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Tuesday, 11 December 2007

US statistics

Arch Intern Med. 2007;167(22):2443-2452.
Trends in Tuberculosis/Human Immunodeficiency Virus Comorbidity, United States, 1993-2004
Rachel Albalak, PhD; Richard J. O’Brien, MD; et al.
Background To our knowledge, this is the first assessment of trends in tuberculosis (TB)/human immunodeficiency virus (HIV) comorbidity in the United States based on national TB surveillance data.
Methods We analyzed all incident TB cases reported to the Centers for Disease Control and Prevention national TB surveillance system from all 50 states and the District of Columbia from 1993 through 2004. Trends in TB/HIV cases were examined according to selected demographic and clinical characteristics.
Results Cases of TB/HIV decreased from 3681 (15% of 25 108 TB cases) in 1993 to 1187 (8% of 14 515 TB cases) in 2004, accounting for 23% of the overall decrease in TB cases during this period. The TB/HIV case rate decreased from 1.4/100 000 in 1993 to 0.4/100 000 in 2004. The highest TB/HIV comorbidity rates persisted in persons aged 25 to 44 years (13.8%), males (9.7%), US-born persons (10.7%), non-Hispanic blacks (17.8%), and persons from the Northeast (11.0%) and the South (10.1%). Propensity stratification, used to account for the unequal probability of patients with TB being tested for HIV during the study period, did not show important differences in TB/HIV comorbidity trends.
Conclusions Comorbidity due to TB/HIV decreased substantially between 1993 and 2004, primarily in US-born persons in states that experienced a TB resurgence between 1985 and 1992. These decreases coincide with improvements in TB control and advances in HIV treatment and diagnosis. The overall decreases obscure the wide variation in comorbidity that exists among some demographic groups and the recent slowing in the decline over the past 3 years.

Sunday, 9 December 2007

More recent history -- Christmas seals

This year the American Lung Association is celebrating 100 years of Christmas Seals® by launching a new Christmas Seals(R) website, "Most Americans alive today have no vivid memories of how widespread deadly tuberculosis was before the 1950s, but it claimed entire families in this country, struck down people from all walks of life, often in their prime."
Jacob Riis, a journalist best known as the author of How the Other Half Lives, pleaded in a newspaper article for someone in America to develop a stamp or seal like the ones he saw being sold in Denmark as a method of raising funds to provide treatment to those without means. Emily Bissell, an American Red Cross volunteer from a prominent Delaware family, took up Riis' challenge. She designed the first Christmas Seal using the American Red Cross proprietary cross and sold them in her local post office. While not a substitute for official U.S. postage, she encouraged people to buy and affix these seals to holiday packages to demonstrate commitment to helping treat tuberculosis. Sales, however, were slow. Leigh Mitchell Hodges, a columnist for the Philadelphia Inquirer, came to the rescue, convincing his editor to run a picture of the seal every day leading up to Christmas and to publish stories about tuberculosis. Buoyed by this publicity, Ms. Bissell succeeded beyond her wildest dreams, and the American Lung Association, then known as the National Tuberculosis Society, gained a means of raising funds.

Saturday, 8 December 2007

BCG Disease

A vaccine meant to protect against tuberculosis is jeopardising the lives of HIV-infected infants, warn experts in a major new report. They call for improvements to vaccination programmes to avoid increasing the health risks for children whose immune systems are weakened by HIV.
The report focuses on how the “global epidemics of HIV and tuberculosis has exploded to create a deadly co-epidemic”, that is rapidly spreading in sub-Saharan Africa. It warns that about a third of the world’s 40 million people with HIV/AIDS are
co-infected with TB, and that the mortality rate these people is five times higher than that for tuberculosis alone.
It also notes that the use of the Bacille Calmette-Guérin (BCG) vaccine against TB in babies with HIV may actually be making the situation worse.
Veronica Miller, a co-author of the report and director of the Washington, DC-based Forum for Collaborative HIV Research, said that there is an "urgent" need for changes to vaccination programmes in sub-Saharan Africa, including improved testing to know whether infants have HIV before vaccinating them against TB.
Live strain
The growing threat of TB and the drug-resistant forms of this bacterial infection that commonly attacks the lungs has increased the need for widespread vaccination, experts say.
Unfortunately, there is a lack of new vaccines against TB, which kills nearly 2 million people each year. For this reason, doctors must rely on the BCG vaccine, developed almost a century ago from a usually non-pathogenic, live strain of Mycobacterium bovis – the cow form of the bacterium that causes TB.
Physicians routinely administer this vaccine to newborns in regions where TB has re-emerged as a threat. This means that millions of infants in developing nations in Africa and Asia receive the vaccine in their first few hours of life.
Unfortunately, though, many of these infants are born with HIV, and subsequently have a weakened immune system. This weakened condition makes them vulnerable to “BCG disease”, a serious illness caused by the M. bovis of the BCG vaccine, which would otherwise not pose a threat.
BCG disease
One recent study conducted in South Africa and published in the journal Clinical Infectious Diseases found that six out of the eight children that became severely ill from the BCG vaccine ultimately died from the M. bovis infection (vol 15, p 559-61). The majority of these children were found to have had HIV.
Miller says that an estimated 600,000 children are born with HIV each year and hundreds are at risk of dying as a consequence of BCG vaccination.
The World Health Organization (WHO) had previously recommended that the BCG vaccine be given to all healthy infants as soon as possible after birth. However, the WHO revised its position and stated in a
May 2007 report that "recent evidence shows that children who were HIV-infected when vaccinated with BCG at birth, and who later developed AIDS, were at increased risk of developing BCG disease."
The report adds that, "among these children, the benefits of potentially preventing severe TB are outweighed by the risks associated with the use of BCG vaccine."
Sophisticated tests
The challenge is to develop more sophisticated HIV tests for newborns, says Miller, who also conducts research at George Washington University in Washington, DC, US. But this will take a bigger financial commitment from governments and aid organisations, she adds.
She explains that the types of HIV tests commonly used in the developing world cannot distinguish the HIV status of infants until they reach about six months of age.
The search for more effective tuberculosis vaccines could produce novel options that avoid the problem of BCG-related illness, says Lewellys Barker at the Aeras Global TB Vaccine Foundation in Rockville, Maryland, US.
He notes that scientists are designing TB vaccines that involve the injection of proteins, as opposed to live bacteria, which would not pose as great a threat to children with HIV.
Journal reference:
HIV-TB Co-Infection: Meeting the Challenge (pdf)

