Wüstenschiff

Jedes Jahr sterben etwa zwei Millionen Menschen an Tuberkulose. Da der Erreger zunehmend resistent wird gegen Medikamente, versuchen Forscher, einen wirksamen Impfstoff gegen die "Krankheit der Armen" zu entwickeln ...

Tuberkulose auf dem Vormarsch
24.03.2010 - Deutsche Welle

Gruß
Birgitt

Tuberkulose ist vor allem in den armen Staaten Afrikas und Asiens verbreitet. Aber auch in Europa kommt die Lungenkrankheit vor. Hier ist vor allem die Ausbreitung resistenter Keime ein wachsendes Problem. mehr...

Grüsse
Alexander

Nicht immer verrät sich eine Tuberkulose-Infektion durch Symptome. Jetzt aber haben Forscher erstmals knapp 2.000 Gene identifiziert, die bei einem infizierten Menschen „anders ticken“ als bei einem Gesunden. Darunter sind Gene, die die Aktivität des Immunsystems regulieren und das Selbstmord-Programm von Immunzellen steuern. Fünf davon eignen sich als Biomarker, als einfach zu analysierende Anzeiger für eine Infektion ...

Biomarker für Tuberkulose identifiziert: Tuberkulose-Infektion verändert knapp 2.000 Gene des Menschen
22.03.2011 - scinexx

Gruß
Birgitt

TUBERCULOSIS - PAKISTAN: INCREASED INCIDENCE
********************************************
A ProMED-mail post
<http://www.promedmail.org>
ProMED-mail is a program of the
International Society for Infectious Diseases
<http://www.isid.org>

Date: Thu 26 May 2011
Source: The Express Tribune [edited]
<http://tribune.com.pk/story/176474/over ... one-month/>


As many as 10 831 new cases of tuberculosis (TB) have been reported
at state-run health care facilities in 35 districts across Pakistan
during February 2011. This alarming number is a cause of serious
concern for the government particularly in the Punjab province that
accounted for 86 percent of the reported cases in 18 districts.

According to FAFEN's [Free and Fair Election Network] monthly Health
Scan, the number of confirmed cases of TB reported in February 2011 is
double than the 4910 cases of the disease reported a month earlier in
37 districts.

FAFEN Monitors collected the data of disease cases from district
health offices in 64 districts for February 2011. Executive District
Officer (EDO)/Health offices in 24 districts of Punjab, 18 districts
in Khyber Pakhtunkhwa (KP), 13 districts in Sindh and 7 districts in
Balochistan, as well as the office of the Agency Surgeon Health (ASH)
in FR Peshawar, and that of the office of Health Management
Information System (HMIS) in ICT shared the requested information with
FAFEN Monitors.

--
Communicated by:
HealthMap Alerts via ProMED-mail
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[Pakistan ranks 6th among countries with the highest burden of TB in
the world in 2010
(<http://tribune.com.pk/story/133614/paki ... ients-who/>),
and Pakistan contributes about 44 percent of the tuberculosis burden
in WHO's Eastern Mediterranean Region
(<http://www.ntp.gov.pk/about.htm>). About 300 000 new tuberculosis
cases are reported each year in Pakistan
(<http://tribune.com.pk/story/133614/paki ... ients-who/>).
Tuberculosis remains Pakistan's leading cause of death among
infectious diseases
(<http://www.usaid.gov/stories/pakistan/fp_pk_tb.html>).

The Pakistan Ministry of Health began implementing DOTS (Directly
Observed Therapy, Short-course, the internationally recommended
strategy for TB control) in 1995, with certain regions selected as
pilot programs. However, many patients do not have access to DOTS even
within the designated DOTS areas
(<http://www.jpma.org.pk/full_article_tex ... cle_id=234>). A
study found that a majority of patients with tuberculosis were very
poor, but nonetheless initially sought care from private practitioners

(<http://www.ncbi.nlm.nih.gov/pubmed/10619693>), who have been found
to have inadequate knowledge to diagnosis and treat the disease
(<http://www.jpma.org.pk/full_article_tex ... cle_id=234>).
Almost all patients in the aforementioned study
(<http://www.ncbi.nlm.nih.gov/pubmed/10619693>), reported problems
with access to treatment, both in terms of time and money; this was
particularly true of women, whose freedom to travel in Pakistan was
said to be limited. In addition, patients were unwilling to disclose
to health care providers that they had received previous treatment for
tuberculosis, which means that many patients, who had failed a
previous course of drug therapy, were prescribed treatment regimes to
which their pathogen was likely resistant.

Emergence and spread of multidrug-resistant tuberculosis (MDR-TB) and
extensively drug-resistant tuberculosis (XDR-TB) are facilitated by
inadequate detection and treatment. MDR-TB is defined as tuberculosis
resistant to both isoniazid and rifampin. XDR-TB is defined as
tuberculosis that has developed resistance to at least rifampin and
isoniazid, as well as to any member of the fluoroquinolone family of
antibiotics and at least one of the following second-line anti-TB
injectable drugs: kanamycin, capreomycin, or amikacin.

Resistance among new cases is defined as the presence of resistant
isolates of _M. tuberculosis_ in patients who, in response to direct
questioning, deny having had any prior anti-TB treatment (for as much
as 1 month) and, in countries where adequate documentation is
available, for whom there is no evidence of such a history. Drug
resistance among new cases is used to evaluate recent transmission.
The impact of including patients with a prior history of TB treatment
may result in an overestimation of the resistance rates among new
cases. Accurate data for Pakistan on the frequency of MDR-TB among new
cases of tuberculosis would be hard to come by in view of the tendency
of Pakistani patients not to disclose their histories of prior
treatment for tuberculosis.

A WHO study reported that the estimated frequency in 2000 of MDR-TB
among all new TB cases of tuberculosis in Pakistan was about 10
percent, but the upper 95 percent confidence limit was about 22
percent
(<http://www.emro.who.int/STB/Media/PDF/JID%20paper.pdf>). However,
WHO reported that between 2002 and 2007, the estimated frequency for
Pakistan of new MDR-TB cases was 3.4 percent and the upper 95 percent
confidence limit was 18.4 percent, but that Pakistan accounted for 60
percent of the MDR-TB burden within WHO's Eastern Mediterranean Region

(<http://www.who.int/tb/publications/2008 ... 6feb08.pdf>).
For comparison, WHO reports that the highest proportion of MDR-TB
among new cases (>10 percent) occurs in countries of the former Soviet
Union
(<http://www.who.int/tb/publications/2008 ... 6feb08.pdf>).

In a study of XDR-TB in Pakistan during 2006-2009, a total of 9523
_M. tuberculosis_ strains were isolated in a reference laboratory,
including 3682 (38.7 percent) MDR-TB strains
(<http://www.cdc.gov/eid/content/16/9/1473.htm>). Although the MDR-TB
rate remained constant, the XDR-TB rate (expressed as a percentage of
MDR-TB isolated in a year) showed a significant increase from 1.5
percent in 2006 to 4.5 percent in 2009. The XDR-TB strains in this
study were genetically diverse, which supports the concept that XDR-TB
in Pakistanis is likely to be a consequence of inadequate treatment of
tuberculosis
(<http://www.cdc.gov/eid/content/16/9/1473.htm>).

Tuberculosis control in the USA and Western Europe is now tempered by
the burden of TB among foreign-born persons residing in the country.
In the USA, the incidence rate among foreign-born persons is at least
8 times higher than that among U.S.-born persons; the top 5 countries
of origin for foreign-born persons in the USA with TB are Mexico, the
Philippines, Viet Nam, India, and China. In the UK, the incidence rate
of tuberculosis among ethnic minority groups (of which about 50
percent are South Asians,
<http://www.statistics.gov.uk/cci/nugget.asp?id=455>) is over 100
times higher than that among the "white" population (see Mod.ML's
comments in ProMED-mail post Tuberculosis - UK: resurgence
20101223.4522).

