-foot-mouth disease, other infectious diarrhea and mumps. 　　

Focus of the Epidemic 　　

(A) measles 　　

21 cases reported this week 　　

(B) foot and mouth disease 　　

759 cases reported this week

The bureau also has an H7N9 page, accessible to Google Translate and Google Chrome, but it hasn't been updated since May 3, and most of the items are from April.

A crash course in tuberculosis

The excellent blog Infection Landscapes has a new mini-course, this one on Tuberculosis. The introduction:

This time on Infection Landscapes we are going to cover one of the most significant infectious diseases to affect humans: tuberculosis. Tuberculosis is an ancient disease and is currently the world's second leading cause of death due to an infectious disease. 

The Pathogen. Tuberculosis is caused by bacteria in the Mycobacteriaceae family. This family is comprised of many slow growing, acid-fast bacilli, most of which live in soil and water and help to degrade organic material. However, there are five species that are capable of causing tuberculosis in humans, and three of these are highly pathogenic. Mycobacterium tuberculosis, M. africanum, M. bovis are the three highly pathogenic agents capable of causing  tuberculosis in humans. M. tuberculosis causes the vast majority of human tuberculosis worldwide.

Uganda: Official blames drug resistant TB on negligent health workers

Via The Daily Monitor: Official blames drug resistant TB on negligent health workers. Excerpt:

A senior medical officer in the Ministry of Health has blamed the emergence of the deadly multi-drug resistant tuberculosis (MR-TB) in the country to negligent health workers. 

Dr Eldard Mabumba, a senior medical officer working with the TB and Leprosy Programme, said TB patients decline to take drugs and medical workers do not counsel them. 

“We still have high cases of TB patients not taking TB drugs which is contributing to the emergence of the deadly multi-drug resistant tuberculosis. But partly you medical workers are to blame because you don’t give the necessary counsel, information and time to these patients,” Dr Mabumba said. 

He was on Wednesday speaking during the southwestern region tuberculosis symposium organised by Makerere University HIV/Aids programme (MJAP) in Mbarara. 

Dr Mabumba added that despite the workload the medical workers have, they should give the necessary counselling and attention to patients. 

“Restore hope in these patients, counsel them then there will be limited cases of multi-drug resistant tuberculosis,” he added.

Australia: XDR-TB on the doorstep

Via the Medical Journal of Australia: Extensively drug-resistant tuberculosis hovers threateningly at Australia’s door. Excerpt:

It was hoped that extensively drug-resistant tuberculosis (XDR-TB) might never arrive on Australia’s shores. But new cases raise the spectre of death for patients, transmission to others and large costs for Australian taxpayers. Papua New Guinea (PNG) national Catherina Abraham, aged 20 years, “made it” to Australia and hit the headlines in October 2012 because she had been diagnosed with XDR-TB. 

After almost a year in an isolation ward at Cairns Base Hospital, she died on 8 March 2013. Her treatment cost Queensland Health about $500 000 and would have cost $1 million had she lived to complete it. 

Now another PNG national has been diagnosed with XDR-TB in Australia. In the preceding 8 years, only two other XDR-TB cases were recorded in Australia. According to Queensland Health, the most recently diagnosed patient came through the Torres Strait, was referred to Cairns Base Hospital and was transferred to PNG health services before the laboratory diagnosis of XDR-TB was made. 

He or she is currently in Daru Hospital (in PNG’s Western Province, the closest to Cape York). Although TB treatment is meant to be free for patients in PNG, potential exposure to other patients, the cost of sourcing active drugs, and the complexity and length of XDR-TB treatment mean that this patient is at significant risk of dying. 

A recent television exposé of Daru Hospital showed numerous patients with XDR-TB and multi-drug resistant TB (MDR-TB) mixing together and leaving their isolation wards, resulting in the risk of drug-resistant TB spreading through the community. 

Experts believe Abraham would have died within 1 month had she not reached Cairns and also predict that Australia could see its own outbreak of XDR-TB within 5 years. In comparison, 24 patients have been diagnosed with XDR-TB in the United Kingdom since 1995, six of whom were diagnosed in 2011. 

Patients with XDR-TB and the still-challenging MDR-TB in the UK are largely migrants from Eastern Europe, Africa and Asia. Last year, the UK government began requiring new entrants from TB-prevalent nations to have a chest x-ray with them on arrival to be granted a visa to enter the UK. 

Yet, owing to the UK’s porous air and sea borders and its accessibility and proximity to Europe, it is much more vulnerable than Australia to receiving patients with MDR-TB and XDR-TB. According to the UK’s Health Protection Agency, screening new entrants for latent TB would also be desirable. 

