Category Archives: Global Health

Africa: Does Democracy Improve Your Health?

18 Nov 2013

Back in the 1990s, the Nobel-prize winning economist Amartya Sen famously wrote that “no famine has ever taken place in a functioning democracy”, coining an argument has shaped thinking across countless sectors – and none more so than healthcare.

If governments face open criticism and are under pressure to win elections, we assume, they are incentivised to improve the health of their populations. Dictators are not.

“Democracy is correlated with improved health and healthcare access … Democracies have lower infant mortality rates than non-democracies, and the same holds true for life expectancy and maternal mortality,” Karen Grépin, assistant professor of global health policy at New York University, wrote in a 2013 paper. “Dictatorship, on the other hand, depresses public health provision.”

She argues that democracies entrench longer-term reforms than their dictatorial counterparts – often involving universal healthcare or health insurance schemes.

“The effects of democracy are more than a short-term initiative, such as an immunisation programme, which don’t always have lasting effects,” she said in a telephone interview. “Democracy can bring larger-scale reforms that create new things or radically transform institutions.”

But does that theory hold water in Africa?

Ghana, one of the continent’s deepest democracies, is doing well. According to Gallup data, 75 percent of its population consider its elections to be honest, compared to a median of 41 percent over 19 sub-Saharan countries. Correspondingly, it was also one of the first countries in Africa to enact universal health coverage laws.

In 2003, roughly a decade after entering a multi-party democratic system, the west African country hiked VAT by 2.5 percent to fund a national health insurance programme.

Voters who had been overstretched by the previous ‘cash-and-carry’ system happily swallowed the tax increases, and the scheme was so popular that when the government unexpectedly changed in 2008, it survived the transition.

The country still has a way to go to attain universal coverage. According to the National Health Insurance Authority, by the end of 2010 34 percent of the Ghanaian population actively subscribed to the scheme. But the institutions are now in place, laying the foundations for the future.

Similar schemes are being rolled out in other democracies like South Africa. But this isn’t a simple equation. There are plenty more multi-party systems which have failed to enact meaningful reform – think of the pitiful performance in Kenya, where the government changed earlier this year – while some more autocratic regimes are performing well.

“Several of the countries that are seen as the big success stories in public health are not very democratic,” argued Peter Berman, a health economist at the Harvard School of Public Health.

Take Rwanda. Led by Paul-Kagame’s decidedly authoritarian Rwandan Patriotic Front, the country is considered “not free” by Freedom House. In the run up to 2010 presidential elections Human Rights Watch alleged political repression and intimidation of opposition party members against the leadership.

Yet the government has a strong developmental track record. “Rwanda started out with somebody who is autocratic, but who genuinely wants to see these indicators change,” Grépin said.

Over the last decade, Rwanda has registered some of the world’s steepest healthcare improvements. After the 1994 genocide – when national health facilities were destroyed and disease was running rampant – life expectancy stood at 30 years.

Today, citizens live to an average of almost double that. Deaths from HIV, tuberculosis and malaria have each dropped by roughly 80 percent over the last 10 years, while maternal and child mortality rates have fallen by around 60 percent.

Part of its success stems from the fact that its healthcare services reach rural citizens. The leadership hands responsibility to local government and authorities and holds them accountable for their efficiency; and almost 50,000 community health workers have been trained to deploy services to marginal populations.

Like Ghana, Rwanda runs a universal health insurance scheme, though it has fared better in its roll out. Upwards of 90 percent of the population is covered by the community-based Mutuelles de Santé programme, which has more than halved average annual out-of-pocket health spending.

“By decreasing the impact of catastrophic expenditure for health care we increase the access,” explained Agnes Binagwaho, minister of health, from her Kigali office.

The benefits of that programme are clear to see at the bustling Kimironko Health Centre, which is a 20-minute drive from central Kigali and deals with most of the suburb’s non-life threatening medical complaints.