A map of Pakistan can be seen at
<http://www.lib.utexas.edu/maps/middle_e ... l_2002.jpg>
and Pakistan can be located on the HealthMap/ProMED-mail interactive
map at
<http://healthmap.org/r/0FUB>. - Mod.ML]

TUBERCULOSIS, TDR - INDIA: (MAHARASHTRA, KARNATAKA)
***************************************************
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http://www.promedmail.org
ProMED-mail is a program of the
International Society for Infectious Diseases
http://www.isid.org


[1]

Date: Sat 7 Jan 2012
Source: Indianexpress.com [edited]
http://www.indianexpress.com/news/mumba ... ../896826/


Almost 3 years after the 1st set of patients were diagnosed with Totally Drug-Resistant Tuberculosis (TDR-TB) in Iran, researchers at the P D Hinduja National Hospital and Medical Research Centre here said today [7 Jan 2012] they have detected India's 1st set of TDR-TB patients, 12 over the past 2 months.

In a paper published in the international journal Clinical Infection Diseases, Zarir Udwadia and his team have described how they detected the 1st 4 TDR-TB patients [Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally Drug-Resistant Tuberculosis in India. Clin Infect Dis. 1st published online 21 Dec 2011 doi:10.1093/cid/cir889].

"Prior to TDR, XDR or extensively drug-resistant TB was the furthest stage patients had been diagnosed with in India. After drug susceptibility testing was performed on 4 TB patients present at the hospital, it was seen that all 4 patients were resistant to both 1st line as well as 2nd line treatment," said Udwadia, adding that there was no treatment for them.

According to Udwadia, the drug-resistant nature of the TB-causing _Mycobacterium tuberculosis_ increases with mutations of the strain often catalysed by incorrect and erratic administration of 2nd-line drugs. "An audit of the patients' prescriptions showed that 3 of the 1st 4 patients received unsupervised 2nd-line drugs often in incorrect dosages by private practitioners in an attempt to treat their multi-drug resistant TB (MDR-TB). By the time they were referred to us, they had moved from the MDR stage and the XDR stage to TDR-TB," he said.

[Byline: Ananya Banerjee]

--
Communicated by:
Mark Liao
MSI
UC Davis School of Medicine


[Similar news releases were also submitted by Ryan McGinnis and ProMED-mail Rapporteur Mary Marshall. - Mod.ML]

******
[2]
Date: Sun 8 Jan 2011
Source: IBNLive South [edited]
http://ibnlive.in.com/news/no-cases-of- ... 0-115.html


Following the reports of deaths of some patients from Totally Drug Resistant Tuberculosis, (TDR TB), which is far more dangerous than Multi-Drug Resistant (MDR) and Extreme Drug Resistant (XDR) forms, in Mumbai, experts say that improper treatment regimens followed by private practitioners and non-compliance to the whole course of proper treatment make tuberculosis patients vulnerable to this deadly infection.

According to the Rajiv Gandhi Institute of Chest Diseases (RGICD), which is a government-run institute specializing in treating tuberculosis, there were no cases of TDR in the State [Karnataka]. A total number of 450 MDR cases were treated since 2005, of which only 219 patients could complete the treatment. The institute had also detected 2 patients with XDR in the years 2010-11.

Speaking to Express [Express News Service], Dr Shashidhar Buggi, Director, Rajiv Gandhi Institute of Chest Diseases (RGICD), said: "Had these patients not completed the treatment, it could have infected several others. The MDR treatment is long and costly. However, at RGICD, we are providing free treatment to such patients with the help of the state government." He also maintained that for MDR patients, thoracic surgery is important, but there is a shortage of surgeons in our country.

Dr VM Katoch, Director General, Indian Council of Medical Research (ICMR), said that private practitioners do not follow the proper course of treatment. Sometimes, patients visit multiple doctors, which leads to non-compliance of the treatment.

--
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******
[3]
Date: Mon 9 Jan 2012
Source: Wired.com [edited]
http://www.wired.com/wiredscience/2012/ ... more-91763


Over the past 48 hours, news has broken in India of the existence of at least 12 patients infected with tuberculosis that has become resistant to all the drugs used against the disease. Physicians in Mumbai are calling the strain TDR, for Totally Drug-Resistant. In other words, it is untreatable as far as they know.

News of some of the cases was published on 21 Dec 2011 in an ahead-of-print letter to the journal Clinical Infectious Diseases. That letter describes the discovery and treatment of 4 cases of TDR-TB since last October [2011]. On Saturday [7 Jan 2012], the Times of India disclosed that there are actually 12 known cases just in one hospital, the P. D. Hinduja National Hospital and Medical Research Centre; in the article, Hinduja's Dr. Amita Athawale states: "The cases we clinically isolate are just the tip of the iceberg." And, as a follow up, the Hindustan Times reported yesterday [8 Jan 2012] that most hospitals in the city -- by extension, most Indian cities -- don't have the facilities to identify the TDR strain, making it more likely that unrecognized cases can go on to infect others.

TB is already one of the world's worst killers, up there with malaria and HIV/AIDS, accounting for 9.4 million cases and 1.7 million deaths in 2009, according to the WHO. At the best of times, TB treatment is difficult, requiring at least 6 months of pill combinations that have unpleasant side effects and must be taken long after the patient begins to feel well.

Because of the mismatch between treatment and symptoms, people often don't take their full course of drugs, and from that and some other factors, we get multi-drug resistant and extensively drug-resistant MDR and XDR TB.

MDR is resistant to the 1st-choice drugs, requiring that patients instead be treated with a larger cocktail of "2nd-line" agents, which are less effective, have more side effects, and take much longer to effect a cure, sometimes 2 years or more. XDR is resistant to the 3 1st-line drugs and several of the 9 or so drugs usually recognized as being 2nd choice.

As of last spring [2011] according to the WHO, there were about 440 000 cases of MDR-TB per year, accounting for 150 000 deaths, and 25 000 cases of XDR. At the time, the WHO predicted there would be 2 million MDR or XDR cases in the word by 2012. That was before TDR-TB.

The 1st cases, as it turns out, were not these Indian ones but an equally under-reported cluster of 15 patients in Iran in 2009. They were embedded in a larger outbreak of 146 cases of MDR-TB, and what most worried the physicians who saw them was that the drug resistance was occurring in immigrants and cross-border migrants as well as Iranians: Half of the patients were Iranian and the rest Afghan, Azerbaijani and Iraqi. The Iranian team raised the possibility at the time that rates of TDR were higher than they knew, especially in border areas where there would be little diagnostic capacity or even basic medical care.

The Indian cases disclosed before Christmas demonstrate what happens when TB patients don't get good medical care. The letter to CID describes the course of 4 of the 12 patients; all 4 saw 2 to 4 doctors during their illnesses, and at least 3 got multiple, partial courses of the wrong antibiotics. The authors say this is not unusual.

"The vast majority of these unfortunate patients seek care from private physicians in a desperate attempt to find a cure for their tuberculosis. This sector of private-sector physicians in India is among the largest in the world, and these physicians are unregulated both in terms of prescribing practice and qualifications. A study that we conducted in Mumbai showed that only 5 of 106 private practitioners practicing in a crowded area called Dharavi could prescribe a correct prescription for a hypothetical patient with MDR tuberculosis. The majority of prescriptions were inappropriate and would only have served to further amplify resistance, converting MDR tuberculosis to XDR tuberculosis and TDR tuberculosis."

As their comment suggests, the other TB challenge is diagnosis, especially of resistant strains, and here again the news is not good. The WHO said last spring [2011] that only 2/3rds of countries with resistant TB epidemics have the lab capacity to detect the resistant strains. As a result, only one MDR patient out of every 10 even gets into treatment, and when they do, cure rates range from 82 percent down to 25 percent. That's for MDR. None of the TDR patients have been recorded cured, and at least one of the known Indian patients has died.

Meanwhile, health authorities estimate that one patient with active TB can infect up to 15 others, and thus resistant TB spreads: XDR-TB was 1st identified just in 2006, and it has since been found in 69 countries around the world.

[Byline: Maryn McKenna]

--
Communicated by:
Michael J. Buman, RN


[Multidrug-resistant TB or MDR-TB refers to tuberculosis that is caused by a strain of _Mycobacterium tuberculosis_ resistant to 2 of the most effective drugs used to treat TB, isoniazid (INH) and rifampin. Extensively drug-resistant TB or XDR-TB refers to a subgroup of MDR-TB strains that are additionally resistant to any of the fluoroquinolone class of drugs (e.g., levofloxacin. moxifloxacin, or gatifloxacin) and any of the 3 injectable drugs used to treat tuberculosis (capreomycin, kanamycin and amikacin).

