Phlegmbo: TB’s Retreat
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CHARLAYNE HUNTER-GAULT: On this World Tuberculosis Day the news is mixed. TB remains the world’s leading infectious killer, with 3 million people dying each year. But new treatments and a declining number of cases in the United States offer reasons for hope. For an update we’re joined by Dr. David Brandling-Bennet, deputy director of the Pan American Health Organization, and Dr. Helene Gayle, who oversees TB prevention for the Centers for Disease Control & Prevention. Thank you both for joining us. Starting with you, Dr. Gayle, what accounts for the domestic decline?
DR. HELENE GAYLE, Centers for Disease Control and Prevention: Well, there are several factors that account for the decline. And we’re really happy to report that cases are down 7 percent this year. And this is the fourth consecutive years that cases are down. We think that a lot of this is due to rebuilding the infrastructure for prevention and the control of tuberculosis in this country and better completion of therapy for people who have tuberculosis. Using directly observed therapy we can now make sure that people who have tuberculosis actually complete what is a long and complicated medical regime for tuberculosis. This has had tremendous effect on the TB case rate.
CHARLAYNE HUNTER-GAULT: What do you mean directly observed therapy?
DR. HELENE GAYLE: Well, people who have tuberculosis and the regiment is a six to eight month complicated regiment of multiple drugs, and in the past, what happened is that people, once they felt better, were very likely to stop taking the medicine and not complete the therapy. So with directly observed therapy people actually have health care workers who observe their taking the treatment and making sure that they chart the course to make sure that people actually complete the whole course of TB therapy. It’s made a dramatic difference.
CHARLAYNE HUNTER-GAULT: And is this a simple medication?
DR. HELENE GAYLE: No. In fact, multiple drugs must be taken in order to actually kill the bacteria and get rid of the active case of tuberculosis. So it’s a very complicated regiment.
CHARLAYNE HUNTER-GAULT: Where is it still a big problem in the United States?
DR. HELENE GAYLE: Well, it’s mainly a problem in the United States in larger urban areas, in cities that have large immigrant population, large populations of people with HIV infections, people–it’s often very common in prison populations, populations where people congregate who are in close proximity, where TB can spread easily. So we’re seeing cases in these populations particularly, but we’re also seeing outbreaks in rural areas as well. So although it’s concentrated in these areas, we definitely want to make sure that the whole nation is vigilant and is prepared to take care of treatment of tuberculosis and detection of cases.
CHARLAYNE HUNTER-GAULT: And it’s spread simply by coughing and sneezing, right?
DR. HELENE GAYLE: Right. It’s spread by passing it on through coughing, sneezing, respiratory spread of the disease.
CHARLAYNE HUNTER-GAULT: And anybody who breathes the air is at risk for getting tuberculosis, right?
DR. HELENE GAYLE: Generally speaking, although people need to be in fairly close contact with somebody to actually come down with tuberculosis. So it’s not so simple that just by being close to somebody for a short period of time you may come down with it. It’s really much more likely for somebody who has prolonged close contact with somebody with active tuberculosis.
DR. HELENE GAYLE: Dr. Brandling-Bennet, I read that in Europe TB is reaching epidemic proportions even as it’s declining in the United States. Why is that?
DR. DAVID BRANDLING-BENNET, Pan-American Health Organization: Well, it is particularly serious in Russia and some of the newly independent states. Romania, for example, has the highest incidence now. And that’s primarily because of the decline in those regions with declining resources and, of course, changes in declining living conditions. Also, they’ve tended to use old methods of dealing with tuberculosis in those countries, which worked when they had the resources but which are no longer effective.
CHARLAYNE HUNTER-GAULT: Like what?
DR. DAVID BRANDLING-BENNET: Well, hospitalization of cases, old treatment regiments, asking patients to come in to get their treatment regiments, going out and finding the patients. They’re not using the directly observed therapy short course, which is the system that WHO, the World Health Organization, and here at the Pan-American Health Organization in our region have found to be effective.
CHARLAYNE HUNTER-GAULT: And this is true because there are 13 countries, as I understand it, in Europe that are responsible for 75 percent–
DR. DAVID BRANDLING-BENNET: Thirteen countries in the world.
CHARLAYNE HUNTER-GAULT: In the world, responsible for 75 percent.
DR. DAVID BRANDLING-BENNET: Russia is one of those countries, of the 13. But large countries in Asia, Thailand, Indonesia, the Philippines, countries in Africa, South Africa, Zaire, Ethiopia, Brazil, and Mexico in this region are amongst those countries included in those 13.
CHARLAYNE HUNTER-GAULT: And it’s all the same reasons, lack of vigilance?
DR. DAVID BRANDLING-BENNET: No, no. Actually there are various reasons why we have them. In this region, for example, Mexico is just getting started. It’s a large country, has a large of tuberculosis, and they’re getting started applying this approach which we call DOTS.
CHARLAYNE HUNTER-GAULT: That’s Directly Observed Therapy–
DR. DAVID BRANDLING-BENNET: Directly Observed Therapy Short Course, right. Which we now know works, and that’s the big breakthrough. We know that it’s effective. We know that if this is applied, we could reduce tuberculosis incidents by half over the course of ten years. Brazil has decentralized. It’s a big country. They have states in Brazil and cities which are responsible for health care. So we have to get the practice into those. Thailand, for example, has a big problem with HIV, as does South Africa. And that’s part of what contributes to this. As we mentioned, Russia, it’s really the breakdown in health services.
CHARLAYNE HUNTER-GAULT: And so the breakthrough that was reported last week that promises to completely eradicate tuberculosis, is this directly observable therapy that’s been in use for a while, why is now being considered a breakthrough if it’s been used to bring the–to a decline the cases in the states?
DR. DAVID BRANDLING-BENNET: Well, I should say we’re not promising eradication at this point. I think if we applied it, we could get very significant reductions in tuberculosis. What’s new is that we now have a system which is highly cost effective which can be applied in the normal health services. You don’t have to treat tuberculosis like a special problem in hospitals with specialists, doctors to do it. We can now get people treated in all services, and we can go out and find people and be sure they’re treated to cure. And that’s the most critical factor, to get the people treated, completely over the course of six to eight months, so they’re completely cured of the disease.
CHARLAYNE HUNTER-GAULT: Dr. Gayle, what about prevention? I mean, how do you–we’re talking about what to do about people who have contracted the disease, but what about preventing the disease?
DR. HELENE GAYLE: Well, first of all, treating people who have active disease is really the main stay of making a difference. If we can treat an active case of tuberculosis, then that person is not going to spread the infection on to others, and so clearly it’s going to prevent the spread of tuberculosis in the population. Now we also use preventive therapy for people who are detected who have the tuberculosis germ in them, but it’s not actively causing symptoms. It’s not an active infection. And so we do want an active finding for people who are at high risk of having tuberculosis and getting them on preventive therapy. But, again, the mainstay of prevention and control efforts for tuberculosis efforts is completely treating people who have active disease so that they can get better themselves but also so they don’t spread it to other people.
CHARLAYNE HUNTER-GAULT: All right. Well, thank you both for joining us.