As dozens of men, women and children queue to hand over their health cards, a young nurse named Francine Nyiramugisha explains that “Ever since the Mutuelles de Santé was introduced, there has been a huge difference. You pay 3,000 RwF ($4.50) per year and then you get treatment.”

In the reception, thirty-year-old Margaret Yamuragiye, a slender sociology student who has been diagnosed with malaria, waits patiently for her prescription. “Before I got my Mutuelles card I would fear that I could not go to the clinic because it would be too expensive. Today if I have simple cough or flu, I come to the doctor, I don’t wait to see if it gets worse,” she said.

Nearby in Ethiopia, another autocratic regime registered by Freedom House as “not free” is also clocking significant health improvements. Like Rwanda, leaders in Addis Ababa have little time for political opposition, but are registering impressive developmental gains.

“They’re not very democratic but they have the power and authority to allocate resources towards population health needs,” Harvard’s Berman said.

There’s no universal coverage scheme in Ethiopia, but government has opted to focus on deploying basic healthcare services across hard-to-reach rural areas.

Starting from a pitifully low base, it has spent a decade training a network of around 40,000 extension workers to bring care to rural communities. Over ten years, the nation registered a more than 25 percent decline in HIV prevalence, according to a 2012 progress report. Under-five mortality has declined to 101 deaths per 1,000 live births in 2009/10, from 167 in 2001/2. Infant mortality halved in the same period.

Those examples should be evidence enough that the relationship between democracy and improved healthcare isn’t a simple one. “There are autocratic governments that care about the people and there are autocratic governments who don’t. There are democracies where politicians respond to a broad public demand, and then there are democracies where the politicians respond to narrower interest groups,” Berman said.

“There is no simple equation between democracy and caring about public health.”
[Courtesy of This is Africa]

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Somalia: Polio Outbreak Thwarts Global Eradication Effort

The global community came tantalizingly close earlier this year to ridding the world of polio. But then in May, the eradication effort took a powerful blow. The virus turned up again in the Horn of Africa, first in Somalia.

The Banadir region of Somalia, which includes a Mogadishu refugee camp, is thought to be the so-called “engine” of the Horn of Africa polio outbreak.

In June, three-year-old Mohamed Naasir became ill. His mother, Khadija Abdullahi Adam, said soon after one leg became permanently disabled.

“My son was fine, but he started having a high fever which lasted for almost four days,” she explained. “I gave him medicine, but there was no change. The following morning he said to me ‘Mom, I can’t stand up.'”

The virus has spread at a rapid pace, triggering massive vaccination efforts.

Earlier in 2013, polio was confined to three so-called “endemic countries” — Nigeria, Afghanistan and Pakistan — where the virus has never been snuffed out. Combined there were fewer than 100 cases in those three countries.

Since the virus re-emerged in the Horn of Africa, there have been at least 160 polio cases in Somalia alone, and the virus has spread to Kenya and Ethiopia.

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Asia-Pacific: HIV/Aids Laws Fail Most Vulnerable

Bangkok – 30 May 2013

Legal protections are unevenly enforced and human rights violations persist for people living with HIV in Asia and the Pacific. According to a new report released today by the United Nations Development Programme (UNDP), weak anti-discrimination laws affect the daily lives of those living with HIV by creating barriers to access to health care, prevention and treatment, and employment and education opportunities. Most people who experience rights abuses do not attempt to seek redress through legal means, according to the report.

Increasingly, countries in the region, including Cambodia, China, Fiji, Lao PDR, Micronesia, Mongolia, Papua New Guinea, the Philippines and Viet Nam, have put in place HIV laws to provide legal protections for people living with HIV. However, little is known on the protective impact of these laws. Legal Protections against HIV-related Human Rights Violations: Experiences and Lessons Learned from National HIV Laws in Asia and the Pacific systematically examines for the first time how these laws have been used and enforced to address rights violations.

