James Moratti

Chapter on Tuberculosis

Sections

1.) What is Tuberculosis?

2.)  Risk groups:

3.) Treatment

 

 

What is Tuberculosis?

 

         Tuberculosis has been around since the beginning of known history.  The earliest evidence of tuberculosis in humans is from a neolithic grave near Heidelberg, Germany.  This grave dates back to 5000BC.  Examinations of the spines of mummies and of tomb paintings from 4000BC confirm TB as a common disease in Egypt, and skeletal remains in Italy from the same date show TB in the spine (28).

         Around 2500 BC - 1500 BC, TB was fully established in the mainland of Europe, but the earliest evidence of the disease in Britain comes from graves dating from the Roman occupation (55 BC - 800 AD).  By the mid 17th century, one in five deaths in London - as recorded in the Bills of Mortality - were due to TB, known as consumption at that time.  TB soon became an epidemic in Britain and in major cities in the USA and Europe (28).  It became known as the "White Plague.”

         The estimation of the worldwide TB death rate was 7 million per year, and the worldwide pulmonary TB rate was 50 million per year by the turn of the 19th century.  London and New York were two of the worst affected cities worldwide.  This led to the fear that by the end of the 19th century, European civilization might be destroyed.  At the turn of the twentieth century, more than 80% of the population in the United States was infected before age 20.

         Then in 1882 in Germany, Dr. Robert Koch discovered the bacterium that was the cause of TB, and in 1931 in France, Drs. Calmette and Guerin discovered Bacillus Calmett-Guerin (BCG) - a 'tamed' living bacterium.  In 1952 at Seaview Hospital in New York, a new wonder drug called 'Isoniazid' was used to treat TB, and the centuries-long losing war against TB began to be a winning war.

         Tuberculosis or TB for short comes from the bacterium Mycobacterium tuberculosis.  This bacterium can attack any part of the human body, but in most incidents, it attacks the lungs.  The disease that attacks the lungs is known as pulmonary TB.  It was at one time the leading cause of death in the United States (2).  Nearly a third of the world's population is infected with tuberculosis (TB).  TB kills almost 8,000 people a day, which adds up to about 3 million people each year (1).  Of those deaths, 100,000 were children.  Worldwide some 2 billion people are affected with TB with an estimated 10 to 15 million people in the United States infected with without displaying symptoms (3). 

         Tuberculosis resurged in the mid-1980's in the United States, which brought greater attention to the disease.  The increasing number of cases has been caused by the high risk for the disease among immune-suppressed persons, in particular those infected with human immunodeficiency virus (HIV) (1).  Drug resistant strains of this deadly disease have also contributed to many problems with the spread of the disease (1).  Humans, because of the incomplete treatment of patients that have the disease, have created these drug resistant strains.  The outbreaks of TB have occurred in homeless shelters, hospitals, correctional institutions, nursing homes, and residential care facilities for AIDS patients (1).  Before these outbreaks, the United States had become complacent with TB because the number of cases was so low that funding for TB had continually decreased.  Because of these outbreaks and new versions of the disease, there has been increased funding for tuberculosis research, prevention, and treatment.  This has allowed for a steady decline in the number of persons with TB since the first outbreaks, but TB is still a major problem.  In 2000 alone, more then 16,000 cases were reported (2).  TB disproportionately affects minorities: 54% of active TB cases in 1999 were among African-American and Hispanic people, with an additional 20% of TB cases found in Asians (3).        

          Tuberculosis is an airborne virus that is spread though the air from person to person.  This bacterium is put into the air when an infected individual with pulmonary tuberculosis or tuberculosis of the throat coughs (2).  It usually takes lengthy contact with someone with active TB before a person can become infected (3).  On average, a person will have a 50% chance of becoming infected with tuberculosis if they spend eight hours a day for six months or 24 hours a day for two months working or living with someone with active TB (3).  However, people with TB who have been treated with appropriate drugs for at least two weeks are no longer contagious (3).