However, Australia is unlikely to enact a similar policy since it would produce many positive results for latent infection without identifying which patients would progress to active or drug-resistant disease (Justin Waring, Chair of the National Tuberculosis Advisory Committee, personal communication). So apart from the Qld–PNG border, it is difficult to predict where other XDR-TB or MDR-TB cases may appear in Australia, since migrants with latent infection can reside in any Australian city or region. 

In Australia, significant resources can, at present, be directed at patients with XDR-TB. Yet in PNG, all forms of TB compete for resources with a catalogue of other health and social problems, including high rates of diarrhoeal illness, pneumonia, HIV (many patients with HIV are co-infected with TB), malaria, maternal mortality, and widespread and crippling poverty.

The famous epidemiologist Charles Dickens made the point in Bleak House, published in 1853: Let disease spread among the poor, and it will inevitably spread to the rich. We have been amazingly obtuse about this simple observation for 160 years.

The Lancet on World Tuberculosis Day

The Lancet has published a special issue today. The executive summary:

To commemorate World TB Day 2013, The Lancet Infectious Diseases publishes a Series of papers on tuberculosis, a disease that has long plagued human beings and was declared a global emergency in 1993 by WHO. 

Without concerted action from political leaders, health policy makers, funders, and others, health systems worldwide are at risk of being overwhelmed by increasing numbers of patients with treatment-resistant tuberculosis. 

As new diagnostic tests, drugs, and drug regimens become available that have the potential to radically improve the detection and management of tuberculosis, the papers in the Series explore the challenges for successful implementation of these interventions.

South Africa: Why doesn't everyone have TB?

Via allAfrica.com, a timely article on the eve of World Tuberculosis Day: South Africa - Why Doesn't Everyone Have TB? Excerpt:

"It's complex" is a phrase that crops up frequently when asking health specialists to explain why South Africa is struggling to control tuberculosis. 

Poverty, the prevalence of HIV/Aids, the legacy of apartheid, and individual health-seeking behaviour are among the factors that Professor Nulda Beyers, director of the Desmond Tutu TB Centre at Stellenbosch University, cites when discussing the TB epidemic in South Africa. 

In contrast to a decrease in TB levels in other countries in the region, and despite South Africa's status as a middle-income developing country and substantial spending on health, TB levels in South Africa continue to rise. 

"When something is out of control it's exactly that - one can't get away from it. Here in the Western Cape one in every three minibus taxis has a person with infectious TB in that taxi. Once it has reached those proportions it's very difficult to unravel what was the reason the figures got so very high," says Beyers.

"I think the question is, why doesn't everyone in South Africa have TB?" Beyers asks and then answers her own question, explaining how a healthy immune system manages to overcome TB. 

"Even if people are infected, 90 percent will never get TB because we have a good immune system. But that is where HIV comes in. If the immune system goes down, then TB can flare up." 

Public health officials often describe TB as HIV's "twin". HIV has been rampant in South Africa for the past two decades, exacerbated by prevarication in the late 1990s and early 2000s when former president Thabo Mbeki questioned the link between HIV and Aids, and his health minister denied the efficacy of antiretroviral medication. 

After these tragic delays in combating the HIV/Aids pandemic, South Africa now provides antiretroviral therapy to some 1.7 million citizens - one of the world's largest public health Aids treatment programmes. 

Besides the effect of HIV, poor nutrition, or other factors in weakening the immune system, poverty is a key factor in explaining the prevalence of TB. A classic public health study of Victorian England shows how TB levels declined throughout the 19th century in direct correspondence with improved living conditions and a reduction in poverty. 

While Beyers is at pains to point out that wealthy, middle class people also contract TB, particularly given its widespread prevalence in South Africa, she says there are many reasons why poor people are more vulnerable to the airborne disease.

South Africa: New totally resistant TB identified

Just in time to ruin World Tuberculosis Day on Sunday, a report via allAfrica.com from Health-e: South Africa: Further Resistance to TB Drugs Identified in SA. Excerpt:

Researchers have identified a new strain of tuberculosis in 17 patients in the Eastern Cape which is totally resistant to the all current drug regimens. 

When an earlier study of extensively drug resistant (XDR) TB in the Eastern Cape showed that patients weren't responding to treatment - 58 percent of patients died within a year and only 8.4 percent became un-infectious after more than four months of treatment – epidemiologists at Stellenbosch University (SU) decided to investigate the bacteria that seemed to be more resistant against the available drugs. The Eastern Cape cases are the first to be identified in South Africa, and the fourth country in the world to report totally drug resistant (TDR) TB – it was discovered in India last year, and in Italy (2003) and Iran (2009). 