Clifton Cortez, Regional Manager a.i. of the UNDP Asia-Pacific Regional Centre, said, “As a follow-up to the report on the Global Commission on HIV and the Law, this report reiterates the importance of investing in enabling legal environments in which legal protections are available, accessible and affordable and people living with HIV and key populations are empowered and supported to take legal action against human rights violations.”

The report highlights gaps in laws and law enforcement practices. For example, no countries in South Asia have national HIV laws, although HIV bills have been in existence for a number of years in India, Nepal and Pakistan. This creates uncertainty in relation to such issues as rights in relation to HIV testing, informed consent and confidentiality.

The report also identifies serious gaps that exist between ‘laws on the books’ and ‘laws on the streets’. In some countries good laws are in place, but people living with HIV still confront significant obstacles in gaining access to justice. Fear that mounting a legal challenge will result in disclosure of identity is a major concern in many countries.

“The report’s findings demonstrate the urgent need for practical measures to be taken to ensure people who experience violations can access the legal system to claim their rights,” says Shiba Phurailatpam, Regional Coordinator of the Asia-Pacific Network of People Living with HIV and AIDS (APN+). “It is not good enough for politicians to pass well-meaning laws if in reality people cannot access justice to enforce their rights. We call on governments and the donor community across Asia and the Pacific to help strengthen access to justice and legal empowerment among people living with HIV.”

The findings indicate that people living with HIV from socially marginalized communities lack the financial resources and access to state justice systems to challenge employers or large institutions in legal proceedings. Access to a lawyer or a human rights advocate can help to redress this power imbalance.

There are some success stories. The report also describes alternative legal approaches that have been pursued in the region to seek justice and enforce rights, as well as presents a detailed analysis of all HIV laws and bills. Legal assistance schemes in Viet Nam have enabled hundreds of cases to be resolved through negotiation and mediation, avoiding the expense of going to court. This has proved to be an effective approach to resolving cases of discrimination in employment, housing and attendance of children at schools. In Thailand, people living with HIV have been supported by non-governmental organizations to successfully challenge patents on HIV medicines to enable greater access to life-saving treatments.

Based upon the findings, the report provides a number of recommendations, including greater investments to enhance legal protections for people living with HIV and key populations, such as men who have sex with men, sex workers, transgender people and people who use drugs, through strengthened engagement of parliamentarians, judiciary, police, lawyers, national human rights bodies and other key institutions.

In support of these actions, donors, including the Global Fund, should promote and allocate greater resources to support government and civil society programming on HIV-related human rights programming. Additionally, national HIV strategies and plans should include specific targeted actions for the legal sector, including law reform, provision of legal aid services and education of people living with HIV, lawyers and the judiciary on HIV-related rights issues.

The findings from the UNDP study will be part of the agenda at the upcoming Judicial Dialogue on HIV, Human Rights and the Law in Asia and the Pacific to be held on 2-4 June 2013 in Bangkok, Thailand. Organized by UNAIDS, UNDP and the International Commission of Jurists (ICJ), this regional dialogue will bring together some 60 participants from 17 countries including judges, representatives from judicial training institutions, community resources persons and other regional experts.

Kenya: Technology Revolutionizes TB Management

NAIROBI, 18 April 2013: The use of technology is revolutionizing the way Kenya manages tuberculosis (TB). Through a computer- and mobile-phone based programme called TIBU, health facilities are able to request TB drugs in real-time and manage TB patient data more effectively, health officials say. They also use the platform to carry out health education.

“One of the challenges we have had with TB treatment is people defaulting [on treatment], but this will reduce significantly because through TIBU we will be able to track down patient treatment progress,” Joseph Sitienei, head of the Division of Leprosy, TB and Lung Disease at Kenya’s National AIDS Control Programme, told IRIN.

“By being able to track a patient, the health workers can send them reminders on their mobile phones when they fail to appear for drug refills,” Sitienei added.

Information sharing

In Kenya, a dearth of information on TB among patients and poor management of patient data have always been a challenge.