         The most common version of TB is pulmonary tuberculosis, which affects the lungs.  The initial symptoms of pulmonary TB are easily confused with those of other diseases.  An infected person may at first feel vaguely unwell or develop a cough (29).  At the same time, a small amount of greenish or yellow sputum may be coughed up when the person gets up in the morning.  In time, more sputum is produced that is streaked with blood.  Persons with pulmonary TB will not run a high fever, but they often will have a low-grade fever (29).  The patient often loses interest in food and may lose weight.  In some cases, the patient experiences chest pain.  If the disease is allowed to escape from the lungs into the chest cavity (pneumothorax) or if the fluid collects in the pleural space (pleural effusion), the patient may then have difficulty breathing.  The TB bacilli may travel from the lungs to lymph nodes in the sides and back of the neck.  Infection in these areas can break through the skin and discharge pus.  Before the development of effective antibiotics, many patients became chronically ill with increasingly severe lung symptoms (29).  They lost a great deal of weight and developed a wasted appearance.  Hence TB was referred to as the White Plague.  This outcome is uncommon today--at least where modern treatment methods are available.

         A new form of TB has emerged recently, called MDR-TB.  MDR-TB is caused by inconsistent or partial treatment, which may happen for a number of reasons.  These reasons include when patients do not take their full course of drug treatment, when doctors and health workers prescribe the wrong drugs or the wrong combination of drugs, or when the drug supply is unreliable.  MDR-TB is very deadly and needs to be watched closely.

From a public health perspective, poorly supervised and incomplete treatment of TB is worse than no treatment at all.  When people fail to complete standard treatment regimens or are given the wrong treatment, they may remain infectious and at the same time, they can develop resistance to anti-TB drugs (25).  People then may become infected with the same drug-resistant strain.  Drug-resistant TB is a lot more difficult and much more expensive to treat and more likely to be fatal (25).  In industrialized countries, TB treatment costs around $2,000 per patient, but rises more than 100-fold to up to $250,000 per patient with MDR-TB (25).

Outbreaks of MDR-TB in Western Europe, Asia, and the United States have been linked to a single strain (the W strain), which originated in Peru (25).  This strain in particular has been shown to cause extremely high mortality in immune suppressed patients.  Given that treatment of MDR-TB requires extensive resources and can take up to two years of chemotherapy per patient, efforts must be made to prevent the transmission of such strains.  Focus should be placed to prevent the emergence of MDR-TB (with DOTS) and to manage present MDR-TB cases in areas of high prevalence.  This combination is the concept of DOTS-Plus (25).

Tuberculosis in Developing Countries

         While a cure for tuberculosis (TB) was developed more the 50 years ago, tuberculosis remains one of the world’s deadliest infectious diseases.  One-third of the world’s population is infected with TB, and one-third of HIV/AIDS patients have TB.  TB threatens the poorest and most marginalized groups.  It disrupts the social fabric of the society and undermines gains in economic development.  Sadly, the global resurgence of tuberculosis over the past few decades has been fuelled by decreasing investments in public health systems, emerging drug resistance, and increasing HIV/AIDS prevalence (13).

The World Health Organization estimates that 80% of all TB cases are found in 22 countries.

The rates for infection in 20 of these countries are:

Country

Population

All cases

India

1,008,937,000

1,856,000

China

1,275,133,000

1,365,000

Indonesia

212,092,000

595,000

Nigeria

113,862,000

347,000

Bangladesh

137,439,000

332,000

Ethiopia

62,908,000

249,000

Philippines

75,653,000

249,000

Pakistan

141,256,000

247,000

South Africa

43,309,000

228,000

Russian Federation

145,491,000

193,000

DR of Congo

50,948,000

163,000

Kenya

30,669,000

149,000

Vietnam

78,137,000

148,000

Tanzania

35,119,000

126,000

Brazil

170,406,000

116,000

Thailand

62,806,000

88,000

Uganda

23,300,000

82,000

Myanmar

47,749,000

80,000

Mozambique

18,292,000

79,000

Cambodia

13,104,000

75,000

Global total

6,053,531,000

8,735,000

(Zimbabwe and Afghanistan are the two countries not listed in the chart.)

