World TB Day: March 24 - 82% of US cases in ethnic minorities

Dr. Robert Koch announced the discovery of the bacteria that causes Tuberculosis on this day in 1882. Today, public health officials are calling for elimination of the disease. While some in our country want to act as if race is no longer an issue, as if 40 years of civil rights legislation have suddenly reversed 400 years of disparities, those of us who work in health care see, everyday, the hard evidence that as a nation, we have a long way to go.

Take tuberculosis - 82% of all reported US cases are in non-Hispanic whites, and 45% are in US born blacks. The northeast and southeast regions are where most of the cases are congregated, and the disease is compounded by substance abuse, HIV, homelessness and incarceration.

10 million people in the world are incarcerated and at risk for tuberculosis. Improved prison conditions - reduction of overcrowding, improved health services and improved nutrition and hygiene to prison populations will do a lot for prevention and control of TB. If the international goal is to eliminate TB by 2015, we must get real about access to health services for the poor and underserved in our communities. The US has the largest penal system in the world. In 2006, 7 million US citizens were incarcerated. 8% of black men, 1 % of white men and 2 % of Latino men are behind bars. Black women are jailed at 3 x the rate of white women.

Support of patients during treating, including direct observation of therapy (DOT) will need to be implemented on a broad scale - including prisons - to treat the 2 billion people infected. That's right - 1/3 of the world's population is infected with TB - most of them poor. $15 billion will be spent educating Californians and $15 billion will be spent incarcerating them. Male high school dropouts are incarcerated at 31 x the rate of young males with college degrees. For black males, the rate is double that - 60 x more likely to end up behind bars. Funding education is funding health prevention - by improving health literacy and access to care, by keeping people out of prison and in the work force - we can prevent communicable diseases like TB and reduce racial disparities in health care and health expenditures.

Thank you CDC for use of photo of overcrowded prison, US.

Labels: education, health disparities, prison expansion, TB

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38th World Conference Lung Health: Cape Town, SA

This year's theme was Confronting the Challenges of HIV and MDR in TB Prevention and Care. TB is a disease of the poor, and researchers complain that the only people interested in developing drugs for a cure are the Bill and Melinda Gates Foundation. No new drugs to treat TB have been developed in 40 years. TB is the number one killer of people with HIV, despite the fact that TB itself is curable.

We have an 80 year old vaccine that doesn't work very well to prevent TB. 2 million people die from the disease every year. Ironic isn't it? In developed countries we are killing ourselves with obesity and sedentary lifestyle related diseases - type 2 diabetes, coronary artery disease, high blood pressure, kidney disease, stroke. Half of the world is eating itself to death, the other half starving to death. In societies already burdened by poverty, hunger, starvation, lack of resources and no access to education people are dying of forgotten diseases.

African sleeping sickness, leismaniasis, filariasis and hookworm claim the lives of millions in undeveloped countries but are unknown in the developed world. The Gates Foundation is funding grants to put these diseases on the global agenda.

Thank you trygveberge for use of photo Tuberculosis.
Thank you Willem & wendy for use of photo of TB patient.

Labels: TB

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Unsolved Mysteries: The Continuing Saga of our XDR-TB case

XDR-TB and all other emerging, infectious diseases have had my attention for a while. For some background information, read:

• XDR-TB: Extremely Drug Resistant, Extremely Scary
• Runaway Bridegroom: XDR-TB Comes (Back) to America

One of my colleagues here at Healthline is a microbiologist, and she was kind enough to help me track down some information to try to answer some of the unanswered questions in the case of our runaway bridegroom. I asked her about the process for identifying the strain of TB a patient has. She said, " In the old day, multiple drug resistance was rare, so TB susceptibility testing was not routinely done. The steps in the process are

• Obtain the specimen [sputum] from the patient
• Identify the bug (microorganism causing the infection)
• Subculture the bug to grow a pure culture: this is where the process can get bogged down, just growing enough inoculum to test
  
• Use the pure culture of the bug to test for drug resistance"

She went on to say "Patients with TB are treated empirically." This means patients are given the usual medications used to treat the causative organism, in this case the bacterium Mycobacterium tuberculosis(M. tuberculosis) ." Susceptibility tests are done only after patients fail to respond to empirical treatment and typically, the most common drugs would be tested. If the patient's sputum sample was resistant to all common medications, then additional medications would be tested. The National Jewish Hospital is/was way ahead of the Public Health Department in developing new drug susceptibility tests."