“People at times default not because they want to but because they lack information, and health facilities do not share patient data and history. Now the government is beginning to appreciate the relevance of technology in managing diseases such as TB,” said Vincent Munada, a clinical officer at the Kenyatta National Hospital in Nairobi.

Sitienei noted that TIBU – which is Swahili for “treat” – has also helped health facilities better manage drug supplies.

“Initially, health facilities used to request for TB drugs manually, but with this new system, they can ask for the same and the request is relayed to the ministry headquarters immediately. That way, drugs are supplied on time,” he said.

Kenya is ranked at 15 on the UN World Health Organization (WHO) list of 22 countries with the highest TB burden in the world, and it has the fifth-highest TB burden in Africa.

The government says an estimated 250 district hospitals, out of the country’s 290, are using the programme, which was launched in November 2012.

The government is also using the technology to support multi-drug-resistant tuberculosis (MDR-TB) patients living far from medical facilities, sending money to patients via the Mpesa mobile phone money-transfer system  to cover transport costs.

Enormous potential

Mobile phone platforms like TIBU could have even wider life-saving potential.

A recent report by multinational firm PricewaterhouseCoopers noted that mobile phone applications such as short text messages could, over the next five years, help African countries save over one million of the estimated three million lives lost annually across the continent to HIV/AIDS, TB, malaria and pregnancy-related conditions.

“SMS reminders to check for stock levels at the health centres have shown promising results in reducing stock-outs of key combination therapy medications for malaria, TB and HIV. For HIV patients, simple weekly text reminders have consistently shown higher adherence amongst the patients,” said the report.

According to the report, Kenya alone could save some 61,200 lives over the next five years by embracing mobile-based health information management.

On TB, PricewaterhouseCoopers said: “TB is a largely curable disease, but requires six months of diligent adherence to the medication regime. mHealth [mobile health] could help control TB mortalities by ensuring treatment compliance through simple SMS reminders.”

The report noted that mobile phone-based care for patients could reduce emergency visits to health facilities by up to “10 percent.”

“You know, at certain times, a patient doesn’t even need to come to a facility. You simply share what you have with them over the phone. It saves patients time and relieves the health worker to attend to other pressing issues,” Kenyatta National Hospital’s Munada said.

A 2012 study in Kenya found that the use of mobile phones between patients and health workers improved antiretroviral therapy adherence among people living with HIV.

In one mobile health project, community health workers were able to track their patients’ conditions through the use of text messages.

[Courtesy of IRIN]

Food can Kill in Bangladesh

12 April 2013 – Food can just as easily kill as it keeps people alive, experts have learned in Bangladesh, where excessive use of pesticide, unregulated street food and lack of awareness about food safety sicken millions annually.

“Every day we are eating dangerous foods, which are triggering deadly diseases,” said Kazi Faruque, president of the nonprofit Consumer Association of Bangladesh (CAB).

Children younger than five in Bangladesh are at the greatest risk from eating unsafe food, which causes at least 18 percent of deaths in that age group and 10 percent of adults’ deaths, according to a 2006 study cited by the US-based University of Minnesota’s Centre for Animal Health and Food Safety.

Shah M. Faruque, director of the Centre for Food and Waterborne Disease at the International Centre for Diarrhoeal Disease Research, Bangladesh, told IRIN this trend has continued, and may worsen as urbanization strains clean water supply in the capital, Dhaka.

On average, he said from 300 to 1,000 patients visit his medical clinic in Dhaka daily, mostly because of diarrhoea or cholera, which are often traced back to food or drink.

Pesticides and poor planning

Experts say the farm is one starting point for how food can turn fatal.

“Many farmers in the country use an excessive amount of pesticide in agricultural products hoping to [boost] output, while ignoring [the] serious health impacts on consumers,” said Nurul Alam Masud, head of the Participatory Research and Action Network (PRAN), a local NGO.