Half a million years

ScienceDaily (Dec. 8, 2007) — Although most scientists believe tuberculosis emerged only several thousand years ago, new research from The University of Texas at Austin reveals the most ancient evidence of the disease has been found in a 500,000-year-old human fossil from Turkey.
The discovery of the new specimen of the human species, Homo erectus, suggests support for the theory that dark-skinned people who migrate northward from low, tropical latitudes produce less vitamin D, which can adversely affect the immune system as well as the skeleton.
Prior to this discovery in western Turkey, which helps scientists fill a temporal and geographical gap in human evolution, the oldest evidence of tuberculosis in humans was found in mummies from Egypt and Peru that date to several thousand years ago.
Paleontologists spent decades prospecting in Turkey for remains of Homo erectus, widely believed to be the first human species to migrate out of Africa. After moving north, the species had to adapt to increasingly seasonal climates.
The researchers identified this specimen of Homo erectus as a young male based on aspects of the cranial suture closure, sinus formation and the size of the ridges of the brow. They also found a series of small lesions etched into the bone of the cranium whose shape and location are characteristic of the Leptomeningitis tuberculosa, a form of tuberculosis that attacks the meninges of the brain.
After reviewing the medical literature on the disease that has reemerged as a global killer, the researchers found that some groups of people demonstrate a higher than average rate of infection, including Gujarati Indians who live in London, and Senegalese conscripts who served with the French army during World War I.
The research team identified two shared characteristics in the communities: a path of migration from low, tropical latitudes to northern temperate regions and darker skin color.
People with dark skin produce less vitamin D because the skin pigment melanin blocks ultraviolet light. And, when they live in areas with lower ultraviolet radiation such as Europe, their immune systems can be compromised.
John Kappelman, professor of anthropology at The University of Texas at Austin, is part of an international team of researchers from the United States, Turkey and Germany who have published their findings in the Dec. 7 issue of the American Journal of Physical Anthropology.
It is likely that Homo erectus had dark skin because it evolved in the tropics, Kappelman explained. After the species moved north, it had to adapt to more seasonal climates. The researchers hypothesize the young male's body produced less vitamin D and this deficiency weakened his immune system, opening the door to tuberculosis.
"Skin color represents one of biology's most elegant adaptations," Kappelman said. "The production of vitamin D in the skin serves as one of the body's first lines of defenses against a whole host of infections and diseases. Vitamin D deficiencies are implicated in hypertension, multiple sclerosis, cardiovascular disease and cancer."
Before antibiotics were invented, doctors typically treated tuberculosis by sending patients to sanatoria where they were prescribed plenty of sunshine and fresh air.
"No one knew why sunshine was integral to the treatment, but it worked," Kappelman said. "Recent research suggests the flush of ultraviolet radiation jump-started the patients' immune systems by increasing the production of vitamin D, which helped to cure the disease."
The Leakey Foundation and the Scientific and Technical Research Council of Turkey funded the research.
Adapted from materials provided by University of Texas at Austin.

Wednesday, 21 November 2007


Brief Communication: Characteristics of Spontaneous Cases of Tuberculosis Associated with Infliximab Angela Raval, PharmD; Gita Akhavan-Toyserkani, PharmD, MBA; Allen Brinker, MD, MS; and Mark Avigan, MD, CM
20 November 2007 Volume 147 Issue 10 Pages 699-702
Background: A warning for tuberculosis was added to the approved labeling for infliximab in October 2001.
Objective: To describe adverse event reports of tuberculosis during infliximab therapy after labeling changes.
Design: Case series.
Setting: Spontaneous adverse event reports maintained in the Adverse Event Reporting System database in the United States.
Patients: 130 patients with infliximab-associated tuberculosis.
Measurements: Clinical and laboratory data.
Results: The U.S. Food and Drug Administration received 130 domestic, spontaneous reports of tuberculosis in patients treated with infliximab between 1 November 2001 and 30 May 2006, including 59 (45%) with extrapulmonary disease. The most commonly reported risk factors included concomitant immunosuppressant use (n = 89), history of latent or active tuberculosis (n = 33), and being born into or having spent extensive time in an area where tuberculosis is endemic (n = 25). In the subset of 67 cases with documented initiation of infliximab therapy after the drug labeling change, 34 patients with a negative tuberculin skin test result before initiation of infliximab therapy developed tuberculosis after receiving infliximab.
Limitation: Conclusions from spontaneous case reports may not be generalizable to the entire infliximab-receiving population.
Conclusion: Clinicians should be vigilant in screening and monitoring for tuberculosis in patients receiving infliximab

Monday, 12 November 2007

Aftermath report on the Speaker fiasco

Breaches in security that allowed a U.S. tuberculosis patient to defy health officials and fly to Europe and back in May can be at least partly fixed with faster communication and better training, according to a federal government report.A report from the U.S. Centers for Disease Control and Prevention on its handling of the matter shows a need for more coordination between airlines and federal agencies in such emergencies, including quick transmission of passenger information.A copy of the "After Action Report" obtained by Reuters on Thursday shows a lack of clear standard operating procedures allowed Atlanta lawyer Andrew Speaker to fly to Greece and Italy for his wedding and honeymoon against direct advice from authorities and then sneak back into the United States. .The report, which has been circulating among congressional staffers, says local officials also need to be told of new, flexible CDC powers to stop people from traveling. Local officials in Georgia said they could not legally act until Speaker had already disobeyed their orders.Better and faster tests for TB are also needed. Speaker did not learn that he had anything but ordinary TB for weeks because testing is so slow.Cetron noted that the CDC has only half the number of staff needed to properly watch travelers at ports of entry as recommended by the Institute of Medicine. A 2005 report from the Institute said CDC needed 1 inspector for every 750,000 travelers."I think there is this idea out there that somehow we will be erecting impenetrable fortresses at ports of entry that, rendered well, will leave us impervious to infectious diseases. That's just not going to happen," Cetron said in a telephone interview.