National Jewish Medical and Research Center, Global Leader in Lung, Allergic and Immune Diseases, is on the international radar because that is where our most famous TB patient since Mimi in Puccini's operaLa Boheme is being treated. Would it take 4 months to test the sputum sample? No. Focus Diagnostics Reference Laboratory indicates the studies would be done in 14 to 21 days from the time they received the pure isolate of the microorganism culture. My microbiologist colleague reports that the culture can be grown from a liquid sample within a week, and if you have just "...a single colony on a solid culture, it can take up to 6 weeks..."

I am no math whiz, but I'm pretty sure that is a little over 2 months. OK. So the scenario I imagine is that he falls, has a chest X-ray, TB is diagnosed and reported to the county public health office and he is treated empirically. He proceeds with his wedding plans. His TB doesn't respond to treatment and the lesion in his lung gets bigger. The only part of this that still doesn't add up to me is Dr. Cooksey, his father-in-law, TB investigator for the CDC. Would not he have discussed his case with him?

• According to the Atlanta Journal-Constitution, Dr. Cooksey "...prepared his son-in-law's specimen for DNA testing as part of his regular duties."
• The CDC's own website reports that Drug Susceptibility testing takes one month. The HPLC genotyping is most likely the aspect of testing Dr. Cooksey is involved in.
  
• AJC reports that Mr. Speaker feels the Fulton County public health officials and the CDC are casting aspersions on his character to "deflect questions about their own actions"
• What actions would those be? Working hard to try to solve some of the most challenging problems of humanity? Dedicating their lives to helping others?
  

Another source of my information is the CDC itself. I receive their Clinician Updates via email, and am on the Terrorism Listserve. Yesterday, I received CDC Clinician Communication: Information from Clinician Outreach and Communication Activity (COCA). The June 7, 2007 communique is a particularly robust "...summary of clinical guidance...of persons potentially exposed to XDR-TB on two transatlantic flights." Per this communique to Health Professionals who may be involved in evaluation and treatment directly impacted by this case, the CDC states:

• If a person is infected, it can take 8-10 weeks after exposure until the tuberculin skin test (TST) to become positive
• A first round of TST should be done as soon after exposure as possible, and a second round repeated in 8-10 weeks after exposure
• Consultation with a TB expert, one experienced in managing MDR and XDR TB, is highly recommended in any contact who is positive, who is suspected of having the disease or who is immunocompromised
• Resources for TB consultation include State TB Control Offices
• and the Regional Training and Medical Consultation Centers under the Division of Tuberculosis Elimination with the CDC
• Then there is the issue of the contacts of the contacts...
  

The case has triggered international investigations in Greece, Canada, the US and Italy. The DHS border guard who allowed the patient back into the US without detaining him has been suspended. Georgia State law does not allow health officials to restrict a patient's movement unless h/she violates a written directive. Mr. Speaker eluded being served a written directive when his fiancee (daughter of CDC TB expert) advised him to leave the country early so that he could rest and relax. Dr. Katkowsky, Director of the Fulton County Department of Health and Wellness, stated the patient changed his flight plan after he was advised not to travel during a May 10, 2007 family care conference. Health officials knew at this time he had MDR-TB.

• May 11, 2007 Fulton County Health officials wrote up a medical directive advising Speaker against traveling. A county disease investigator attempted to hand deliver the directive to Speaker at his home and business.
  
• May 12, 2007 A county disease investigator attempted to hand deliver the directive to Speaker at his home an business, but learned he had already left the country. He had informed health officials that his departure date was May 14, 2007. Sources confirmed that Mr. Speaker called Air France and asked to leave on an earlier flight.
• May 17, 2007: Health officials learned that Mr. Speaker has XDR-TB. Sources say he was instructed to go into voluntary isolation in a hospital in Italy. Speaker already knew enough about his diagnosis to have pre-arranged to be treated at National Jewish Hospital with medications and surgery. He had been told he had "...one chance to get the treatment right."
• Mr. Speaker was "...appalled..." that the CDC and the government was not going to help him out by footing the $140,000 bill for the private air ambulance.
  

Thank you alexanderljung for use of photo Partial microscope bacteria view.

Labels: CDC, consumption, La Boheme, microbiology, TB

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