In 2003, 2 middle-class, HIV-negative Italian women died of tuberculosis that was caused by strains resistant to every anti-tuberculosis drug (Migliori GB et al. 1st tuberculosis cases in Italy resistant to all tested drugs. Eurosurveillance Weekly Release 12: 5, 2007). The authors of the report attributed the development of drug resistance in these patients to medical mismanagement and inappropriate use of anti-tuberculosis therapy. WHO referred to these cases as extremely drug-resistant tuberculosis or XXDR-TB, which was defined as TB due to strains resistant to all 1st and 2nd line anti-TB drugs (http://euro.who.int/tuberculosis/public ... 20071204_5 and http://www.aidsmap.com/en/news/CBA086E0 ... B35E8D.asp).

In 2009, 15 "Totally Drug Resistant" or TDR isolates (10.3 percent) of 146 MDR-TB strains were reported from Iran (Velayati, AA, Masjedi MR, Farnia P, et al. Emergence of new forms of totally drug-resistant tuberculosis bacilli: Super extensively drug-resistant tuberculosis or totally drug-resistant strains in Iran. Chest 2009; 136: 420-425). These TDR strains were resistant to all 1st- and 2nd-line drugs tested and thus seemingly similar to XXDR-TB strains.

In December 2011, the 1st 4 of the 12 patients from Mumbai, India were reported with what was labeled TDR tuberculosis [Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally Drug-Resistant Tuberculosis in India. Clin Infect Dis. 1st published online 21 Dec 2011 doi:10.1093/cid/cir889, available at http://cid.oxfordjournals.org/content/e ... 20html?sid]. The drug susceptibility testing was performed at the Hinduja Hospital, Mumbai's busiest referral laboratory and a Revised National Tuberculosis Control Programme (RNTCP) accredited laboratory for Mumbai. The isolates from each of the 4 patients in this report were resistant to all 1st-line (isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin) and some 2nd-line (ofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, para-aminosalicylic acid, and ethionamide) drugs tested; thus, this TDR designation is again seemingly similar to XXDR-TB strains and does not include what are called 3rd-line anti-TB drugs, such as the macrolides (e.g., clarithromycin), clofazimine, amoxicillin/clavulanic acid, linezolid, imipenem, high-dose isoniazid, and several new investigational drugs (http://www.medscape.com/viewarticle/706826_6).

The latest WHO global resistance report estimated 110-132 cases of MDR tuberculosis from India in 2006, which accounts for 20 percent of the world's MDR tuberculosis load (http://cid.oxfordjournals.org/content/e ... 20html?sid). Indian patients with MDR tuberculosis currently are not covered by India's RNTCP, with most MDR patients seeking care from private physicians. According to Udwadia et al (http://cid.oxfordjournals.org/content/e ... 20html?sid ), an audit of the Indian patients' prescriptions revealed that 3 patients had received erratic, unsupervised 2nd-line drugs, added individually and often in incorrect doses, from multiple private practitioners, which undoubtedly contributed to the emergence of drug resistance.

Mumbai, formerly known as Bombay, is a port city on the western coast of India and is its richest and most populous city, with a total metropolitan area population of approximately 20.5 million (http://en.wikipedia.org/wiki/Mumbai). It is the capital of the Indian state of Maharashtra, which is bordered by the state of Karnataka to the south.

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1mm2. - Mod.ML]

TUBERCULOSIS, TDR - INDIA (02): (KARNATAKA), REQUEST FOR INFORMATION
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[1] Date: Wed 11 Jan 2012
Source: DNAIndia.com [edited]
http://www.dnaindia.com/bangalore/repor ... re_1636125


Following the discovery of 4 cases of totally drug resistant tuberculosis (TDR-TB) in a Mumbai hospital 3 days ago, 2 confirmed cases with the deadly new strain of TB have been detected at the Rajiv Gandhi Institute of Chest Diseases (RGICD) in Bangalore. But the scarier scenario is this: one among them, a 56-year-old man (the hospital has not disclosed his name), has gone absconding, raising the threat perception many levels higher, considering that he could infect others with the deadly strain.

Shockingly, the RGICD has not informed the state health department. Dr Shashidhar Buggi, director, RGICD, said: "If they ask us, we will let them know. We are a national institute; if the state government asks us for the report, we will definitely give it to them."

This spells another concern. While one of the confirmed TDR-TB patients has gone missing, state health department officials remain in the dark.

TDR-TB is a strain of tuberculosis which cannot be treated by any available drug. This means that a person afflicted by this strain faces a 100 percent mortality rate and, until death, can infect many others.

Both the TDR-TB cases in Bangalore were confirmed after the RGICD sent their sputum (phlegm) samples to Chennai's Intermediate Reference Laboratory, where the samples tested positive for the deadly TDR-TB strain. The other patient suffering from the TDR-TB is a 29-year-old woman (name undisclosed).

"These patients were being treated for over 2.5 years. After 8 months, when they were not responding to medication, we sent their sputum samples to the Intermediate Reference Laboratory in Chennai. It was then found that they had both become extremely resistant to the drug‚ a condition named extreme drug resistance (XDR). When this condition continued for more than a year, it was confirmed that they had multi drug resistance (MDR). Now, it has been 2 years since they have been getting treatment, and the tests have confirmed that they have TDR," said Dr Buggi.

Over 498 cases of MDR alone have been registered with the RGICD since 2005, of which 230 have been treated and discharged. "In 2009, we had 114 cases; in 2010, there were 74 fresh cases. The number came down to 50 MDR cases in 2011," he said. "We have sent samples of 8 suspected TDR-TB patients to Chennai and are awaiting the results. The tests identify micro-organisms causing infections in the lower respiratory tract like TB," he said.

When DNA [DNAIndia.com] tried contacting senior health officials, none of them were available.

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******

[2] Date: Wed 11 Jan 2012
Source: DNAIndia.com [edited]
http://www.dnaindia.com/bangalore/repor ... se_1636131


Even as 2 cases of totally drug-resistant tuberculosis (TDR-TB) have been detected in Bangalore, one of the patients is missing. This poses a grave threat of rapidly spreading the deadliest strain of _Mycobacterium tuberculosis_, the bacterium that causes the disease.

A 56-year-old man has been missing for 2 weeks, as he has not turned up at Rajiv Gandhi Institute for Chest Diseases (RGICD) for treatment and may be a cause of concern in the city. "TB can spread fast. A person with TB, if not treated, can spread it to 10 other people around him, on average," said Shashidhar Buggi, director of SDS Tuberculosis and Chest Diseases Hospital and RGICD.

Now, this patient is like a ticking time-bomb. And nobody is coming forward to inform the authorities about his whereabouts, or whether he has died.

"We don't know why he stopped coming to the hospital. But we have not seen him in 2 weeks. We are now considering operating [on] the other patient (a 29-year-old woman) depending on her condition. But for now, we have no news of the other patient," he said.

The absconding patient is said to have been taking treatment for TB at the RGICD for 2 years. "We had 2 cases of TB for which we had been giving treatment for more than 8 months. We sent their phlegm for testing in Chennai, where it was confirmed that both have developed extreme drug resistance. After another 6-8 months of treatment, it was found that they were suffering from multi-drug resistance (MDR)," Buggi said.

It has been 2 years since the 2 patients started treatment for MDR. Buggi said the RGICD had recently sent samples of phlegm for testing at Chennai's Intermediate Reference Lab; out of the 10 samples, 2 were confirmed to have TDR.

[Byline: Deepthi MR]

--
Communicated by:
ProMED-mail Rapporteur Mary Marshall

******
[3] Date: Thu 12 Jan 2012
Source: DNAIndia.com [edited]
http://www.dnaindia.com/bangalore/repor ... ng_1636519


The revelation of 2 confirmed totally drug resistant-tuberculosis (TDR-TB) cases at Rajiv Gandhi Institute of Chest Diseases (RGICD) has shaken the health ministry and officials who had instantly gone into a denial mode, even as they blame the RGICD for not bringing the cases to their notice.