Despite repeated warnings from the government about this issue, lack of coordination among public agencies has hampered effective controls, said Hasan Ahmmed Chowdhury, a UN Food and Agriculture Organization (FAO) advisor on food safety policies.

FAO is advocating a “farm to table” approach that addresses how food is grown or raised, to how it is collected, processed, packaged, sold and consumed.

Urban poor

In 2009, Bangladesh’s parliament passed the country’s first consumer protection law covering food safety and security (source: Roundup Lawsuit 2017 and Cancer Side Effects Information). New standards included requiring food labels, creating safety testing standards, monitoring products for chemical and microbial hazards, and holding producers accountable by levying fines for violations.

This law joined several others aimed at regulating food quality: Bangladesh Pure Food Ordinance (1959), Fish and Fish Product Rules (1997) and the Radiation Protection Act (1987).

Safe and nutritious food for all is also guaranteed in the constitution – but on the streets, it is a different matter.

“Street vendors operating small, unregulated carts feed millions of people daily, offering no guarantee of safety, with approximately one in six people becoming ill after eating out,” said Sohana Sharmin Chowdhury, head of urban development and communicable diseases at the local NGO Eminence.

This risk makes life even harder for slum dwellers who rely on street food for its ease and affordability, she said. “Health care is already a challenge for [the] slum population. This disease burden from unsafe food consumption adds up to their misery.”

At least 5 percent of Bangladesh’s 170 million people live in illegal housing settlements. According to a 2008 Asian Development Bank study, poor people in Bangladesh, particularly those in cities, find it difficult to prepare food at home as they spend so much time outside the home earning a living.

“Many of them end up eating cheap [ready-made meals] of low quality purchased from small shops or street vendors,” Chowdhury said.

Even though street food sales are illegal, and therefore unregulated, unofficial estimates hold that authorities tolerate about 200,000 food carts selling everything from samuchas – deep fried minced meat or vegetables wrapped in flour – to yogurt “lassi” drinks.

Profit at any cost

Faruque of CAB said vendors’ “philosophy of making profit at any cost” puts consumers at risk.

A common practice among food vendors is to spray fish, fruits and vegetables with chemical preservatives including formalin – a commercial solution of formaldehyde and water – to boost food’s lifespan and appearance.

Formaldehyde is typically used to preserve human corpses, as well as leather and textile products, said Razibul Islam Razon, a medical doctor in the capital who has treated food poisoning.

The chemical’s short-term effects include: a burning sensation in the eyes, nose and throat; coughing; wheezing; nausea; and skin irritation. As for potential long-term health consequences, formaldehyde has been identified as a human carcinogen.

Shah Monir Hossain, a senior adviser at FAO in Bangladesh, said renal failure, cancer and liver damage – all potentially fatal – can be linked to the consumption of unsafe food, but the “extent of food-borne illness is yet unknown”. He predicted the situation will improve with more oversight.

But the private sector is hitting back.

“We are using a special preservative detector machine to check food [for] formalin at our sourcing in order to make sure that our customers receive safe food,” said Sabbir Hasan Nasir, executive director of a company running 40 all-in-one shopping centres nationwide serving about 20,000 customers daily.

“Customers can even check foods in our store through a machine in order to detect formalin,” he added.

Meanwhile, the local NGO Citizens Solidarity recently sent a notice to the government requesting legal steps to force vendors to cease and desist unethical vending practices.

But even when vendors do not knowingly engage in unsafe food handling, their lack of knowledge, coupled with long work hours and their own precarious health, can sicken customers, according to a 2010 FAO-government initiative to boost healthy street food.

The projects’ researchers tested 426 food samples from Dhaka vendors who had not undergone any food hygiene training and 135 from those who had. Samples from untrained vendors had almost uniformly “overwhelming” high bacteria counts, while results from trained vendors largely fell within international safety standards.

The researchers called on the government to develop a policy to “assist, maintain and control” street food vending.

Government efforts

The government is set to create the Bangladesh Food Safety and Quality Control Authority to boost control of street food and to criminalize unsafe food handling, the Minister of Food and Disaster Management, Muhammad Abdur Razzaque, told IRIN.