Reference for this section:

1.) http://www2.state.tn.us/health/ceds/TB/introduction.htm

2.) http://www.foh.dhhs.gov/public/nycu/worldtbday2003.asp

3.) http://www.niaid.nih.gov/newsroom/tbday02/tbglance.htm

10.) http://www.avert.org/tuberc.htm

13.) http://www.usaid.gov/pop_health/id/tuberculosis/burden.html

25.) http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html

28.) http://www.ukcoalition.org/HIV___TB/History_of_TB/history_of_tb.html

29. http://www.hendrickhealth.org/healthy/001409.htm

 

Risk Groups

People at higher risk of having active TB than the general population include poor and homeless people; Aboriginal Americans; individuals born in countries reporting high TB rates; alcoholics and injection drug users; elderly people (especially single men); individuals co-infected with HIV and tuberculosis; health care workers; refugees; and prisoners.

         TB is widespread and contagious, making everyone at risk.  A potentially fatal infectious disease in one person is a threat to everyone’s survival (27).  During 1995, examples of TB infection and sickness appeared throughout parts of the world that at one time were considered safe from this disease (27).  For instance in Minneapolis, a person with TB infected 41 people in a neighborhood bar.  A postal worker in Tampa, Florida, was carrying TB bacilli as well as the mail!  In Western Canada, a health care worker gave TB to 100 other people (27).  In recent years, outbreaks of TB in wealthy countries have been investigated in discotheques, churches, subways, schools, airplanes, courtrooms, and even on a riverboat casino.

 

         All these groups have something in common.  They have either lifestyle conditions, living conditions or physical conditions that lead to a weakened immune system or greater contact with the disease.  These conditions combined lead to a much greater risk in contracting tuberculosis and getting the active version of it.  It is best to try to limit the risks that these people have in order to help stop the spread of this very deadly but also curable disease.

          Aboriginal Americans, poor people, and homeless people have much in common.  First, they live in very bad conditions.  They live in destitute areas with widespread disease, leading to a greater risk in contacting any disease.  At the same time, they tend to have bad diets and unhealthy life styles.  These factors are combined with a low income and lack of adequate health insurance.  These individuals are less likely to take the drugs in full though, and at the same time they are less likely to have adequate insurance to cover other health problems that could weaken their immune systems.  They do not have enough resources to protect themselves form the diseases.

         The same goes for the elderly, who may have weakened immune systems and may be poor and living in poor conditions.  In addition, some elderly live in communal living areas such as nursing homes.  These places help spread disease because of the close proximity to others.  More than one-fourth of the nearly 23,000 cases of TB reported in the United States in 1995 developed in people above age 65, while elderly people are only approaching one-fifth of the population (29).  Many elderly patients developed the infection when they were younger and the disease was more widespread.  The aging process itself weakens the body's immune system, which is then less able to ward off the disease.  Finally, bacteria that have lain dormant for some time in elderly persons may be reactivated and cause illness.

Individuals co-infected with HIV and M. tuberculosis 

            Studies in Italy, Rwanda, Spain, the USA and Zaire found that people who were infected with the bacteria that cause TB and were also infected with HIV were 30-50 times more likely to develop active tuberculosis than those without HIV (10).  This is because of the weakened immune system of an HIV positive person.  This increases greatly the risk of developing TB, and the development of active TB accelerates the progression of the HIV disease itself towards full-blown AIDS (9).  TB is the most common among the opportunistic infections in people that have AIDS.  It is very easy for people that have AIDS to get TB.  Tuberculosis is the first manifestation of AIDS in over fifty percent of all AIDS cases in the developing world (9).  Tuberculosis is the leading killer worldwide of people that have AIDS (9).  Seventy percent of TB patients in developing countries are infected with HIV (9).  Up to half of HIV-infected patients in Africa will develop TB and out of these, one in three will die from it (9).  By the year 2005, sub-Saharan Africa could have more tuberculosis cases (3.4 million) than any other region in the world (9).  Once HIV is introduced into a community where there are people infected with the TB germ, the population faces parallel epidemics of AIDS and TB (10).  A long-standing annual decline in TB cases ended abruptly in the United States in 1985, at the peak of the HIV spread (10).  Of all TB cases in Asia, 14% will be attributable to HIV by the end of the 1990s (10).  Only 2% of all TB cases in Asia were attributable to HIV at the start of that decade (10).  This is not only a menace for those infected with HIV; TB can also be spread through the air to HIV-negative people.  Tuberculosis is the only major AIDS-related opportunistic infection to pose this kind of risk (10).