South African scientists crack drug-resistant TB code

South African scientists have sequenced the entire genome of a strain of extremely drug-resistant Mycobacterium tuberculosis (XDR-TB).
Scientists from the Nelson R. Mandela School of Medicine at the University of KwaZulu Natal, and the National Genomics Platform sequenced the genome 20 times to distinguish mutations from sequencing errors and provide a reference for further sequencing projects of XDR and multidrug-resistant TB. Lifelab, a funding mechanism of the South African Department of Science and Technology, funded the sequencing initiative. The cost of the research has not been disclosed.
James Sakwa, manager of the National Genomics Platform, told SciDev.Net that the next step will be to to develop a diagnostic kit that can quickly and efficiently diagnose this strain of XDR-TB. The breakthrough was achieved by using "pyro-sequencing" technology, where massive amounts of information are produced in parallel.
"This enabled us to sequence the whole genome within a week," he said. If the scientists had used older technologies, it would have taken about a year to achieve the same result.Proposals for the sequencing of other TB strains are currently being considered by the National Genomics Platform. "The truth is we don't know how many mutations of XDR TB there are," Sakwa said.The findings were announced at a press conference in Durban, KwaZulu Natal province, South Africa in October.

Sunday, 11 November 2007

new drug, SQ109

A new tuberculosis drug given special status by both U.S. and European regulators might lead to simpler, more effective TB treatment regimens.Approximately one-third of the world’s population is infected with the tuberculosis bacterium, and approximately 1.6 million people died of the disease during 2005.Currently, TB patients must adhere to a complex treatment regimen over a six- to nine-month period. That demanding schedule, researchers said, often results in patients skipping treatment doses, which, in turn, gives rise to drug-resistant strains such as multi-drug-resistant, or MDR, tuberculosis and the recently identified extensively drug-resistant form of the disease.
The new drug, SQ109, is an antimicrobial agent developed through a partnership between the National Institute of Allergy and Infectious Diseases and the biotech company Sequella Inc.SQ109 has recently been granted "orphan drug" status by the U.S. Food and Drug Administration and the European Medicines Agency. The orphan designation involves tax reductions and marketing exclusivity to encourage development of drugs to treat diseases affecting fewer than 200,000 people.


Controlling tuberculosis in Europe requires the participation of community groups and activists, according to an official “offer of partnership” to be presented to Europe’s ministers on Monday,
October 22 at the Ministerial Forum, “All Against Tuberculosis,” convened by the World Health Organization (WHO) and the German government. Ministers of health, finance, and justice from the 53 European Member States are expected to declare TB a “public health threat” and to commit new resources to tackle the epidemic in Europe.
TB is a preventable and curable disease. Yet, in 2005, 65,700 people in the European region died from TB, according to the WHO. The countries of the former Soviet Union account for 72 percent of all cases of TB reported in the European region. Greece, Sweden, and the United Kingdom also reported significant increases in TB infections in recent years.
“Rises in the rates and severities of infections make it clear that TB can no longer be dismissed as a disease of the past,” said George Soros, OSI Chairman. “I applaud the European ministers for finally recognizing TB as a regional health priority. Europe should also increase funding to fight TB in the developing world, where it continues to be one of the top killers.”
The WHO has invited Zemfira Kondur, an advocate from the Ukraine who works with marginalized Roma communities, to present civil society’s offer of partnership at the Ministerial Forum. “The burden of TB is greatest on the most marginalized communities, including Roma and other ethnic minorities,” said Kondur. “We urge our government leaders to accept our offer of partnership so we can work together to end this disease of poverty and inequality once and for all.” Most TB cases are concentrated among groups who have limited access to health care or who live in conditions that facilitate the spread of TB.
In London, TB outbreaks have disproportionately impacted homeless people, prisoners, and people who use drugs.
Cases of drug-resistant TB in Europe are among the worst in the world, and the number of people infected with both HIV and TB is also growing.
“The outbreak of HIV and TB co-infection has a devastating impact on patients, their families, and communities,” said Paul Thorn, director of the Tuberculosis Survival Project. “In order to control the spread of TB, we need health services to work with us, not just for us.”

Monday, 5 November 2007

South Africa projected increase in XDR-TB rates

Without new interventions, cases of extensively drug-resistant tuberculosis (XDR-TB) in rural South Africa will increase dramatically over the next five years, according to a study published 27 October in The Lancet. The study, which modelled the effect of various infection control measures on the spread of XDR-TB in the rural community of Tugela Ferry in KwaZulu-Natal, South Africa, suggests that infection rates will increase from 194 cases in 2007 to an estimated average of 234 cases a year by 2012. Multidrug-resistant TB will also increase from 352 cases in 2007 to 425 a year over the same period. They estimate that 72––96 per cent of all new XDR-TB cases in Tugela Ferry will occur in people infected with HIV. The study suggests that a combination of controls —— including using masks, reducing hospitalisation time, improving ventilation and rapid drug resistance testing —— could avert almost half the predicted XDR-TB cases by 2012 at Tugela Ferry and at similar resource-limited hospitals around the country.