Under the National Food Safety and Quality Act 2013, this authority will be created within the next two months, said Ahmed Hossain Khan, director-general of the Directorate General of Food in the same ministry.

The draft act addresses weaknesses in the existing food safety regulatory system, including the scant enforcement of food control laws along the entire supply chain. It also introduces a national food-borne disease surveillance system and outlines an emergency response plan in case of a disease outbreak linked to food.

“We identified existing loopholes in our food safety system, and this act will help us radically improve our approach in food safety regulation,” Khan said.

But Nazrul Islam, an associate professor at the Dhaka School of Economics, said regulatory policies alone have failed to solve the food safety problem, and that the government needs to examine the economic roots of unsafe food: the underclass of farmers responsible for feeding the country.

One start, he suggested, is guaranteeing farmers fair prices, a longstanding grievance of producers who accuse middlemen traders and end consumers of profit gouging.

“This may encourage farmers not to go for unethical practices up to a certain extent,” said Islam, adding that better agricultural extension services, easier access to information for farmers and strict regulatory measures are equally important.

The Asian Development Bank is supporting private agribusiness production facilities that will pay guaranteed prices to 50,000 contracted farmers.

But more is needed, Islam said. “The biggest challenge the country is facing in ensuring a meaningful food security for its…people is food safety.”

The 2012 Global Hunger Index places the country’s hunger situation in an “alarming” range, with too few people being able to eat nutritious, life-sustaining food.

[Courtesy of IRIN]

TB vaccines – Update

 

8 April -As researchers consider who might benefit most from the next wave of tuberculosis (TB) vaccines, some argue that we’re not doing enough with the vaccine we already have.

The disappointing results of the first infant TB vaccine tested for efficacy in 40 years were published in February 2013, but new research suggests that while babies might be easier to reach, given existing childhood vaccination programmes, new vaccines will be more cost-effective if geared towards teens and adults.

The findings by the London School of Tropical Medicine are based on mathematical modelling that compared the cost-effectiveness of potential TB vaccines in the top 22 countries with the highest burden of TB, as listed by the World Health Organization (WHO), including South Africa, India and China, which account for 82 percent of all TB cases globally.

Dr Gwen Knight and colleagues used information like the number of new TB cases recorded annually, population projections, and TB mortality. Where available, they also factored in TB treatment and vaccine delivery costs. Finally, they created various scenarios based on projections of, for instance, how well a future vaccine might protect people from active TB, and how long this protection would last.

Knight’s preliminary results were presented at the TB Vaccines Third Global Forum in Cape Town. They indicate that in most scenarios, TB vaccines given to teens and adults were about seven times cheaper than those administered to infants. The most cost-effective TB vaccine would be designed for adults and teens, and would confer 80 percent protection on recipients – a high level of protection compared to most vaccines today.

The options in terms of cost-effectiveness

The cost per Disability Adjusted Life Year (DALY) for a vaccine for adults and teens could be as little as 85 US cents, making it comparable to the lowest prices for the rotavirus and human papillomavirus (HPV) vaccines.
Vaccines for older people were modelled as much more effective in reducing TB cases, with deaths occurring at an infection level largely determined by the transmission dynamics within the group. For example, a vaccine offering life-long protection against active TB would avert almost eight times as many new cases as a TB vaccine given to babies.

The model may be important in helping researchers prioritize TB vaccine candidates and selecting groups to include in future clinical trials. “Previous modelling has shown that the global TB burden is unlikely to be controlled without new TB vaccines,” Knight told IRIN. “What we didn’t know is whether these vaccines would be economically valid, and what type of vaccine should be an economic priority in relation to others.”

In the absence of a TB vaccine, Knight and her team projected that as many as 19 million people would die from the disease between 2024 and 2050.