Health Care Workers

The threat of health care workers contracting tuberculosis is a growing concern.  Even though the greatest risk is for health care workers that have constant contact with TB patients, it is still very important for all health care workers to take measure to protect themselves from TB (6).  The increasing threat caused by TB’s comeback leads to increasing risk for health care workers. 

According to the Occupational Safety & Health Administration (SHE) of the United States, an estimated 5 million U.S. workers are exposed to TB in the course of their work (7).  The risk of these workers as a result of their contact with TB-infected persons may be as high as 10 times the general population risk (7).  Health care workers are at high risk for many diseases because of their contact with many patients that are sick.  Often they do not take the proper measures to protect themselves from these sicknesses. 

The United States federal government has deemed the danger of tuberculosis spread amongst health care workers in the US to be so important that the Department of Labor has to establish a set of guidelines that make health care facilities follow certain guidelines when dealing with TB patients (6).  Once a TB patient has had his/her treatment started, he/she should be immediately isolated in an acid Flash cacilli isolation room that must be maintained in a negative pressure state and appropriately exhausted ventilation (6).  This facility should provide three forms of air purification, including ventilation, high-efficiency particulate air (HEPA) filtration, and ultraviolet germicidal irradiation (UVGI) (6).  This ventilation and filtration should be sufficient to remove most bacteria from the air, and the ultraviolet lighting in the room should be sufficient to kill the remaining bacteria.  Health cares workers entering such a room must wear a respirator that has been NIOSH-certified (National Institute for Occupational Safety and Health) (6).
Prisoners:

            TB has been a recognized problem in prisons worldwide.  In recent years, there have been marked increases in the number of cases reported in correctional facilities in the United States (8).  In 1993, the inmates of the New York State correctional system, for instance, had 8 times the TB rate of the entire state--139.3 per 100,000 compared to 21.7 per 100,000 (8).  Another example is that in one California state prison, the annual incidence rate of TB in 1991 was 184 cases per 100,000, which is more than 10 times the statewide annual incidence rate for people not in prison (8).  Some studies have been used to show that there is a correlation between tuberculin skin test positive rates and the length of time one has been in prison (8).  This therefore indicated that the disease transmission most likely had occurred within the correctional facilities (8).  These prisoners are in close contact with many other persons who could have sicknesses.  Prisons are breading grounds for disease.  Prisoners also get weakened systems because of the diets they eat, the amount of sickness around them, and in many cases, the lack of adequate health care.

The incidence of TB within Russian prisoners is fifty-eight times higher then that of the rest of the population (16).  The death rate is also 29 times that of the rest of the population.  Russia has the world’s highest correction rate in the world.  About ten percent of Russia’s prison population, or 100,000 convicts, have TB (16).  About 5000 Russian prisoners die each year from TB (19).  Part of the problem is that there are massive funding problems with in the Russian Prison system.  For instance, the funding problems are so bad that only 4.5 cents prisoner is spent a day on food, (17).  The problem in the Russian prisons adds to the health problems of Russia as a whole with about 13,000 Russian Prisoners who are possibly infected are released in to the general population every year.  The release of these prisoners adds to the already poorly funded and over worked health care system of Russia.

            The Russian Prison system is a breading ground for Multidrug resistant (MDR)-TB (defined as resistance to at least INH and RIF) (18) .  The implementation of a DOTS program at Colony 33 in Mariinsk (initiated 1996; fully implemented 1997) has resulted in TB cure rates increasing from a low of 36% to 62% and a treatment failure rate decreasing from 56% to 23% (18).  The rate of TB cases that are resistant to isoniazid, rifampin, and streptomycin has remained relatively stable (22.6% in 1997 to 18.9% more recently) (18).  To treat MDR-TB, second line agents must be used , there treatments  are more expensive, less effective, and a lot more toxic than the first line agents   In Tomsk, and there is some evidence that there is misuse of second line agents.  The misuse of second line agents can lead to the development of resistance strands of TB, resulting in incurable disease.  The increasing rate of MDR-TB among the Russian civilian population is very likely related to MDR-TB in the prisons system.  The MDR rate among civilians was only 6% in 1997, and increased to 10% by 1998.  There are likely dual epidemics of MDR-TB in the civilian and prisons sectors, with both epidemics contributing to one another.  In the Colony 33 detention center, 90% of prison detainees are from the local area.  In the Tomsk prison, 63% of the MDR cohort is from the local area (18).