Monday, 29 October 2007

Anti-TB programme 'led to resistance' in South Africa

A study has found that the WHO's tuberculosis programme in South Africa inadvertently helped a strain of TB-causing bacteria develop additional drug resistance.
Researchers from the University of KwaZulu-Natal's Nelson Mandela School of Medicine tracked the development of drug resistance in a strain of Mycobacterium tuberculosis over a 12-year period.
They found that by the time the WHO introduced their programme in South Africa in 2001 — using a second-line medication to combat multidrug-resistant strains of TB — at least one strain had already developed resistance to one or more of the second-line drugs.
But because the programme didn't conduct drug susceptibility tests, the new second-line medication was not only useless to TB patients infected with the resistant strain, but also led to the strain developing additional drug resistance. This is because when an M. tuberculosis strain is resistant to a drug, it survives and can subsequently evolve resistance to additional drugs. The strain eventually became extensively drug-resistant (XDR-TB), resistant to seven anti-TB drugs in total, including first-line and several second-line drugs.

Sunday, 21 October 2007

Close contact!

PHILIPSBURG, St. Maarten - Dozens of people in St. Maarten are being treated for latent tuberculosis after health officials warned that they may have been exposed to the illness by a stripper infected with an active form of the disease.
At least 40 people tested positive after the health department treated an exotic dancer from the Dominican Republic several months ago and sent her home, according to a government news release issued Friday.
Health officials struggled to identify those exposed, launching a public campaign to urge anyone who had contact with the woman to seek treatment. They now believe they have identified everyone infected.

WHO EURO region's Ministerial Forum

"If the Berlin Ministerial Forum wishes to act now to eradicate tuberculosis, it must reach out far beyond the borders of Europe." The WHO EURO region's Ministerial Forum on tuberculosis on October 22, 2007, in Berlin, must take account of the threat of TB both outside as well as inside Europe if it is to be tackled adequately. These are the conclusions of authors of a Comment published in this week's edition of The Lancet. The Comment is authored by Dr Bruce Currey, Professor Quazi Quamruzzaman, and Professor Mahmuder Rahman, Dhaka Community Hospital, Dhaka, Bangladesh. They say that in a 21st century that is becoming more and more global, to reduce the incidence of tuberculosis within Europe, European ministers must act together and act now, not simply to control, but also to eradicate poverty and tuberculosis in the source communities of Europe's migrant workers and major trade partners outside Europe. The Ministerial Forum must confront the raging red bull of tuberculosis infections outside Europe. It goes on to say that the Berlin forum paper emphasises the 66 000 deaths from tuberculosis inside Europe in 2005, but overlooks the 1•6 million deaths outside Europe. It adds that radical reduction of the incidence of tuberculosis both inside and outside Europe requires prevention of the progression to new active cases as well as management of active cases. Eradication is possible, but not with drugs alone. Further, it adds: "Trade and trade embargoes affect the incidence of tuberculosis. The Centres for Disease Control and Prevention has shown how radical intervention in the Hmong refugee centres of Thailand can reduce the incidence of tuberculosis and multidrug-resistant tuberculosis in the Hmong in Fresno, California." The Comment authors propose a six-pronged approach to tackling the tuberculosis threat, including incorporating populations outside Europe, and the Forum accepting responsibility for actions such as arms trading and oil prices which increase inequality and tuberculosis incidence worldwide. The last of the six parts of the authors' suggested action calls on the Forum to get behind the UK Prime Minister's address to the UN in July 2007, to "act now" to tackle global poverty and "eradicate" the scourge of diseases such as tuberculosis, and his commitment that there are resources available to eradicate the disease. The Comment concludes: "If the Berlin Ministerial Forum wishes to act now to eradicate tuberculosis, it must reach out far beyond the borders of Europe."

Thursday, 18 October 2007

UN Special Envoy

The UN special envoy to stop TB visited Washington Wednesday to lobby US officials
for more funding to fight the disease. Congress is currently debating whether to double funding for TB programs to $200 million.
It’s estimated that each year, nearly nine million people develop tuberculosis, with more than one and a half million dying from the disease. That’s despite the fact that it’s both preventable and curable.
The UN special envoy to stop TB - former Portuguese president Jorge Sampaio – says there’s renewed interest and concern about the disease.
“The fact that Congress is dedicating much more attention to TB, because everyone thought that TB was finished and it was not a first-degree concern – the fact that it’s now unfortunately becoming a concern I think is a very positive step because in a way these things need to be fought against, needs to be on the agenda,” he says.
Sampaio says tuberculosis and other killer diseases are linked and often should be treated at the same time.
“Attack the three pillars - and I mean by that TB, HIV and malaria – TB now is also the main killer of HIV people on AIDS treatment – another thing is that it’s developing new strains which are resistant to the well-known treatment. So, TB presents new facets of danger, considering globalization, considering that it is a very quickly transmissible disease,” he says.
Those newer strains are called MDR and XDR-TB. The UN special envoy agrees with the description that TB is the Achilles Heel of AIDS treatment.
He says, “It’s an Achilles Heel simply because of the fact that there’s a dramatic irony in all this. Because you don’t have the cure for AIDS, but you do have anti-retrovirals, but of course people with AIDS a great percentage of them simply die because they catch TB, which is not diagnosed on time, which is in fact not controlled in time. They die because they are not treated carefully and in time for a curable disease.”
He says if all countries and health and aid agencies work together, it is possible to achieve the Millennium Development Goal of saving up to 14 million additional lives by 2015.