However, minister for medical education, health and family welfare, SA Ramdas, following a DNA report on Wednesday [11 Jan 2012], has decided to constitute a 3-man committee to submit a detailed report on the status of tuberculosis in the state to the government. He also conducted a "surprise visit" to RGICD and declared that he is not convinced that the 2 were TDR-TB cases because "the 2 cases were only confirmed by clinical tests, and biological tests have not been done while confirming them."

He alleged that RGICD has only conducted a clinical analysis of the 2 patients wherein sputum (phlegm) culturing was not conducted. He blamed RGICD for guessing that, since the patients have not responded to the medication for 2 years, it must be TDR.

Biological tests (also called culture and sensitivity tests) include culture of the sputum being subjected to multiple tests during which the DNA strands are isolated.

The tests involve allowing the bacteria "_Mycobacterium tuberculosis_" to grow, and various drugs are used on it to indicate whether the samples are TDR-TB-positive or not. These tests are conducted only in Chennai and at New Delhi's National Institute of Tuberculosis.

Ramesh, joint director, Lady Willingdon State Tuberculosis Centre's Revised National Tuberculosis Control Programme, which is a state government-administered organisation, said: "We have not received TDR cases so far, and if Rajiv Gandhi Institute for Chest Diseases has them, then they should have informed us." Despite that, RGICD authorities stand by their version that 2 patients are indeed confirmed as TDR-TB cases, one of which‚ a 56-year-old man, is missing

Ramdas, however, does admit that there are 56 cases of major multi drug resistant tuberculosis (MDR-TB), and 6 cases of extreme drug resistant tuberculosis (XDR-TB).

"We have sent 4.8 lakh [a lakh is a unit in the South Asian numbering system equal to 100 000] sputum samples from the state to Chennai's Intermediate Reference Lab and received 68 000 TB-positive cases, of which 56 are MDR positive and 6 have extreme drug resistance [XDR]. If there are other cases, we will trace the patients and give them appropriate treatment," he said.

There is no denying that the state ministry is concerned despite its initial reaction, hence the constitution of the 3-member committee, which in all likelihood comprises Dr Suryakanth, officer in-charge at Lady Willingdon State Tuberculosis Centre's Revised National Tuberculosis Control Programme; Dr Sathya Prakash, senior scientist, National Tuberculosis Institute; and Dr Raghupathi, resident medical officer, state health department.

[Byline: Deepthi MR]

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Communicated by:
ProMED-mail
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[For a discussion of MDR-, XDR-, XXDR- and TDR-TB, see the moderator's comments in the prior ProMED-mail post Tuberculosis, TDR - India: (MH, KA) 20120110.1005663.

The situation concerning the presence of so-called "totally drug resistant" tuberculosis (TDR-TB) in the Indian state of Karnataka is quite confusing. According to the news report posted one day ago by ProMED-mail (Tuberculosis, TDR - India: (MH, KA) 20120110.1005663), Rajiv Gandhi Institute of Chest Diseases (RGICD), which is a government-run institute specializing in treating tuberculosis, stated that there were no cases of TDR-TB in the state of Karnataka, of which Bangalore is the capital. However, the 1st 2 news reports above state that 2 confirmed cases with TDR-TB have been detected at the Rajiv Gandhi Institute of Chest Diseases (RGICD) in Bangalore. Nevertheless, the 3rd news report above raises questions about the validity of the TDR-TB diagnosis in these patients, stating that these diagnoses were based on lack of clinical response to drug therapy, not on drug susceptibility testing. We await further information to make sense of the situation.

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1mm2. - Mod.ML]

TUBERCULOSIS, TDR - INDIA (03): (MAHARASHTRA) FATAL
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Date: Sun 15 Jan 2012
Source: The Times of India (TOI), Times News Network (TNN) [edited]
http://timesofindia.indiatimes.com/indi ... 494463.cms


The state government has decided to shift patients with totally drug-resistant tuberculosis (TDR-TB) to a sanatorium in Jaysingpur near Maharashtra's Sangli. A central team of TB experts will assess the patients on Monday [16 Jan 2012] before they leave the city [Mumbai]. State doctors were busy on Saturday [14 Jan 2012] working out quarantine [sic] plans to contain one of the worst health disasters -- the emergence of TDR-TB in Mumbai.

More than a week after a Mumbai doctor chronicled the existence of TDR-TB in 12 patients in Mumbai, Union health minister Ghulam Nabi Azad flew down on Saturday [14 Jan 2012] for an unrelated meeting that quickly approved of the quarantine plans. Azad told TOI that "the central team will arrive on Monday [16 Jan 2012]. Only after the assessment will we be able to decide the seriousness of the situation."

The patients will be housed in a 30 bed sanatorium at Jaysingpur, a picturesque, small town near Sangli that is relatively pollution-free. "11 of the 14 patients identified with TDR-TB so far in the city will be sent to isolation," said state TB control officer Dr P Gaikwad.

Hinduja Hospital in Mahim had found the TDR-TB bacilli in 12 patients during research in October 2011. One of them died a month later. The hospital has since reported the death of one more patient and the transmission of the bacilli to the mother of a patient. "JJ Hospital in Byculla [a neighbourhood in South Mumbai], too, has seen 2 such patients. One is dead and the other untraceable," said a state official.

[byline: Malathy Iyer, Sanjeev Shivadekar]

--
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[The news report above updates the number of cases of TDR-TB in Mumbai, India: there are now 15 cases that include 2 fatalities. See the prior ProMED-mail post Tuberculosis, TDR - India: (MH, KA) 20120110.1005663.

Infectious diseases that spread from person to person are said to be contagious. Isolation is a term that refers to the separation and restriction of movement of people who are ill with a specific infectious illness that is potentially contagious from those who are healthy to stop the spread of that illness. Quarantine is a term that refers to the separation and restriction of movement of people who, while not yet ill, have been exposed to an infectious agent and therefore may become ill with a contagious disease.

For a discussion of MDR-, XDR-, XXDR-, and TDR-TB, see the moderator's comments in the prior ProMED-mail post Tuberculosis, TDR - India: (MH, KA) 20120110.1005663.

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1pr7. - Mod.ML]

TUBERCULOSIS, TDR - INDIA (04): (MAHARASHTRA) FATAL
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Date: Tue 17 Jan 2012
Source: UN Integrated Regional Information Networks (IRIN) News [edited]
http://www.irinnews.org/report.aspx?reportid=94656


The "totally drug-resistant" tuberculosis (TDR-TB) reportedly emerging in India is actually an advanced stage of drug-resistant TB, which researchers called totally drug-resistant for lack of a better term.

"Whilst waiting for the WHO [World Health Organization] to define this advanced stage of resistance, TDR is a good descriptor," Zarir Udwadia, a doctor from PD Hinduja National Hospital and Medical Research Centre in Mumbai, India, told IRIN.

Udwadia and colleagues reported in late December [2011] on the 1st cases of what they called TDR-TB in 4 patients who did not respond to 12 drugs used to treat TB, based on lab tests.

Drug-resistant TB develops when patients do not complete the recommended 6-month antibiotic treatment correctly or take sub-standard drugs, which then increases treatment time and costs. 3 of the 4 patients in Mumbai studied had "received erratic, unsupervised 2nd-line drugs, added individually and in incorrect doses" from multiple doctors trying to cure their multidrug resistance, noted the researchers.

WHO recognizes 2 groups of drug-resistant TB: multidrug-resistant (MDR-TB) occurs when patients do not respond to the 2 most effective anti-TB drugs. In the case of extensively drug-resistant TB, (XDR-TB), fluoroquinolone and anti-TB injectable drugs also fail.

"In reality it is not clear what 'total' really means -- hardly ever do labs test against all drugs," Paul Nunn, a TB expert with WHO's TB control department, who has led the agency's global response to XDR-TB since 2006, told IRIN. WHO has issued treatment guidelines for 14 drugs -- 6 that were not tested by the Indian labs -- for TB cases that do not respond to the 4 "1st-line" drugs [http://whqlibdoc.who.int/publications/2 ... 81_eng.pdf].

In a 13 Jan 2012 briefing note, WHO explained how the lack of international standards on lab testing to determine sensitivity to some anti-TB drugs made it difficult to rule out a cure [http://www.who.int/tb/challenges/mdr/td ... index.html]. While a strain of TB may not respond to a drug in a lab, it may be do so in an infected person, said Nunn. In addition, as new anti-TB drugs are still under development, their effectiveness against the reportedly totally drug-resistant strains cannot yet be proven, said WHO.