What they found was an emerging strain of TB even more resistant to drugs than XDR, which is already resistant to all first line drugs and some second line drugs. This new strain has shown resistance to at least 10 anti-TB drugs currently in use in the health sector. 

According to Prof Tommy Victor, from SU's Division of Molecular Biology and Human Genetics, the World Health Organisation and many experts in the field, including him, think the name "totally drug-resistant" (TDR), which is currently used in scientific literature, is not appropriate. They believe there may be a cure for TDR among some of the new drugs currently being developed, or old medication not in use anymore. 

"We really are facing bacteria that has become increasingly resistant, and there are now some bacteria that are hyper resistant, irrespective of the definition," said Victor who was one of the authors of the study. 

In the scientific paper, which was published in the Emerging Infectious Disease Journal in March this year, they used molecular techniques to study cultures of the tuberculosis bacterium of just under 400 Multi-drug resistant (MDR) TB patients in the Eastern Cape. Among these a large number were pre-XDR and XDR's, and 17 cases of TDR. 

There are approximately 18 000 new MDR cases diagnosed each year and "there may be be more TDR cases in South Africa ," says Victor, explaining that 17 cases emerged from only 400 MDR samples tested. 

A shortcoming of the study, which was acknowledged by the authors, is that they only studied the cultures from the infected patients, and don't have any data on patient outcomes – so they don't know how long they may have survived, or if any have been cured. Although a related study on the Eastern Cape cohort showed that patients responded quite badly to even the fiercest treatment.

Addressing the needs of individuals coinfected with HIV and TB

Via blog.AIDS.gov: Addressing the needs of individuals coinfected with HIV and TB.

This weekend, we observe World Tuberculosis (TB) Day (Sunday, March 24), a day to remember that the global burden of TB remains enormous, particularly among people with HIV/AIDS, among whom TB is the leading cause of death, worldwide. 

According to the World Health Organization  (WHO), in 2011, 1.4 million people died from TB, including 430,000 deaths among people who were HIV-positive. TB is also one of the top killers of women around the globe, with 300,000 deaths among HIV-negative women and 200,000 deaths among HIV-positive women in 2011. 

TB is also a health threat among people living with HIV in the United States. In 2011, the Centers for Disease Control and Prevention (CDC) estimates that 6% of all TB cases in the U.S. and 10% of TB cases among people aged 25–44 occurred among people who are living with HIV. 

Thankfully, the rate of TB is declining in the U.S. According to the CDC, the number of TB cases reported annually has decreased since its peak in 1992. In addition, most cases of TB disease in the U.S. now occur among immigrants; in 2011, a total of 62% of reported TB cases in the United States occurred in foreign-born persons (CDC). (Read more about TB trends in the U.S. in the March 22, 2013 issue of CDC’s Morbidity and Mortality Weekly Report (MMWR).) 

However, tuberculosis remains a serious concern for people living with HIV/AIDS. That’s because a dangerous synergy exists between HIV and TB, such that people who have a suppressed immune system due to HIV infection are much more likely to develop active TB disease if they are exposed to the TB bacteria. Also, active TB infection appears to increase HIV replication among co-infected persons. Therefore, the populations of people who are infected with these two pathogens often overlap. 

Or, as an historical leader in the field of HIV (Dr. Jim Curran) once observed: “HIV and TB hang out together and they are a bad influence on each other!”

50,000 Chinese die of TB annually: official

Via Xinhua: 50,000 Chinese die of TB annually: official.

As many as 50,000 people die of tuberculosis annually in China, with about 1 million new cases reported each year, a health official said on Thursday. 

That indicates that one person dies of the disease every ten minutes, according to Wang Yu, director with the Chinese Center for Disease Control and Prevention. 

Currently, there are 5 million Chinese people who suffer from active tuberculosis or TB, ranking China second following India among 22 countries that are most heavily plagued by the disease. 

About 120,000 new cases of multi-drug resistant TB (MDR-TB) are estimated to occur each year, ranking China first in the world and posing challenges to public health. 

The mortality rate of tuberculosis saw an 80 percent drop from 1990 to 2010 in China due to free diagnosis and treatment provided by the country's health departments, according to Wang. 

He noted that the prevalence rate was also halved during the same period. 

However, insufficient medical staff and funds cannot meet the needs of tuberculosis treatment in the country's rural areas, according to Wang. 

He said that health departments at all levels should mobilize social resources to accelerate the building of the country's tuberculosis prevention system. 

Even though tuberculosis is preventable and treatable, the disease kills 1.4 million people worldwide each year, according to Wang. 

The 18th World Tuberculosis Day falls on March 24.