Blood tests for TB

Physicians & TB controllers around the country can now quickly and accurately detect M. tuberculosis infection with today's U.S. Food and Drug Administration (FDA) approval of QuantiFERON(R)-TB Gold In-Tube (QFT(TM)). This blood test detects cellular immune responses to proteins specifically associated with tuberculosis (TB) infection. It replaces the original QuantiFERON(R)-TB Gold, and offers the same specificity and accuracy advantages. In addition, the new In-Tube format, already widely used in Europe and Asia, simplifies testing and fits with existing laboratory equipment, giving convenient TB testing from Kalispell to Key West. Both tests replace the 100-year-old tuberculin skin test (TST).
CEO of Cellestis, Dr Tony Radford, comments, "With the In-Tube system, the blood incubation requires virtually no labor and no set-up time. It makes a QFT(TM) test as simple as a routine antibody test and extends the availability of QFT(TM) testing by streamlining logistics to allow the initial incubation process to be done almost anywhere. The FDA approval now permits our U.S. customers to enjoy the cost-savings, and quality result of In-Tube, as well as a better process fit with hospitals and labs."
The TST, which involves a crude tuberculosis extract injected into the skin, is over 100 years old. Despite its limitations, it is widely used for detecting TB infection. Significantly, the TST is often confounded in persons vaccinated with Bacillus Calmette-Guerin (BCG) (TB vaccination), as well as those exposed to some environmental bacteria, giving many people a false- positive TST results. The TST has poor reproducibility and requires two patient encounters; one to inject the subject and a second, 2-3 days later, to read the inflammation it may produce. Measuring the inflammation requires trained medical personnel but is still highly subjective, and is notorious for inaccuracy. This leads to poor use of valuable medical resources, and the need for a second clinic visit means many people fail to have their TST read.
QFT(TM) is supported by data from over 100 clinical publications, requires a single blood test, and gives objective and reproducible results. The In-tube format simplifies testing logistics, enabling remote location blood collection. It measures immune responses to peptides that simulate M. tuberculosis proteins, which are not present in the BCG vaccine or most non- tuberculosis mycobacteria. Thus, QFT(TM) is 99% specific and a positive test result is strongly predictive of true infection with M. tuberculosis. As people suspected of TB infection are normally recommended for TB therapy, which carries risks of liver toxicity and nerve damage, use of the highly specific QFT(TM) test will reduce unnecessary therapy and overtreatment, therefore having significant medical benefit.
QFT(TM) provides a new standard for TB control and gives the US TB control community an effective, reliable and accurate screening method. In addition, QFT(TM) yields dramatic cost savings in medical staff time and by eliminating the common false-positive results of the TST. For TB control programs across the nation, QFT(TM) can relieve the medical, logistic, administrative and cost burden associated with TB testing compliance.
About Cellestis:
Cellestis is a listed Australian biotechnology company commercialising QuantiFERON(R) technology for diagnosing TB and other diseases worldwide. QuantiFERON(R)-TB Gold tests for the presence or absence of a protein (gamma- interferon) produced by a patient's white blood cells after stimulation with specific TB proteins. The test has received regulatory and policy approvals in the USA, Japan, Europe and elsewhere. The Company operates through subsidiaries in the USA, Europe and Australia Physicians & TB controllers around the country can now quickly and accurately detect M. tuberculosis infection with today's U.S. Food and Drug Administration (FDA) approval of QuantiFERON(R)-TB Gold In-Tube (QFT(TM)). This blood test detects cellular immune responses to proteins specifically associated with tuberculosis (TB) infection. It replaces the original QuantiFERON(R)-TB Gold, and offers the same specificity and accuracy advantages. In addition, the new In-Tube format, already widely used in Europe and Asia, simplifies testing and fits with existing laboratory equipment, giving convenient TB testing from Kalispell to Key West. Both tests replace the 100-year-old tuberculin skin test (TST).
CEO of Cellestis, Dr Tony Radford, comments, "With the In-Tube system, the blood incubation requires virtually no labor and no set-up time. It makes a QFT(TM) test as simple as a routine antibody test and extends the availability of QFT(TM) testing by streamlining logistics to allow the initial incubation process to be done almost anywhere. The FDA approval now permits our U.S. customers to enjoy the cost-savings, and quality result of In-Tube, as well as a better process fit with hospitals and labs."
The TST, which involves a crude tuberculosis extract injected into the skin, is over 100 years old. Despite its limitations, it is widely used for detecting TB infection. Significantly, the TST is often confounded in persons vaccinated with Bacillus Calmette-Guerin (BCG) (TB vaccination), as well as those exposed to some environmental bacteria, giving many people a false- positive TST results. The TST has poor reproducibility and requires two patient encounters; one to inject the subject and a second, 2-3 days later, to read the inflammation it may produce. Measuring the inflammation requires trained medical personnel but is still highly subjective, and is notorious for inaccuracy. This leads to poor use of valuable medical resources, and the need for a second clinic visit means many people fail to have their TST read.
QFT(TM) is supported by data from over 100 clinical publications, requires a single blood test, and gives objective and reproducible results. The In-tube format simplifies testing logistics, enabling remote location blood collection. It measures immune responses to peptides that simulate M. tuberculosis proteins, which are not present in the BCG vaccine or most non- tuberculosis mycobacteria. Thus, QFT(TM) is 99% specific and a positive test result is strongly predictive of true infection with M. tuberculosis. As people suspected of TB infection are normally recommended for TB therapy, which carries risks of liver toxicity and nerve damage, use of the highly specific QFT(TM) test will reduce unnecessary therapy and overtreatment, therefore having significant medical benefit.
QFT(TM) provides a new standard for TB control and gives the US TB control community an effective, reliable and accurate screening method. In addition, QFT(TM) yields dramatic cost savings in medical staff time and by eliminating the common false-positive results of the TST. For TB control programs across the nation, QFT(TM) can relieve the medical, logistic, administrative and cost burden associated with TB testing compliance.
About Cellestis:
Cellestis is a listed Australian biotechnology company commercialising QuantiFERON(R) technology for diagnosing TB and other diseases worldwide. QuantiFERON(R)-TB Gold tests for the presence or absence of a protein (gamma- interferon) produced by a patient's white blood cells after stimulation with specific TB proteins. The test has received regulatory and policy approvals in the USA, Japan, Europe and elsewhere. The Company operates through subsidiaries in the USA, Europe and Australia


