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6 Addressing TB and Drug-Resistant TB in Vulnerable Populations
6 Addressing TB and Drug-Resistant TB in Vulnerable Populations
Pages 71-88
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From page 71... ...
Speakers at the workshop addressed each of these three populations, discussing MDR TB among children in India, Peru, and globally; data from India and elsewhere linking HIV infection to drugresistant TB; the occurrence of drug-resistant TB among Tibetan refugees living in India; and case studies dealing with vulnerable populations (children in Cambodia and MDR TB patients in Ethiopia, many coinfected with 71
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From page 72... ...
Unknown Burden of Pediatric MDR TB Data on MDR TB in children are virtually nonexistent. WHO does not include children in drug resistance surveys, and most countries have not collected these data systematically.
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From page 73... ...
Previously treated children had significantly higher rates of drug resistance than new TB cases, and HIV infection was not associated with drug resistance in children, which is also the case in India. In data from India, MDR TB rates among children with TB were found to be 2 percent about two decades ago (Ramachandran and Prabhakar, 1992)
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From page 74... ...
Instead, drug-resistant TB in a child must be suspected when the child has been in contact with a known case of drug-resistant TB, the child's adult contact has been on chronic irregular treatment and continues to be sputum-positive, the adult contact dies after irregular treatment, or the child shows initial improvement with anti-TB treatment and then deteriorates clinically and radiologically. Contact investigation is vital to detecting pediatric cases of TB and especially MDR TB.
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From page 75... ...
• Rapid molecular tests need to be studied in the context of pediatric MDR TB. • More data are needed on the burden of disease in children, includ ing drug resistance.
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From page 76... ...
First, each patient who had started the MDR TB treatment regimen between 1996 and 2002 was identified. A study team visited the households of these index patients and interviewed them and others in the household, asking specifically about TB treatment in any of the household members.
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From page 77... ...
Furthermore, because 30 percent of the children had less than 4 years of follow-up, this proportion may be an underestimate. Second, of the 67 children treated for TB, only 8 had DST results in their medical chart, because in children it is difficult to obtain adequate sputum specimens for testing.
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From page 78... ...
Salmaan Keshavjee, Harvard Medical School, responded that this practice would represent a major policy change in the developing world, although it is seen in the developed world. DRUG RESISTANCE IN HIV-INFECTED POPULATIONS4 Coinfection with HIV and drug-resistant TB is a serious threat to TB control, said Digambar Behera, Director, LRS Institute of Tuberculosis and Respiratory Diseases.
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From page 79... ...
. Although HIV infection has been associated with MDR TB outbreaks in institutional settings, such as hospitals and prisons, whether HIV infection also is associated with MDR TB outbreaks in community settings remains unclear.
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From page 80... ...
Overall, said Behera, studies in India have not demonstrated an association between HIV infection and MDR TB, a finding that contrasts with results of studies conducted elsewhere. However, the National Laboratory Committee has decided that all future drug resistance surveys should capture HIV status and that TB patients should routinely be referred for HIV testing.
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From page 81... ...
Reference Mondal and Jain, 2007 Tertiary care center, 68 Not reported 5 (7.4) Emerging Infectious Lucknow Diseases, 2007 Singh et al., 2007 Tertiary care center, 12 All HIV-infected 4 (33.3)
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From page 82... ...
Refugee status is a driver of TB, said Kunchok Dorjee, Director, Tibetan TB Control Programme, Delek Hospital, because it results in displacement, a scarcity of shelter, and overcrowding, which in turn lead to the spread of infections, including TB. Refugee status also can lead to delayed diagnosis as a result of such factors as financial and personal hardships, reluctance to visit a doctor for anything less than an urgent condition, language and cultural barriers, and a lack of health education.
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From page 83... ...
Tibetans born in Tibet tend to have fewer cases of MDR TB than of drug-sensitive TB, even though acquired drug resistance is relatively high in Tibet, while Tibetans born in India have more. The number of women with MDR TB is slightly higher than the number of men, and the great majority are between 14 and 40 years old.
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From page 84... ...
The study involves a cross-sectional survey in a province of eastern Cambodia abutting Vietnam where the Global Health Committee/Cambodian Health Committee has worked since 1994. The study enrolled household contacts of index patients with TB, children attending 28 outpatient health centers, and children admitted to 2 district hospitals, with enrollment being conducted from July 2010 to February 2011.
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From page 85... ...
In 2009, the Global Health Committee/Cambodian Health Committee, working under the name Global Health Committee in Ethiopia, initiated the countrywide MDR TB treatment program in partnership with the Jolie-Pitt Foundation and the Ethiopian Ministry of Health. Among a population of 80 million people, an estimated 130,000 new TB cases occur each year in Ethiopia, including about 6,000 new MDR TB cases, and these numbers are likely to be underestimates, said Goldfeld.
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From page 86... ...
and funding from the Jolie-Pitt Foundation, the Global Health Committee/Cambodian Health Committee initiated MDR TB care, in partnership with the Ethiopian Ministry of Health, at St. Peter's hospital in February 2009.
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From page 87... ...
funds to support treatment of MDR TB, as the substantial funds allocated are directed to historical USAID partners not doing direct care. Similarly, in Cambodia, the initiation and expansion of MDR TB care in the country done by the Global Health Committee/Cambodian Health Committee has been supported by a private donation from the Annenberg Foundation and not by the USAID grants awarded to that country.
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From page 88... ...
• "South-to-south transfer," or the sharing of expertise and best practices from one resource-limited setting to another, offers an opportunity to learn from relevant experiences elsewhere in the world. Finally, since the workshop, a research network on pediatric drugresistant TB, The Sentinel Project on Pediatric Drug-Resistant TB, has been launched by two workshop participants.7 7 Since the workshop, Mercedes Becerra, Assistant Professor, Harvard Medical School, and Soumya Swaminathan, Head, Division of Clinical Research, National Institute for Research in Tuberculosis, collaborated to launch a research network on pediatric drug-resistant TB.
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