Making the most of what we have

The world relies on the Bacille Calmette-Guérin (BCG) TB vaccine, developed almost 100 years ago. Given at birth, BCG’s protective effect wanes as children grow to adulthood, but the vaccine has seldom been considered a candidate for global adult or teen vaccination programmes after poor results in trials.

Now there are growing moves in the vaccine community to move away from approaches based solely on infant immunization and to begin developing policies on immunizing adolescents and adults. Adolescents may also be a prime target for re-vaccination with the BCG TB vaccine, according to Christopher Dye, director of health information in the Office of HIV/AIDS, Tuberculosis, Malaria and Neglected Tropical Diseases at WHO.

Dye says the world could do more with the only available TB vaccine in its arsenal. Citing examples from the United Kingdom and Norway, he presented instances in which adult BCG vaccination campaigns in the 1950s and 1960s had not only shown the vaccine to be as much as 80 percent protective, but that it had also reduced new TB cases by 20 percent.

“If those results were obtained today with a TB vaccine, they would be the subject of worldwide acclaim, and they form the basis of my claim that we don’t do enough with BCG,” he told IRIN.

In their search for a cure-all for TB epidemics, policymakers at the time may have dismissed results too readily. “The interpretation was pretty pessimistic,” he said. “In my reading, this was a search for a panacea and when that was not the result obtained, the results were pushed aside.” Disappointing results from India and Malawi could be explained by the presence of other tropical bacterial infections that could reduce BCG’s effectiveness.

Rethinking vaccines, rethinking TB control

Vaccinating teens and adults might also make sense in places like South Africa, where data collected in the Cape Town area in 2010 shows that people between the ages of 16 and 35 experience elevated risks of TB infection when compared to children and older adults.

“Children between the ages of five and ten are extremely resistant to developing active TB, but then become at risk when they move into adolescence,” Dye told IRIN. “Where possible, they need to be re-protected.”

He said adolescent BCG vaccination could easily be added to existing campaigns in countries where girls and, in some instances, boys, are vaccinated against HPV before they become sexually active.

Using mathematical models, Dye proposed that repeated mass vaccination campaigns to protect people as infants, and again as teens or young adults, could cut the annual number of new TB cases in South Africa by 50 percent over a 30-year period. In combination with improved case management and preventative TB therapy for people living with HIV, the models projected that revaccination with BCG could cut TB incidence by more than 90 percent by 2050.

“With all of these intense efforts put into TB control through treatment, the impact at the clinical level has been profound, but the trajectory of the TB epidemic has been [more or less flat],” he told IRIN. “It’s clear from analysis that while drugs have had a clinical impact, they have failed to control the epidemic – that’s why we need vaccines and other tools.”

[Courtesy of IRIN]

Political leadership needed to deal with drug-resistant TB

Twenty years ago, tuberculosis (TB) was one of the least glamorous branches of medicine. The cause had long been known, as had the cure, so all that was left was the unromantic slog of reducing the poverty, hunger and overcrowding that fostered the disease, and working out better ways to get patients to comply with the lengthy course of treatment needed to cure it.

But in 1993 the sudden upsurge in TB cases associated with HIV and AIDS, and the growth of multidrug-resistant (MDR) strains of the bacterium, led the World Health Organization (WHO) to declare the disease a global emergency, which unlocked research funding. Now we are beginning to see the results.

Authors contributing to a special series of articles published by the London-based medical journal, The Lancet, note that “these investments have led to the most promising pool of new tuberculosis drug and vaccine candidates in more than 40 years, with several new drugs and drug regimens poised to enter late-stage clinical trials throughout the next few years.”

The new drugs are not here yet, so much of the scientific debate centres on new tools for managing the MDR outbreak, used with the available drugs. One of the most promising, but also one of the most controversial, of these new tools is a diagnostic kit known as the GeneXpert MTB/RIF assay, endorsed by the WHO in 2010.