A Sana’a University study has shown that there is a high rate of extra pulmonary tuberculosis cases among Yemeni tuberculosis patients, when compared to other Arab states. The study titled, Patterns of TB among patients attending the National TB Institute, was conducted by researchers at the university’s Faculty of Medicine and Health Sciences and supervised by Dr. Abdullah Moharram. Researchers studied 479 TB patients from different Yemeni governorates who received treatment at the National Tuberculosis Institute between September 2005 and January 2006. The study found that about 54 percent of patients attending the institute had pulmonary TB while the remaining 47 percent had extra-pulmonary TB. The rate of extra-pulmonary TB cases is higher than that of other Arab countries such as Egypt (28 percent), Saudi Arabia (27 percent) and Somalia (16 percent). TB produces lesions on bodily organs, especially the lungs. It can involve the central nervous system, lymphatic system, circulatory system, genitourinary system, bones and joints. About 40,000 infectious particles can be produced by a single sneeze. One cough from a pulmonary TB patient produces up to 3,000 infectious particles. People with prolonged, frequent, or intense contact with the disease face the highest risk of becoming infected, with an estimated 22 percent infection rate. A person with untreated, active TB can infect 10 to 15 people each year. If untreated, the death rate for these active TB cases is more than 50 percent. The risk of contracting TB increases with the frequency of contact with people who have the disease, with crowded or unsanitary living conditions and with poor nutrition. “This disease is an economic one. It is influenced by the economic state of the patient,” said Hamood Mahyub, a doctor and manager at the NTBI. TB is considered to be one of the major public health problems in Yemen, according to the 2004 World Health Organization report. Yemen registered 9,063 cases of TB at the NTBI in 2005, according to Abdul-Bari al-Hammadi, statistics officer at the NTBI. “351 have had a relapse after being treated because of their ignorance and misuse of the medication,” he said. “The Hodeidah Governorate has 603 cases, the highest number of cases in the country and Sayoun has the fewest number of recorded cases, with only ten. This means that for every 100,000 people in Yemen, there are 40 TB cases,” he said. According to the report, the number of pulmonary cases at the NTBI was 7, 691, compared with 9,466 extra pulmonary cases. Moreover, the report recorded 2,500 cases resulted in the patients death.The most common types of extra pulmonary TB were found in the lymph node, (33 percent), in the pleura (21 percent), and in the abdomen & bones (16 percent). The study found that 55 percent of adults who participated in the study were pulmonary TB cases while about 58 percent of children and 52 percent of elderly people had extra pulmonary TB. The study also found that almost half the patients (48 percent) were illiterate and 75 percent were living in low economic conditions. Doctors in the NTBI complain about the neglect shown by many patients’ towards their state of health. “They do not continue their Directly Observed Treatment Short-course program treatment once they start feeling better. They are often illiterate, which makes our work more difficult,” said Dr. Mahyub. “The media does not help to illuminate people about the dangers of this disease, its causes and means of avoiding infection.” The overall objective of global TB control is to reduce deaths due to the disease, to lower the occurrence of the disease itself, and finally to drastically reduce the transmission of infection. The Bacillus Calmette-Guerin vaccination is the most widely used vaccine in the world, but it has virtually no impact on the transmission of TB because its preventive effect on the infectious forms of TB is very limited. Nevertheless, because it is effective in preventing serious and life-threatening forms of TB in infants and young children, BCG vaccination continues to be recommended in countries where TB is common. In the 172 countries where BCG is used, around 85 percent of newborn babies are vaccinated with protective efficacy up to 80 percent for 10 to 15 years. 89 percent of the patients who attended the NTBI were found to be unvaccinated compared to just 11 percent who were vaccinated. It was also found that 50 percent of vaccinated patients and 46 percent of unvaccinated patients were infected with extra-pulmonary TB. Most TB patients suffered from fever, loss of weight, night sweats, chronic coughing, sputum and hemoptysis, the study found. TB patient may also suffer from other diseases affecting the immune system. The study found that 11 percent of patients had diabetes and there were two cases of chronic renal failure. The study found that about 16 percent of patients treated in the institute were completely cured, while 25 percent were undergoing treatment. Alarmingly, 58 percent of patients had failed to continue treatment and one percent had died. According to the World Health Organization, 8 million people become ill with TB and 2 million people die from the disease worldwide every year. In 2004, around 14.6 million people had active TB with 9 million new cases reported. The WHO estimated that 1.7 million deaths resulted from TB in 2004. TB is the world’s greatest infectious killer of women of reproductive age and the leading cause of death among people with HIV/ AIDS. The study recommended increasing the coverage of DOTS program to include all TB patients; providing TB treatment centers with the necessary equipment; providing patients with good knowledge of TB; and encouraging the Ministry of Public Health and Population to increase the coverage of BCG to include all children in their first months as can as possible.

Tuesday, 16 October 2007

TB in Nepal

After a decade of the introduction of DOTS (Directly Observed Treatment Short-Course) the graph for TB notification rate has started to look downward. The rate which was 112 per 100,000 population in 1999/00 had risen to 123 in 2004/05 has come down to 119 in 2005/06.It takes two decades or more to see the result of the treatment of TB and the country already achieved the global targets, said director at the National Tuberculosis Centre Dr. Pushpa Malla.Nepal has achieved the global targets in TB control ? with the detection rate of 70 per cent and the treatment success rate of 88 per cent, Dr. Malla told The Rising Nepal. She said that after DOTS was started in the country the number of deaths has reduced to around 7,000 from 10,000 annually.Forty-five per cent of the total population is infected with Tuberculosis (TB) and mostly those who die are of economically active age group. According to the National TB control Programme, 40,000 people get TB every year of them half of them are new cases identified through sputum tests.Dr. Malla said that DOTS services were being provided from 4,000 places, including public health institution and sub-health posts. She said that 60 per cent of all health institutions have been providing DOTS and the government aims at expanding the services to all public health institutions from the current fiscal year.The government has also been providing DOTS Plus for multi-drug resistance patients, in which the patients should take medicines regularly for two years. The DOTS Plus scheme was started two years ago. Of those who are under the DOTS Plus course, 70 per cent of them have been found to be negative after six months of taking the medicine. More than 20 patients have already completed the two-year course and they are hail and hearty now.The DOTS Plus is being provided from five centres, one each in the five development regions and more than 20 sub-centres. The government is planning to expand the service to Dhangadi, Chitwan and Tanahu from this fiscal year and to reach to several districts of the mid-western region in the near future.The National TB control Programme was started in 1996 aiming to reduce mortality, morbidity and transmission of tuberculosis so that it does not pose a public health problem, Dr. Malla said. The Nepal Stop TB Strategy was adopted in 2006 to address TB among people living with HIV/AIDS and MDR-TB.Dr. Malla said that people those living with HIV/AIDS are highly prone to TB and they could develop complications at any time but that could be prevented like other TB patients if they take regular DOTS."There are challenges for long-term sustainability of the DOTS scheme as we depend on the donors for 70 per cent of the funding," she said. Even now, TB patients especially those with HIV and MDR require more nutrition and social support, which we have not been able to provide. Again, many patients have to come to the centres regularly for DOTS from their villages walking several days and that could be one of the reasons for the irregularity of the intake of medicines. This problem is being tackled by utilizing female health volunteers, who reach medicines to the patients at their doorsteps, Dr. Malla said.

