Drug resistant TB is spreading worldwide
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7219.1220a (Published 06 November 1999) Cite this as: BMJ 1999;319:1220All rapid responses
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The problem with MDR TB is as much that it is being created within
our own shores as being spread from outside. About half of the 30-40 new
cases seen each year are home grown. My own experience is that all the
cases referred to me have arisen through poor management within the UK.
We need to train our own doctors in the management of drug sensitive
tuberculosis to avoid making things worse here.
Peter Davies.
Competing interests: No competing interests
Editor – your news item on the global spread of drug-resistant
tuberculosis (6 Nov, p1220) was alarming and raised the issue of screening
new arrivals to the UK that come from countries with a high incidence of
tuberculosis. One particular group of new arrivals, in which such
communicable diseases are an issue (1), are refugees and asylum seekers.
These individuals may have arrived from areas of war or famine, where
existing medical systems have broken down and they may be incompletely
immunised.
Last year, thousands of individuals arrived at port health units –
mainly Gatwick and Heathrow airports – claiming political asylum. Nearly
3000 arrived from the former USSR, an area highlighted in your news story,
and many more from tuberculosis hotspots (2). According to regulations (3)
these, and indeed anyone planning to reside in the UK for longer than 6
months who arrive from areas where tuberculosis is common (40 cases per
100000 population), should be screened by means of a chest radiograph at
port of entry as part of the tuberculosis-screening programme. This is not
currently occurring - these port health units no longer have the
resources to deal with the large number of asylum seekers and other
immigrants arriving every day.
According to the regulations, the CCDC in the health authority in
which the asylum seeker plans to reside is contacted, and it is up to the
CCDC to contact the asylum seeker and initiate follow-up tests to find
skin-test positive individuals, those requiring vaccination, and to
initiate chest radiographs for those individuals who did not get one at
port health. Most health authorities, however, have insufficient resources
to offer comprehensive contact tracing and screening of newly arrived
asylum seekers.
In the absence of a national policy of reception for this group, and
with a tuberculosis-screening programme that is not picking up all at risk
individuals, it is left to general practitioners to deal with the health
concerns of these new arrivals. GPs, however, do not appear to be
initiating screening either. In a recent study of 58 GPs in EHH health
authority (4), London, most of whom had refugees on their lists, only 4
referred asylum seekers to a chest clinic for tuberculosis screening, with
48 unaware of the tuberculosis-screening programme. Most felt that some
sort of screening should take place.
Although screening for tuberculosis at ports of entry is perhaps
limited in detecting active cases in this group, some kind of follow-up
within the community, or reception centre, needs to be organised to
address tis health issue. Tuberculosis and drug-resistant tuberculosis are
not only personal concerns, but, potentially, major public-health issues
too. We have seen a sharp increase in the number of asylum seekers coming
to the UK in the past few years-- the system inplace to tackle the spread
of tuberculosis in the UK therefore requires attention.
References
1. Watson JM. Tuberculosis in Britain today. BMJ 1993; 306:221-22
2. Home Office. Asylum Statistics 1998.
3. Joint Tuberculosis Committee of the British Thoracic Society. Control
and Prevention of tuberculosis in the UK: code of practice 1994. Thorax
1994; 49:1193-200.
4. S Hargreaves, Alison Holmes, Jon S Friedland. Health-care provisions for
asylum seekers and refugees in the UK. Lancet 1999:353; 1497-98.
Competing interests: No competing interests
Drug resistant TB is spreading in India
Inspite of the World Health Organization declaration in 1993 of TB as
a global emergency and the increase from 10 to over 100 countries
implementing the DOTS strategy, progress against TB is stalled by slow
progress in many of the 22 countries ( “ hot spots ’’ ) including India
that account for 80% of the world’s TB burden.
In India more than 70% of TB cases are being treated by Private
Practitioners including quacks.Many private doctors in India are
violating tuberculosis guidelines by giving their patients wrong
combinations and inappropriate doses[1]. Rifampicin is the most important
drug in the management of tuberculosis. It’s very common to see patients
weighing 80kg or even more getting only 450mg of rifampicin.
I see 3 to 5 cases of resistant tuberculosis every week in my
hospital. As there is no provision of getting free medicines for MDR-TB
poor Indian patients fail to purchase medicines and thus keep on spreading
infection.
MDR-TB is already a global pandemic, with focal “ hot zones ” of
increased transmission. In settings of high transmission of MDR-TB, “ DOTS
-plus ” ( a complementary DOTS based strategy with provisions for treating
MDR-TB ) is warranted [2].
The WHO has for the first time assembled hard evidence that the
emergence of drug resistant tuberculosis can be held back by properly
controlled treatment programs[3].
References:
1. Mudur G. Private doctors in India prescribe wrong tuberculosis
drugs. BMJ 1998; 317:904
2. Tanne JH. Drug resistant TB is spreading worldwide. BMJ 1999; 319: 1220
Brown P. Drug resistant tuberculosis can be controlled, says WHO. BMJ
2000; 320: 821
Competing interests: No competing interests