 Refugees

 

         In 1994, nearly 23 Million refugees had to flee their homes, and an additional 26 Million persons were displaced worldwide.  Refugees are also highly at risk to get Tuberculosis with an estimated  Half of  the world’s refugees  infected with TB (26).  Conditions in refugee camps are ideal for the spread of TB ,untreated TB can spread quickly in crowded living arrangements, .  In addition, since they are on the move, it is difficult to treat them fully because of the lengthy treatment regimen required by existing drugs.  Each year, over 17,000 refugees get sick with the disease.  People who have been displaced for other reasons-such that as of homeless people are also a very great risk.

 

            Reference for this section:

http://www.who.int/gtb/publications/tbrep_96/

6.) http://www.lungusa.org/occupational/tuberculosis _workers.html

7.) http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13717

8.) http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm

9.) http://www.tbalert.org/news/tb_aids.htm

10.) http://www.avert.org/tuberc.htm

16.) http://www.worldpaper.com/2000/sept00/pumpyansky.html

18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1

19.) http://www.canadafirst.net/immi-kill/russian_tb_threatens_the_world.html

26.) http://www2.provlab.ab.ca/bugs/hlthprom/tbschnee.htm

27.) http://www.stoptb.4t.com/whystopTB.html

29. http://www.hendrickhealth.org/healthy/001409.htm

Treatment:

            The World Health Organization recommended treatment strategy for detection and cure of TB is DOTS or Directly Observed Treatment, Short-course (4).  DOTS is a combination of five different elements: drug supplies, political commitment, microscopy services, surveillance and monitoring systems and use of highly efficient regimes with direct observation of treatment (4).  In directly observed therapy, a trained health care worker monitors the patient taking each dose of anti-tuberculosis medication.  When TB patients receive all medications as prescribed under a program of DOTS, both patients and community benefit by response to therapy is closely monitored, Patients complete therapy, Survival may improve in patients infected with the human immunodeficiency virus (HIV), because DOTS ensures treatment for TB, (15).  DOTS is so important because it helps to deter the spread and development of Drug Resistant TB This is important the course of treatment for drug-resistant TB is USD250, 000 and that of normal TB is about USD 2000 (25).

            Although the DOT the strategy promoted by the World Health Organization to control and treat tuberculosis (TB) - has been widely accepted, many developing countries have been unable to expand coverage as rapidly as needed and have failed to achieve the global targets of detecting 70% of infectious cases and curing 85% of those detected by the year 2000 (14) The major obstacles to expanding the TB control are political, managerial, and financial, rather than technical (14).

            According to WHO the estimated costs of the 22 high-burden countries range of US$ 700–900 million per year, this is excluding investment in new interventions that are specifically designed to raise case detection and cure rates.  It is also estimated that the existing resource gap for TB control in the 22 most burdened countries is probably between US$100-300 million a year; this is provided that current loans and aid are sustained (14)

            Now patients with infectious TB have been identified using microscopy services, health, community workers, and trained volunteers observe and record the patients swallowing the full course of the correct dosage of anti-TB medicines in which Treatment lasts six to eight months (4).  The most common of the anti-TB drugs are isoniazid, rifampicin, pyrazinamide, streptomycin and ethambutol.  After two months, spectrum smear testing is repeated.  It is repeated to check the progress and again it is repeated at the end of treatment.  The patient’s progress is recorded and documented thought out the treatment and the outcome of the treatment is recorded (4).

            One a six-month supply of drugs for DOTS treatments costs as little as US $11 per patient per year in some parts of the world.  The World Bank has ranked DOTS as the “most cost-effective of all health interventions” (4).  DOTS have a cure rate of up to 95 percent this is even in the poorest of the poor countries (4).  DOTS helps to prevent new infections by curing the patients that are infectious.  It at the same time helps to prevent the development of MDR-TB by ensuring the full course of treatment is followed; it ensures this though directly observing the patients.      Since DOTS has been introduced on a global scale, millions of people have received effective cost affective treatment.  For instance, in half of China the cure rates among new cases are 96 percent (4).  Another example is that in Peru the widespread use of DOTS for more than five years has led to the successful treatment of 91 percent of cases.