TB in Australia

THE killer disease tuberculosis, not seen in Australia for decades, has been reintroduced by migrants - largely refugees from Africa.
TB, which like the common cold is spread through the air, is on the increase in Victoria.
There were 352 cases of tuberculosis reported to the Department of Human Services in 2005 - a 7 per cent increase on the 2004 figure.
And a 26 per cent increase on 2002 figures.
The numbers have remained high with 353 cases last year.
And already there have been 89 cases in the first quarter of this year.
Much of the increase has been attributed to newly arrived refugees.
Africa has the highest incidence and mortality rate from tuberculosis in the world.
"As the geographic focus of Australia's humanitarian programs have changed in recent years, an increase in the number of notified tuberculosis cases have been observed," a report from the Public Health Branch on surveillance of infectious diseases stated.
"The most significant risk factor for tuberculosis in Victoria is having migrated from a high prevalence country.
"Health care workers should be aware of the increased risk of tuberculosis in newly arrived refugees and migrants and of the cultural issues that influence their health seeking behaviour."
Most notified cases, 93 per cent, were residents of metropolitan Melbourne mostly in the north and west.
And the highest number of cases were reported for the 20 to 30 year age group.
All refugees have health check screenings on entry to Australia.
Individuals who are suspected of tuberculosis sign a health undertaking (TBU) for follow-up screening. But a study found the numbers going for follow-up screening was low with fewer than half completing their TBU assessment.
It is estimated 1.6 million deaths resulted from TB in 2005 worldwide.,21985,22542632-662,00.html

TB in Myanmar

The regime is reckoned to spend less than 2% of its budget on health care, but over 40% on the armed forces. Infectious diseases are as widespread as in poor African countries. Myanmar has one of the world’s highest rates of tuberculosis and drug-resistant forms of both tuberculosis and malaria are spreading. HIV infection is also growing in the general population. But government restrictions on aid workers’ movements forced the Global Fund to Fight AIDS, Tuberculosis and Malaria to pull out in 2005. Aid groups have also been forced to restrict their operations.

TB in Pakistan

In a country with a population of 164,741,924 it is astounding to note that about 1.5 million people are currently affected by Tuberculosis (TB) .The worst part of the whole situation is that the number is constantly increasing due to the lack of adequate precautionary measures in, a study reveals this week. This is mainly arising out of the supposed insufficient medical education of doctors, the study adds. “The core obstacle to effective TB control in Pakistan is inadequate medical education,” according to the study conducted by Aga Khan University Hospital (AKUH) in which 460 medical interns were surveyed. The study was conducted by employing researchers at five teaching hospitals of the city (Aga Khan Hospital, Liaquat National Hospital, Jinnah Post-Graduate Medical Centre, Ayub Medical College and Lady Reading Hospital). The researchers assessed the knowledge and practices of recently graduated medical interns (house officers) about TB.

Monday, 8 October 2007

Space technology to speed up TB detection

Microscope diagnosis is time-consuming and often inaccurateKatherine Nightingale4 October 2007Source: SciDev.Net
Technology developed to reveal the secrets of space is being tested as a method of detecting tuberculosis (TB).
The project, led by the UK-based Open University and the London School of Hygiene and Tropical Medicine (LSHTM), received a £1.34 million (US$2.7 million) award from UK medical research charity The Wellcome Trust today (4 October).
The project is part of the charity's technology transfer programme.
The researchers aim to develop a small, portable mass spectrometry device that can be used to detect TB in resource-poor settings.
"The application [of this technology] is especially exciting because a lack of sensitive and point-of-care test for diagnosing TB is one of the major barriers to improving global TB control," says Liz Corbett, a reader in tropical and infectious diseases from LSHTM, based at the Biomedical Research and Training Institute in Harare, Zimbabwe.
TB is usually diagnosed by looking at a sputum smear under a microscope. But this method is labour-intensive and misses about two thirds of positive cases.
The mass spectrometry technology has already been developed and miniaturised for Beagle 2 — a mission to search for life on Mars — and the Ptolemy instrument, which will analyse the composition of comets.
"Chemicals have their own 'signature'," lead researcher Geraint Morgan of the Open University said in a press release. "The bacterium that causes TB has a special coating and it is the pattern of chemicals in this coating that the mass spectrometer will be 'searching' for."
The technique has already yielded promising results in tests on non-pathogenic relatives of Mycobacterium tuberculosis, the bacterium that causes TB, Corbett told SciDev.Net.
The device will next be tested and optimised starting in late 2007 or early 2008 using TB patients' specimens in the United Kingdom. Two miniature mass spectrometers will be moved to Zimbabwe in the second year of the project so that large-scale field trials can be carried out.
Most other diagnostics for TB currently being developed focus on simplicity and rapid results rather than sensitivity, says Corbett.
The clinical evaluation will attempt to identify a diagnostic method that is as simple and safe as sputum smear microscopy and more sensitive, she says. A more sensitive test, or one that is equally sensitive but could give results on the same day, could remove the lengthy waiting times and the repeated testing many TB patients have to endure before they are diagnosed, Corbett added.