WHO is convening a meeting of TB experts in March 2012 to consider whether a new TB definition is needed. "If 'totally drug-resistant' TB defines a subset of XDR-TB with different characteristics to other XDR-TB cases, particularly with respect to the outcome of such cases, then an internationally recognized definition may be needed," noted WHO in its recent post. "We must at least concede that this is a much more difficult-to-treat form than XDR where some SLD [2nd-line drug] options exist," said Udwadia.

Medical literature has recorded 21 cases labelled TDR-TB in Germany, Italy, Iran, and now India. "It is very likely that many countries will have a handful of [such] cases -- in eastern Europe probably even more," said Nunn. By the end of 2010, 69 countries reported to WHO at least one case of XDR-TB, with China and India accounting for almost half the world's estimated number of MDR-TB cases. In 2010, 16 of the 36 countries with a high burden of TB or MDR-TB did not have at least one laboratory capable of performing TB culture and drug susceptibility testing per 5 million people.

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[It is important that WHO is addressing the situation of "totally drug resistant tuberculosis" or TDR-TB. TDR-TB may, indeed, not be exactly totally drug resistant. The TDR-TB strains from India were reported resistant to all 1st-line (isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin) and the 2nd-line (ofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, para-aminosalicylic acid, and ethionamide) drugs tested. No mention was made of the activity of so-called 3rd-line anti-TB drugs, such as the macrolides (for example, clarithromycin), clofazimine, amoxicillin/clavulanic acid, linezolid, imipenem, or high-dose isoniazid, and several new investigational drugs against these strains. The in vitro drug susceptibility testing, however, for some anti-TB drugs remains problematic. According to the January 2012 WHO document (http://www.who.int/tb/challenges/mdr/td ... index.html):

"The term "totally drug resistant" has not been clearly defined for tuberculosis. While the concept of "total drug resistance" is easily understood in general terms, in practice, in vitro drug susceptibility testing (DST) is technically challenging and limitations on the use of results remain: conventional DST for the drugs that define MDR and XDR-TB [isoniazid, rifampin, the fluoroquinolones, kanamycin, amikacin, and capreomycin] has been thoroughly studied and consensus reached on appropriate methods, critical drug concentrations that define resistance, and reliability and reproducibility of testing. Data on the reproducibility and reliability of DST for the remaining SLDs [2nd-line drugs] are either much more limited or have not been established, or the methodology for testing does not exist. Most importantly, correlation of DST results with clinical response to treatment has not yet been adequately established. Thus, a strain of TB with in vitro DST results showing resistance could in fact, in the patient, be susceptible to these drugs. The prognostic relevance of in vitro resistance to drugs without an internationally accepted and standardised drug susceptibility test therefore remains unclear and current WHO recommendations advise against the use of these results to guide treatment.

"Lastly, new drugs are under development, and their effectiveness against these "totally drug resistant" strains has not yet been reported.

"For these reasons, the term "totally drug resistant" tuberculosis is not yet recognised by the WHO. For now these cases are defined as extensively drug resistant tuberculosis (XDR-TB), according to WHO definitions."

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/1pr7. - Mod.ML]

TUBERCULOSIS, MDR - WORLDWIDE: RATES
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Date: Fri 3 Feb 2012
Source: Vaccine News Daily [edited]
http://vaccinenewsdaily.com/vaccine_dev ... esistance/


The World Health Organization [WHO] recently announced that tuberculosis [TB] cases found in Moldova, Belarus, and Russia display the highest levels of drug-resistance known.

The WHO, however, said that its data remain somewhat incomplete. Africa and India are thought to have higher TB rates, but were not included in their entirety in a newly released study. Experts said that rates of multi drug-resistant TB remain unknown or are unclear in many parts of the world, according to USA Today.

Research published in Bulletin, the WHO's medical journal, reported that in some places in Russia, 29 percent of new TB cases are drug resistant. Rates of MDR-TB [multidrug resistant tuberculosis] in Minsk, Belarus, are thought to be approaching 50 percent of cases, but the WHO warned that reliable surveillance data is lacking, a situation it called "highly worrisome," USA Today reports. The TB situation in Moldova is becoming increasingly more troubling. WHO research found 65 percent of previously untreated TB patients are infected with strains that are resistant.

The WHO's Global Project on Anti-tuberculosis Drug Resistance Surveillance was launched in 1994 and has generated what the WHO considers to be the most reliable TB drug-resistance estimates available for 127 countries.

Experts agree that continued surveillance will be critical in fighting MDR-TB, especially as the growing reservoir of resistant cases start to pose a challenge to national TB programs.

[Byline: Ted Purlain]

--
Communicated by:
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[This news report refers to an article published in the February 2012 edition of the WHO Bulletin (Zignol M, van Gemert W, Falzon D, et al: Surveillance of anti-tuberculosis drug resistance in the world: an updated analysis, 2007-2010. Bull World Health Organ 2012; 90: 111-9D. Available at http://www.who.int/bulletin/volumes/90/2/11-092585.pdf) and an accompanying editorial (Matteelli A, Centis R, D'Ambrosio L, Migliori GB: Multidrug-resistant tuberculosis today. Bull World Health Organ 2012; 90: 78. Available at http://www.who.int/bulletin/volumes/90/2/11-097360.pdf).

The study found that TB drug resistance data are available for 2 thirds of all countries in the world. Cases of MDR-TB (that is, tuberculosis that is caused by a strain of _Mycobacterium tuberculosis_ that is at least resistant to 2 of the most effective drugs used to treat TB, isoniazid (INH) and rifampin) have been reported in 80 countries, in some instances in almost 30 percent of all newly diagnosed cases and some countries reporting MDR-TB in more than 65 percent of patients who have been previously treated for TB. High rates of drug resistance were reported in Belarus, Estonia, the Russian Federation, and Tajikistan. However, national representative data are lacking in many large countries with high TB burden, including India and several African countries. Routine drug susceptibility testing of all confirmed TB cases should be the goal, but there are very few laboratories to diagnose MDR-TB in developing countries, and only 34 countries and settings have a system in place to routinely test all patients with MDR-TB for 2nd-line anti-TB drug resistance. - Mod.ML]

TUBERCULOSIS, MDR – (NIGERIA): (GOMBE)
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Date: Wed 7 Mar 2012
Source: Leadership.ng [edited]
http://leadership.ng/nga/articles/18465 ... nt_tb.html


The Gombe State Tuberculosis and Leprosy Control Unit has identified 30 people suspected to have contracted the multi-drug resistant tuberculosis (TB) in the state.
Dr Sirajo Abdulkarim, the officer in charge of the programme, made this known in an interview with the News Agency of Nigeria (NAN) in Gombe on Wednesday.

Multidrug resistant TB is a form of tuberculosis that is resistant to all TB drugs. [By definition, multidrug resistant TB or MDR-TB is due to strains resistant to at least isoniazid (INH) and rifampin, not necessarily "all" drugs used to treat TB. - Mod.ML]

Dr Abdulkarim said 5 of the 7 victims with severe infection had died while the remaining 2 were referred to the University of Ibadan Teaching Hospital for treatment. "We have been able to identify suspects -- about 30 of them who were sent to Zaria [a city in Northern Nigeria]; and out [of] them, 7 cases were confirmed with the disease. Because of the efforts and the surveillance system we’ve put in place and the efforts that we made in identifying these suspects, the National Programme supplied us with this machine which can easily detect the disease within 8 minutes. You can make a diagnosis of multidrug resistant TB and any TB that is difficult to diagnose." Abdulkarim said it was the effort made by the programme that led the National TB and Leprosy Control Programe to provide the machine for detecting the disease in Gombe.

According to Abdulkarim, the period for the treatment of the multidrug resistant TB can take as long as 20 months, whereas treatment of other forms of TB takes only 6 months. He, therefore, called on the federal government to establish another centre in the northern part of the country to solve the problem of distance, where the access to treatment was concerned. Abdulkarim said it would be preferable to establish the centre in Gombe since the state already had the diagnosis machines.

NAN reports that Bauchi, Borno, Taraba, Yobe, Jigawa, Nasarawa, and Plateau states have been referring TB patients to the centre in Gombe for diagnosis.