            All 22 of the high TB burdened countries, which bear 80 percent of the estimated incident rates by the end of 1998, have adopted DOTS.  This brings the total of 43 percent of the world’s population that have access to DOTS, which is double what it was in 1995 (4).  In addition, at the same time in 1998 21 percent of the TB patients received treatment under DOTS, which is also double of what it, was in 1995 (4).  With only 21 percent receiving treatment under DOTS, it really needs to be greatly expanded.

            An example of a DOTS program in the west is the NYC Department of Health & Mental Hygiene Tuberculosis Control Program.  Because of how TB treatment is difficult and requires taking two or more medicines for at least 6 months.  Most people have trouble remembering to take their medicines, or they stop taking their medicines when they start to feel better.  When this happens, a person with TB could get sick again, and the TB germs could become resistant to the medicines.  Because of this DOTS was envisioned and this is why New York uses it to control the TB problem (15).  Some benefits that patients get thou using the DOT program in New York are Free TB medication, free tokens, food, and gift certificates to fast food restaurants, free social services, frequent medical checkups, and Help with transportation to and from clinics.  In addition, this is provided free of charge to all residents of New York (15).  The New York City program sets an example for the rest of the Developed and for the developing world on how to set up a TB treatment plan, which is effective and patient friendly.

            An example for a program of TB treatment in the Developing world is the TB Clubs in Ethiopia.  In Ethiopia, a strategy to combat TB was to set up though using peers as a support group to help others go though the TB treatment (23).  In exploring ways to increase the TB treatment adherence and outcomes they created, these so called TB clubs.  These Clubs were established by people who have TB and who live in the same geological area (23).  The people meet each other while attending outpatient appointments.  Medical officers and the Community support these groups.  Each of these groups have between three and ten members, they elect a leader of the club who ensures that the members attend the TB Clinic.  The leader also arranges the weekly meetings and checks up on their progress.  Members of these clubs support each other, share progress, and problems and send members that are not progressing correctly onto the Clinic.  The clubs with help from the community help to identify persons in the community who are suspected to have TB and they encourage these community members to be tested and to be treated.

            What have these TB clubs achieved?  During the first six months of the clubs in 1997, the clubs referred 181 people with suspected tuberculosis for investigation, of which two-thirds were diagnosed as TB cases (23).  They also identified 69% of all TB patients and 76% of new sputum smear-positive pulmonary TB patients with smear-positive sputum diagnosed in the district during the same six-month period (23).  TB clubs have helped to increase community awareness of the symptoms of TB and the need for treatment, Attendance at TB clinics has also improved significantly and treatment success rates are higher than in other parts of the country (23).

            This TB club approach shows what can be achieved - even in remote rural areas with limited resources and using a long course of treatment - if TB patients are at the centre of TB control efforts and if there is effective community involvement.  This shows how important community support is in a TB treatment program.        

         It is possible to control the spread of MDR-TB, but according to Atiel Pablo-Mendez who is from the Rockefeller Foundation presented arguments that DOTS alone may be sufficient to control TB globally.  This has been effective in a country like Peru (which has one of the best DOTS programs in the world and is relatively small), would be equally successful in a larger country such as India, where DOTS is not as widely used (18).  Although recent reports have noted so-called MDR-TB hotspots, the median prevalence of MDR-TB globally is 1%, with eight countries reporting no MDR-TB.  Rates of MDR-TB range from 14% in Estonia to 0% in France in the United States, the rate of MDR-TB has decreased from 1.6% to 1.2%.  It was stated that MDR-TB outbreaks are often due to poor infection controls for instance in New York City, Russian prisons) and that therefore improvement will occur when infection control is improved, not just the institution of DOTS-Plus.