It works by identifying DNA sequences and their mutations, in this case of the TB bacterium and the changes that make it resistant to the most basic of TB drugs, Rifampicin. The GeneXpert is a lot more sensitive than the traditional microscope test for TB, and far quicker than more accurate tests where the bacteria are grown in a laboratory. Culture tests, used for smear-negative patients, take an average of 56 days from acquiring the sample to getting the patient started on a suitable treatment. The new machine cuts that delay to less than a week.

In the first article in The Lancet series, a group of researchers led by Prof Alimuddin Zumla, of University College, London, describe the testing kit as ‘a landmark event in tuberculosis research’, but debate whether the benefits are worth the very substantial development costs. Even at the most discounted price for the poorest countries, the equipment and software amount to $17,000, plus just under $10 for the cartridge needed for each individual test. In South Africa, which has gone furthest in adopting the technology, it is expected to increase the annual cost of the TB diagnosis programme by more than 50 percent.

The authors conclude that although the tests are very good, they are still far from perfect. Live bacteria can’t be distinguished from those killed by treatment, so tests can’t be used to discover whether treatment has been successful. The technology also does not work as well on children or people co-infected with HIV, although this is also the case with older testing methods.

The GeneXpert tests are easy to do, and staff don’t have to be trained lab technicians, but the equipment is delicate. It needs air-conditioned surroundings with constant power, and a good supply chain for the cartridges, which don’t have a long shelf life. These requirements make it difficult to put the equipment where it is needed most – the clinics, often in rural areas, where patients first arrive with TB symptoms.

The study group points out that other diagnostic tools are in development, including hand-held systems the size of smartphones, urine dip-sticks, and even breathalyzers. “Several fully automated assays that compete with the Xpert MTB/RIF assay, and that will be more applicable for point-of-care, are likely to be developed in the future. However, how the donor assistance that has heavily subsidized the implementation of Xpert MTB/RIF in resource-limited settings will affect the development and entry of newer diagnostic assays to the marketplace in not clear. Commercially, funding is not a level playing field.”

Other writers contributing to The Lancet series are more excited about the GeneXpert system’s potential for tracking drug resistance, which is spreading at a frightening rate, especially in countries that can afford first-line TB drugs but have weak healthcare systems, such as India, China, Russia and Brazil. In Minsk, Belarus, almost 50 percent of TB cases are multidrug-resistant.

A group led by Dr Marco Schito, of the National Institutes of Health in Bethesda, Maryland, discusses how the test should be applied in a paper entitled ‘Drug Susceptibility Testing, a Framework for Action’. Should every patient be tested for both the TB bacterium and the resistant strain? Test all patients diagnosed with TB? Or only those treated for TB in the past – a more economical approach when rates of resistance are not high?

The paper also argues that we need to develop tests for new drugs most likely to be the backbone of treatment in the future, so that surveillance work can track emerging drug resistance. “Generally, surveillance is restricted to activities that align with current rather than future treatment priorities,” the authors comment. “Such data are insufficient to assess development and implementation priorities for new tuberculosis regimens and diagnostics.”

The emergence of MDR and extremely drug-resistant (XDR) TB is alarming – at present, scientists can only guess how widespread these new forms of TB are. In 2011 less than 4 percent of new TB cases and 6 percent of previously treated cases were tested for resistance to first-line drugs. The new DNA-based assays could improve this dramatically, but would then raise the question of how to treat a possibly far higher number of drug-resistant patients.

The second-line treatments now available are lengthy, expensive, poorly tolerated and not very effective. People with strains of drug-resistant TB could spread these, but there is also no way that a large volume of patients could be kept in hospital for the length of time needed to effect a cure. New drugs and new combinations of drugs are urgently needed.

The Lancet series calls for visionary global leadership. “The global economic crisis and reduced investments in health services threaten national tuberculosis programmes and the gains made in global tuberculosis control. The world needs to acknowledge the serious threat of drug-resistant tuberculosis before it overwhelms health systems, as is being seen in several countries in the Soviet Union.”

[Courtesy of IRIN News]