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[In the WHO African region (http://www.afro.who.int/en/countries.html), which includes Nigeria, 1.9 per cent of new cases of tuberculosis, and 9.4 per cent of previously treated cases are reportedly multidrug-resistant (http://www.who.int/bulletin/volumes/90/2/11-092585.pdf). However, national data are lacking for many of the WHO African region countries with a high TB burden, including Nigeria (see figure 1 at http://www.who.int/bulletin/volumes/90/2/11-092585.pdf). The lack of data on drug-resistant TB in many African countries is of great concern, especially since the African region accounts for over 80 per cent of the TB cases among people living with HIV infection and since higher mortality from multidrug-resistant TB (MDR-TB) has been documented in HIV positive patients.

Conventional diagnosis of drug resistant TB relies on mycobacterial culture and drug susceptibility testing, a slow and cumbersome process. During the prolonged time required for testing, patients may be inappropriately treated and drug-resistant strains may continue to spread in the community. In addition, although routine drug susceptibility testing of all confirmed TB cases should be the goal, there are very few laboratories that can diagnose MDR-TB in developing countries, and only 34 countries and settings have a system in place to routinely test all patients with MDR-TB for 2nd line anti-TB drug resistance.

The availability of a new molecular technology -- that is, Xpert MTB/RIF -- allows in less than 2 hours the detection of _Mycobacterium tuberculosis_, as well as detection of rifampin resistance, by amplifying DNA present in unprocessed sputum samples with minimal hands-on technical time, even in countries with severely limited laboratory infrastructure (Boehme CC, Neeta P, Hillman D, et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med. 2010; 363: 1005-15. Available at: http://www.nejm.org/doi/full/10.1056/NEJMoa0907847). Rifampin resistance often indicates MDR-TB. Perhaps the "machine" used to diagnose MDR-TB that is referred to in the news report above is Xpert MTB/RIF. Molecular technologies are expected to contribute substantially to surveillance of drug-resistant TB in low-resource settings in the future (Small PM, Pay M. Tuberculosis diagnosis -- time for a game change. N Engl J Med. 2010; 363: 1070-1. Available at: http://www.nejm.org/doi/full/10.1056/NEJMe1008496).

Gombe State, located in the north eastern part of Nigeria, is one of the country's 36 states, the boundaries of which roughly correspond to those of the Gombe Emirate (http://en.wikipedia.org/wiki/Gombe_State). Gombe city is the capital of Gombe State and has an estimated population of 261 536 (http://en.wikipedia.org/wiki/Gombe, _Nigeria). Ibadan, where 7 Nigerian patients with MDR-TB have been hospitalized, is located in south western Nigeria, 128 km (about 80 miles) inland north east of the coastal city of Lagos. A map of the states of Nigeria can be accessed at http://www.waado.org/nigerdelta/Maps/Ni ... tates.html and the HealthMap/ProMED-mail interactive map of the country at http://healthmap.org/r/1qGF. – Mod.ML]

PlusNews by IRIN hat geschrieben:
HEALTH: Blueprint for future TB vaccines unveiled
21.03.2012 - PlusNews by IRIN

Almost a century ago, French scientists discovered the world's only tuberculosis (TB) vaccine. Now the World Health Organization warns that without a new one, the world will not win the fight against TB.

A new plan, launched in Johannesburg, South Africa, on 20 March ahead of World TB Day, outlines the gaps and needs in five main areas of TB vaccine research and development: Innovation in research and discovery; better understanding of TB immunity; clinical trials; TB vaccine candidate selection; and advocacy and resource mobilization.

The eight-page plan, or blueprint, and related commentaries have been published in the March 2012 edition of the medical journal, Tuberculosis.

According to Michael Brennan, senior adviser for global affairs at the TB vaccine research and development NGO Aeras, this is the second such plan to be developed by a global consortium of TB partners, and was spurred by massive developments in the vaccine field over the last decade.

Ten years ago, there were no potential TB vaccines in clinical trials. Today - and more than US$600 million dollars later - there are 12 TB vaccine candidates.

"If these new vaccines were successful, we need to be prepared to design the multi-country phase-three clinical trials to get these vaccines marketed and distributed globally," he told IRIN/PlusNews. "If these failed, we need to be prepared with the next generation of vaccines in the pipeline using novel technologies."

Among the major issues highlighted in the blueprint are the need to better understand why some people develop active TB and others do not; develop appropriate clinical trials for HIV patients and those with drug resistant TB; and the need for resource mobilization.

According to Brennan, the large, advanced-stage clinical trials needed to show a TB vaccine's efficacy and safety prior to regulatory approval could cost up to US$200 million. In 2010, only about US$80 million was going towards vaccine research and development, according to the latest survey by the New York-based Treatment Action Group.
[ http://www.plusnews.org/Report/94355/HE ... te-funding ]

Thinking globally, acting locally

Globally, there are about nine million new TB cases annually and 1.4 million people lose their lives to active TB each year. In South Africa, TB - driven by high HIV prevalence rates - is now the leading cause of natural death. Although many people carry TB, only 10 percent will ever develop the active disease. However, people with compromised immune systems, such as those living with HIV or diabetes, are up to 40 times more likely to develop active TB.

In the new National Strategic Plan (NSP) for HIV and AIDS, sexually transmitted infections and TB 2012-2016, the country has prioritized the need for innovative research into new TB drugs, diagnostics and vaccine development, which the government is currently funding. Should a new, effective TB vaccine be discovered, South Africa's NSP also calls for the use of novel licensing mechanisms to facilitate rapid uptake. [ http://www.irinnews.org/Report/94365/SO ... IV-TB-plan ]

"In our country alone, a vaccine could save hundreds of thousands of lives each year and could be instrumental in ultimately eliminating TB as a public health emergency," said South African Health Minister Aaron Motsoaledi in a statement.

"Governments have an important role to plan and, guided by this common strategy, we will do our part to make a vaccine a reality."

This week, South African researchers and policymakers will meet in Johannesburg to set - and cost - HIV and TB research priorities that will ultimately be presented to the South African National AIDS Council and government, according to Gavin Churchyard, chief executive officer of the South African health research institute, Aurum.

In 2010, South Africa made history by becoming the first government to join a patent pool. As a member of the pool established by pharmaceutical company GlaxoKlineSmith's (GKS), South African TB researchers have access to more than 2,300 existing patents and related knowledge on neglected diseases like TB.

Due to the country's high TB burden, and regulatory and research capacity, half of all TB vaccine trials are being conducted in South Africa, according to South African TB Vaccine Initiative (SATVI) researcher Hassan Mahomed.

TB vaccine study

Mahomed is currently part of a clinical trial testing a TB vaccine in infants. With findings expected in 2013, this study will be the first to show the efficacy of a TB vaccine since the French scientists Albert Calmette and Camille Guérin developed the world's only current TB vaccine. Bacillus Calmette-Guérin, more commonly known by its acronym as the BCG vaccine, is widely given to HIV-negative infants in developing countries. However its protective effect wanes in adolescence and adulthood.
[ http://www.irinnews.org/Report/85091/GL ... ive-babies ]

TB vaccines have to be tested in countries with high TB burdens, like those in sub-Saharan Africa and Southeast Asia, to show that they work. Mahomed said it was important to ensure that these communities would also reap the benefits of a successful trial.

"Many trials are done in developing countries. Should there be a successful vaccine, this should be made available to the countries that need it most at affordable rates," he told IRIN/PlusNews. "With whatever [vaccine] manufacturer we deal with, we try to ensure that kind of agreement."

The South African government has warned that it will fiercely protect the affordability of any successful TB vaccines that may come out of clinical trial testing within its borders.

"These efforts have been basically done through a non-profit platform... It would be very sad that after a success, that non-profit platform was replaced with a different platform that is profit-driven," said David Mametja, chief director of TB control and management for the South African Department of Health. "Hopefully we don't have the same issues as we had with antiretrovirals. We will jealously guard against any excessive cost that will be linked to making these vaccines available."