TB in New York City

            New TB     Cases MDR-TB

1992        3,811       441

1997        1,730        53

Change -55%       -88%

Thus, there was a greater decrease in MDR-TB rates than overall TB rates.  There is a high correlation between incomplete therapy and MDR-TB, as well as the treatment failure rates (18).  Thus, for the programs that have low treatment success rates less then 60%), the preference would then be to provide a better implementation of DOTS prior to implementing DOTS-Plus program.  For programs that have a greater then 80% treatment success rate, use of DOTS-Plus could be considered.

            Controlling MDR-TB through DOTS-Plus: In settings where the prevalence of Multi- Drug Resistant -TB is low, cure rates with DOTS can exceed 90%; thus DOTS alone will suffice in many settings (18).  However, in settings with high rates of MDR-TB, cure rates of DOTS decreases to 40-60%.  For instance, in Baku, Azerbaijan, the cure rate using DOTS is 54% (18).  In areas with documented MDR-TB, cure rates have been found in a range from 6% (Ivanovo, Russia) to 59% (Peru) (18).  The common objections to DOTS-Plus include the argument that DOTS alone was responsible for the decrease in rates of TB and MDR-TB in New York City in the early 1990s, the expense of DOTS-Plus, the lack of cost-effectiveness, and the difficulty in implementing such treatment regimens (18).

            MDR-TB in the United States: The proportion of MDR-TB patients who died during therapy decreased from 41% in 1993 to 29% in 1996 (18).  Patients with MDR-TB were a lot more likely to die than those with non-MDR-TB.  Among AIDS patients with MDR-TB, 69% died during therapy, compared to the 27% of AIDS patients with non-MDR-TB.  Among patients who did not die during therapy, completion of therapy was less common in persons with MDR compared to non-MDR-TB.  This is leading to ways that we need to improve treatment so that we do not have to worry about increasing the rate of MDR-TB growth.  Implementing a strong cost-effective Tuberculosis treatment programs such as DOTS, will help stop the Spread of MDR-TB

References for this section:

 

4.) http://sprojects.mmi.mcgill.ca/tropmed/disease/tb/dots.htm

14.) http://www.who.int/gtb/policyrd/Dots_expansion/index.htm

15.) http://www.ci.nyc.ny.us/html/doh/html/tb/tb.html

18.) http://www.hopkins-id.edu/ats_2000/ats_4.html#1

20.) http://www.who.int/gtb/dots/index.htm

23.) http://www.who.int/gtb/policyra/commcae.htm

25.) http://www.stoptb.org/tuberculosis/poorly.managed.tb.prg.html

 

References for the whole chapter.

1.) Tuberculosis . 13 Aug. 2002. Tennessee Department of Health. <http://www2.state.tn.us/health/ceds/TB/introduction.htm>

2.) World TB Day 2003. US Federal Occupation Health. <http://www.foh.dhhs.gov/public/nycu/worldtbday2003.asp>.

3.) At A Glance - NIAID Tuberculosis Vaccine Research. National Institute of Allergy and Infectious Diseases. <http://www.niaid.nih.gov/newsroom/tbday02/tbglance.htm>.

4.) Dots. McGill University . <http://sprojects.mmi.mcgill.ca/tropmed/disease/tb/dots.htm>.

5.) World TB Day 2002 Questionnaire . Stop TB. <http://www.stoptb.org/world.tb.day/WTBD_2002/default.asp>.

6.) Tuberculosis and Health Care Workers. American Lung Association. <http://www.lungusa.org/occupational/tuberculosis%20_workers.html>.

7.) Occupational Exposure to Tuberculosis; Proposed Rule - 62:54159-54309 . 17 Oct. 1997. Occupational Safety & Health Administration. <http://www.osha-slc.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13717>.

8.) Controlling TB In Correctional Institutions 1995. 7 Sept. 2002. Centers for Disease Control & Prevention National Center for HIV, STD, and TB Prevention Division of Tuberculosis Elimination. <http://www.cdc.gov/nchstp/tb/pubs/corrections/introduction.htm>.

9.) TB and HIV: The Overlapping Epidemics. TB Alert. <http://www.tbalert.org/news/tb_aids.htm>.

10.) AIDS, HIV & Tuberculosis. AVERT. <http://www.avert.org/tuberc.htm>.

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