South Africa has been battling patents on some second and third line antiretrovirals for years. Still under patent protection and with no generics available, the cost of these regimens have kept them out of the public sector. [ http://www.fixthepatentlaws.org/?p=144 ]

Quelle: IRIN

Gruß
Birgitt

Nun- das ist natürlich sch....
Aber, meiner Meinung nach, nur eine logische Konsequenz auf die überimpfte Gesellschaft.
Bis heute weiss niemeand genau, was Impfung eigentlich macht- langfristig gesehen.
Verweise hierzu auf die Epigenetik- eine Forschung die endlich in das Beusststein dringt.

TUBERCULOSIS, MDR – (INDIA): (MAHARASHTRA)
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Date: Tue 24 Apr 2012
Source: health.india.com, IANS (Indo Asian News Service) report [edited]
http://health.india.com/news/63-new-mdr ... d-in-pune/


As many as 63 new MDR-TB [multidrug resistant tuberculosis] cases have been reported in [Pune] district over the last 2 months. 26 of them are from Pimpri-Chinchwad and 23 from Pune. The districts rural interiors have reported 14 new MDR-TB patients as well. Since the State TB Training and Demonstration Centre (STDC) became functional, experts have been separating MDR cases from TB cases.

Tuberculosis can become resistant if any of the following occurs: patient is not treated well enough; patient is not treated long enough; patient doesn't take the prescribed medication properly; or, patient is prescribed the wrong drugs.

Of the 1.2 million "new" TB cases notified in 2009 in India, as many as 14 991 (1.3 per cent) were reported to have failed the regular anti-TB drug regimen. Similarly, of the [289 756] re-treatment TB cases, 11 265 (4 per cent) failed the 1st line re-treatment regimen.

MDR-TB (resistance to [at least] 2 of the potent 1st line anti-TB drugs, isoniazid and rifampicin) is one of the important causes for the failure of TB treatment. As per the guidelines of the Revised National Tuberculosis Control Programme (RNTCP), patients with drug susceptibility test (DST) results showing resistance to rifampicin are considered eligible for MDR-TB treatment, irrespective of resistance to isoniazid, streptomycin, or ethambutol.

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[According to the World Health Organization (WHO), the proportion of new TB cases reported from 80 countries and 8 territories as showing resistance to rifampin and isoniazid (that is, MDR-TB) ranged from 0 per cent to 28.9 per cent and in previously treated cases, 0-65 per cent in the years 2007 to 2010 (table 1, http://www.who.int/bulletin/volumes/90/ ... le-T1.html). Data on XDR (extensively drug resistant)-TB (that is, resistance to any fluoroquinolone and 2nd line injectable agent, in addition to resistance to rifampin and isoniazid) were reported to WHO from 38 countries and 3 territories, 34 of which routinely test all patients with MDR-TB for 2nd line anti-TB drug resistance. Only 6 out of 41 (15 per cent) countries and territories reported more than 10 cases of XDR-TB; the proportion of MDR-TB cases that were extensively drug resistant exceeded 10 per cent in Estonia (19.7 per cent), Latvia (15.1 per cent), South Africa (10.5 per cent), and Tajikistan (Dushanbe city and Rudaki district, 21.0 per cent) (table 2, http://www.who.int/bulletin/volumes/90/ ... le-T2.html).

However, WHO reported that national data are lacking on the frequency of MDR-TB among new or previously treated patents and the frequency of XDR-TB among MDR-TB cases in many large countries, including India (figure 1, http://www.who.int/bulletin/volumes/90/2/11-092585.pdf). India and the Russian Federation -- the other 2 large countries that, with China, contribute to more than 50 per cent of the estimated global burden of MDR-TB -- have only produced reliable subnational level data to date. A survey in 2006 in the Indian state of Gujarat found that 3.2 per cent of 216 MDR isolates tested were XDR (table 2, http://www.who.int/bulletin/volumes/90/ ... le-T2.html).

Conventional diagnosis of drug resistant TB relies on mycobacterial culture and drug susceptibility testing, a slow and cumbersome process. During the prolonged time required for testing, patients may be inappropriately treated and drug resistant strains may continue to spread in the community. In addition, although routine drug susceptibility testing of all confirmed TB cases should be the goal, there are very few laboratories that can diagnose MDR-TB in developing countries, and only 34 countries and settings have a system in place to routinely test all patients with MDR-TB for 2nd line anti-TB drug resistance.

The availability of a new molecular technology -- that is, Xpert MTB/RIF -- allows in less than 2 hours the detection of _Mycobacterium tuberculosis_, as well as detection of rifampin resistance, by amplifying DNA present in unprocessed sputum samples with minimal hands-on technical time, even in countries with severely limited laboratory infrastructure (Boehme CC, Neeta P, Hillman D, et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med. 2010; 363(11): 1005-15; available at http://www.nejm.org/doi/full/10.1056/NEJMoa0907847). Rifampin resistance often indicates MDR-TB. Molecular technologies are expected to contribute substantially to surveillance of drug resistant TB in low-resource settings in the future (Small PM, Pay M. Tuberculosis diagnosis -- time for a game change. N Engl J Med. 2010; 363(11): 1070-1; available at http://www.nejm.org/doi/full/10.1056/NEJMe1008496).

Pune is the 8th largest metropolis in India and the 2nd largest in the state of Maharashtra after Mumbai, the capital of Maharashtra (http://en.wikipedia.org/wiki/Pune). Pimpri-Chinchwad is a city in the Pune district (http://en.wikipedia.org/wiki/Pimpri-Chinchwad).

A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/2gZV. - Mod.ML]

TUBERCULOSIS, TDR - (INDIA) (05): (MAHARASHTRA) FATAL
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Date: Mon 30 Apr 2012
Source: The Asian Age [edited]
http://www.asianage.com/mumbai/nti-conf ... istant-696


The National Tuberculosis Institute (NTI), Bangalore has validated Hinduja Hospital's study that confirms drugs resistance to all the known TB drugs (1st and 2nd line) in 8 patients whose samples were re-tested.

On 6 Jan 2012, Hinduja Hospital had announced that they had detected 12 totally drug resistant (TDR) TB cases, a terminology that was not accepted by the World Health Organisation (WHO). Drugs resistance is developed because of mismanagement of multi-drug resistant tuberculosis (MDR-TB). They had published the study in the scientific publication Clinical Infectious Diseases Advance Access on 21 Dec 2011.

However, after the Central Tuberculosis Division (CTD), with their team of experts including NTI, arrived in Mumbai to take stock of the situation, they said that the patients suffered from XXDR-TB, which in medical literature is extremely drug-resistant tuberculosis. Of the 12 cases, 8 samples were then sent for re-testing to NTI.

"Of the 8 samples sent, 2 patients died early this year. The other 6 patients live in Mumbai, one of who is a 15-year-old. 5 of these patients are undergoing treatment with the Revised National Tuberculosis Control Programme (RNTCP) for extensively drugs resistant (XDR) TB, while one is being treated at the Hinduja Hospital," said Dr Minni Khetarpal, city TB officer, Brihanmumbai Municipal Corporation.

"The NTI has confirmed the Hinduja report. We will place this report on record before the Directly Observed Treatment Shortcourse (DOTS) committee and figure out the future line of treatment that could be offered to these patients now," said Dr P.Y. Gaikwad, state TB officer.

However, Dr Gaikwad added that 2 of these patients are sensitive to one 2nd-line drug. "All the other patients are doing well. It shows that immunity of the host (patient) also matters, not just the drug sensitivity to the bacteria. Many of these patients are working for a living," said Dr Gaikwad.

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[Multidrug-resistant TB or MDR-TB refers to tuberculosis that is caused by a strain of _Mycobacterium tuberculosis_ resistant to at least 2 of the most effective drugs used to treat TB, isoniazid (INH) and rifampin. Extensively drug-resistant TB or XDR-TB refers to a subgroup of MDR-TB strains that are additionally resistant to any of the fluoroquinolone class of drugs (e.g., levofloxacin. moxifloxacin, or gatifloxacin) and any of the 3 injectable drugs used to treat tuberculosis (capreomycin, kanamycin and amikacin). Extremely drug-resistant (XXDR) has been used to refer to a subgroup of XDR-TB that are resistant to all 1st and 2nd line anti-TB drugs (http://euro.who.int/tuberculosis/public ... 20071204_5 and http://www.aidsmap.com/en/news/CBA086E0 ... B35E8D.asp).

1st line anti-TB drugs are: INH, rifampin, pyrazinamide, ethambutol and streptomycin; and 2nd line drugs are: amikacin, kanamycin, capreomycin, viomycin, fluoroquinolones, ethionamide, cycloserine, and para-aminosalicylic acid (http://www.ncbi.nlm.nih.gov/pubmed/15971391). 3rd-line drugs include the macrolides (such as clarithromycin), clofazimine, amoxicillin/clavulanic acid, linezolid, imipenem, high-dose isoniazid, and several new investigational drugs.

The TDR-TB strains from India were reported resistant to all 1st-line (isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin) and the 2nd-line (ofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, para-aminosalicylic acid, and ethionamide) drugs tested. No mention was made of the activity of so-called 3rd-line anti-TB drugs. The in vitro drug susceptibility testing, however, for some anti-TB drugs remains problematic.

According to a January 2012 WHO document (http://www.who.int/tb/challenges/mdr/td ... index.html):
"The term "totally drug resistant" has not been clearly defined for tuberculosis. While the concept of "total drug resistance" is easily understood in general terms, in practice, in vitro drug susceptibility testing (DST) is technically challenging and limitations on the use of results remain: conventional DST for the drugs that define MDR and XDR-TB has been thoroughly studied and consensus reached on appropriate methods, critical drug concentrations that define resistance, and reliability and reproducibility of testing. Data on the reproducibility and reliability of DST for the remaining SLDs [2nd-line drugs] are either much more limited or have not been established, or the methodology for testing does not exist.

Most importantly, correlation of DST results with clinical response to treatment has not yet been adequately established. Thus, a strain of TB with in vitro DST results showing resistance could in fact, in the patient, be susceptible to these drugs. The prognostic relevance of in vitro resistance to drugs without an internationally accepted and standardised drug susceptibility test therefore remains unclear and current WHO recommendations advise against the use of these results to guide treatment.

"Lastly, new drugs are under development, and their effectiveness against these "totally drug resistant" strains has not yet been reported.

"For these reasons, the term "totally drug resistant" tuberculosis is not yet recognised by the WHO. For now these cases are defined as extensively drug resistant tuberculosis (XDR-TB), according to WHO definitions."

A statement from the Indian Revised National Tuberculosis Control Programme (RNTCP) (January 2012) (http://www.tbcindia.nic.in/pdfs/RNTCP%2 ... update.pdf), in response to challenges of drug resistant TB in India, essentially agrees with that of the WHO:
"Recently, a letter to Clinical Infectious Disease Journal in December 2011 described 4 patients from Mumbai, India with "totally drug resistant" tuberculosis (coined "TDR-TB" from earlier reports) i.e., resistant to all 1st- line and 2nd-line drugs tested. Such cases have been reported sporadically in Europe and 15 cases in Iran in 2009. Subsequent media reports have added reports of further cases in Mumbai and in Bangalore.

"A careful audit of their prescriptions revealed that these 3 patients had received erratic, unsupervised 2nd-line drugs, added individually and often in incorrect doses, from multiple private practitioners (on average from 4 physicians during a 18-month period) in an attempt to cure their multi-drug resistant (MDR) tuberculosis. The author urged that patients with MDR tuberculosis only be treated within the confines of government sanctioned MDR TB treatment programs to prevent the emergence and spread of this untreatable form of tuberculosis.

"The patients in question represent MDR TB patients, who may also have XDR TB. The term TDR TB "totally drug resistant" is non-standardized, and in any case testing for resistance beyond XDR TB is not reliable, and correlation of DST results with clinical response to treatment has not yet been established, and some treatments might have some efficacy. Current WHO recommendations advise against the use of these DST results beyond those used to identify XDR-TB to guide treatment. Furthermore, new drugs to treat MDR TB are under final stages of development, hence the notion of "total drug resistance" may be fleeting. For these reasons, the term "totally drug resistant" tuberculosis is not yet recognized by the WHO. For now these cases are defined as extensively drug resistant tuberculosis (XDR-TB), according to WHO definitions, and accordingly can be managed by national XDR TB treatment guidelines."

Hinduja Hospital is a leading multispecialty health care hospital and medical research center in Mumbai, India (http://www.hindujahospital.com/). Mumbai, formerly known as Bombay, is the capital of the Indian state of Maharashtra. A map of the states of India can be accessed at http://www.globalsecurity.org/military/ ... ourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/2gZV. - Mod.ML]

PlusNews by IRIN hat geschrieben:
HEALTH: New TB vaccine on the horizon
16.10.2012 - PlusNews

LONDON - A research team at Oxford University in the UK is very close to determining the efficacy of their new tuberculosis (TB) vaccine. If current clinical trials are successful, it will be the first new TB vaccine in almost a century.

The urgent need for a new vaccine is emphasised by research [ http://www.thelancet.com/journals/lance ... X/abstract ] showing that extensively drug-resistant (XDR) forms of the disease are rapidly spreading.

Today, most babies in the world are immunized with the old Bacille Calmette-Guerin (BCG) vaccine, first used in 1921. The leader of the Oxford research team, Helen McShane, says it saves children's lives, but beyond infancy its effects are limited.

"We know that when BCG is given at birth, it does work well to protect against tubercular meningitis and the disseminated disease that has spread outside the lungs. What we also know is that BCG is very variable in protecting against lung disease, which is where the burden of the disease is, particularly in adults and adolescents," she said.

Oxford's vaccine, known as MVA85A, is designed to boost the effects of BCG. "It's that efficacy against severe disease which is the rationale behind keeping BCG and making it better," McShane said.

Clinical trials are taking place in South Africa, following 3,000 babies, all of whom received BCG; half of them also received the new booster vaccine. Trials of the vaccine's effectiveness in adults are taking place in both South Africa and Senegal, with results expected in the first quarter of 2013.

Boosting immune response

The vaccine is designed to stimulate an immune response known as cell-mediated immunity. "This is different from all the vaccines we have licensed today - with the exception of BCG - which work by the production of antibodies," McShane said.

"Because TB is very good at hiding within cells, we need T-cells [a kind of white blood cell] to protect against TB. And indeed that's the reason why HIV-infected people are more susceptible to TB - because HIV damages your T-cells. So the vaccine that we have developed works by boosting the T-cells which are induced by BCG."

TB is a major cause of death among the HIV-positive. Asked whether this kind of vaccine could prevent TB in people living with HIV, McShane said that it might - but only for those with immune systems strengthened by antiretroviral medications. "I do think that's going to be crucial for these vaccines to work, [but] I think it would be very hard for it to work in HIV-positive individuals with very low CD4 counts [a measure of immune health]."

Market consideration

After decades of neglect, the world is seeing a flurry of activity around the development of new TB vaccines, reflecting increased interest and funding from donors such as the Bill and Melinda Gates Foundation and the British and Dutch governments. Added pressure comes from the emergence, first, of multi-drug resistant TB, and, more recently, of XDR-TB, which can be nearly impossible to treat.

MVA85A is the front-runner among the vaccines in development, but there are others on the way. Some use virus vectors, like the Oxford vaccine, which uses an adenovirus, from the family of organisms that cause the common cold. Others use peptides, and one, says McShane, is a recombinant form of BCG, modified to express more antigens and to make it safer for use in people living with HIV.

Some researchers are working on improved TB treatments to address the disease's growing drug resistance, but the process of bringing new drugs to market is slow, and few new treatments have even started clinical trials. Vaccines may be a better bet and, given the market, may be easier to put into production.

The problem is that TB is a disease of poverty: According to the World Health Organization, over 95 percent of cases and deaths are in developing countries [http://www.who.int/mediacentre/factshee ... index.html], where sufferers often cannot afford treatments. This makes the expensive process of developing new TB medications unattractive to drug companies. Most of the current research is publicly funded.

"It's been hard to make a convincing market argument for TB drugs," Ann Ginsberg, vice president of scientific affairs at Aeras, a non-profit organization working on TB vaccines, told PlusNews. "The reality is that the vast majority of companies working on TB drugs do not expect to make any profit from it. They are in it because they think it is the right thing to do. They hope not to lose money in the process, but they don't expect to make any," she said.

"But because of global vaccination, you are talking about so many people who would ideally be vaccinated that there's probably a reasonable profit to be made there."

Quelle: PlusNews by IRIN

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