Tuesday, 2 October 2007

Fighting TB: An area of promise

Experts have long complained that the lack of new antibiotics in development or ready for market, combined with the presence of increasingly resistant bacteria, has been exhausting treatment options. There are early signs, however, that this situation may be improving.
"This is a very exciting time. It's very encouraging that it appears that the pharmaceutical companies are coming forward with new agents that have new mechanisms of action," said Karen Bush, PhD, a distinguished research fellow at Johnson & Johnson Pharmaceutical Research & Development in Raritan, N.J.
Dr. Bush was speaking at last month's Interscience Conference on Antimicrobial Agents and Chemotherapy, in Chicago. According to informal surveys by infectious disease experts, researchers at this meeting presented data on more than 120 completely new compounds, an unprecedented number. It's too early to predict which compounds eventually will reach patients, but observers hope the heightened level of activity signals a reversal of the trend of fewer new antibiotics coming online each year.
To add momentum to the antibiotic pipeline, some experts at the meeting were advocating a change in the way scientists pursue new germ-killers. For a decade or more, research has focused on targets emerging from the genetic sequencing of various pathogens. Scientists say that although this work has been valuable with regard to increasing the understanding of these bugs, it has not fulfilled hopes for discovering new treatments. Instead, those in the field are urging scientists to return to hunting in the natural world -- the source of the earliest antibiotics. New developments regarding the treatment of tuberculosis also are adding to the optimism and providing important insights into strategies to fight other infections.
For instance, data were presented at the meeting regarding at least seven possibilities for tuberculosis. This condition hasn't had new treatment options for decades, and medications being investigated include completely new agents as well as old ones that are not usually used for this infection.
"We now have more tuberculosis drugs in clinical development than at any other time in history," said Melvin Spigelman, MD, director of research and development at the Global Alliance for TB Drug Development. "For doctors to have seven drugs in development is really a remarkable achievement."
In the case of TB, experts want these new approaches to address emerging resistance as well as allow patients to take fewer medications for shorter periods. TB's six-month-or-longer, multidrug regimen is viewed as one of the biggest barriers to controlling the illness.
"We have excellent tuberculosis treatment," said Dr. Jacques Grosset, a professor at the Center for Tuberculosis Research at Johns Hopkins University School of Medicine in Baltimore. "But 50% of patients don't complete the treatment that should cure them. There are a lot of failures and a lot of deaths and a lot of drug resistance because of this. We should shorten the duration of treatment because the treatment now is extraordinarily difficult to complete."

Sunday, 30 September 2007

Drug resistant TB

Extensively drug resistant tuberculosis (XDR-TB) represents a spectre for the civil society and a major challenge for the TB control community. In this issue, the TBNET study reports on 4,583 confirmed TB cases in Italy, Germany, Estonia and Russia (Archangels Oblast). Treatment outcomes of 64 XDR (1) cases, 267 multidrug-resistant (MDR) (2) cases resistant to all first-line drugs, and of 94 "other" MDR cases (susceptible, at least, to one first-line anti-TB drug) are compared. The results of the study demonstrate that XDR cases have a worse outcome (death or failure, i.e. treatment fails to render the patient non-infectious) than MDR cases resistant to all first-line drugs, and of "other" MDR cases (susceptible, at least, to one first-line anti-TB drug). The study also demonstrates that the XDR definition proposed by WHO has both a clinical (predicts poor outcome), and operational value (confirming these cases are resistant to both first-line drugs and key second-line ones).
(1) XDR: cases resistant at least to isoniazid and rifampicin, plus at least one fluoroquinolone (new generation second-line drug) and one injectable second-line drug(2) MDR: cases resistant to at least isoniazid and rifampicin, the two most powerful anti-TB

Offering Choice To Tuberculosis Patients Improves Treatment Outcomes

Tuberculosis (TB) is an important disease. More than a third of the world's population has been infected with the disease. Given the right conditions, these infections can progress from latent to active disease. Even in Europe, TB is increasing in several countries. If latent TB infection is treated effectively, then many individuals can be prevented from developing TB and passing it on to their friends and families before they realise they are ill. This study, undertaken by Timothy Rennie (NE London TB Network, Homerton University Hospital, London, UK) and his colleagues, shows that giving the choice of treatment for latent infection (either a three- or a six-month course) improves adherence to therapy. More patients taking the three-month course completed treatment (60%) than those taking the six-month course (46%). Patients generally preferred the shorter three-month course. Child patients were more likely to complete treatment and patients who missed clinics before starting treatment were less likely to complete therapy. Just under one in 18 patients had the therapy stopped because of side effects, but there was no difference in side effects between the different courses of treatment. TB still needs long courses of antibiotics compared with other bacterial infections. Simple measures, such as offering choice, can be very effective. Safe, short regimens are likely to be preferred by patients and greater efforts should be made to identify these

Tuesday, 25 September 2007

Money for research - Gates' Foundation

The Bill and Melinda Gates Foundation announced a new package of funding, 18 September, to accelerate and build on existing technologies to combat tuberculosis (TB).
The US$280 million grant is the largest single donation for TB research and development by the foundation, which aims to donate US$900 million to research by 2015.
The grants will be used for vaccine development (US$200 million), developing diagnostic tests (US$62 million) and drug discovery (US$18 million).
Tachi Yamada, president of the Gates Foundation Global Health Program, told a press briefing that the diagnostic test for TB —— sputum smear microscopy —— is one hundred years old and fails to diagnose half of all cases in developing countries.
Yamada also said that the only TB vaccine, known as the BCG, is over 80 years old and rarely effective after childhood, while existing TB drugs are becoming less effective as resistance to them grows.
New, effective vaccines could save 30 million lives by 2030, said Jerald Sadoff, president of Aeras Global TB Vaccine Foundation, whose company is receiving the US$200 million over five years to take six newly-identified TB vaccine candidates into clinical trials.
The South African Tuberculosis Vaccine Initiative will work with Aeras to implement the trials. The Initiative's clinical director, Tony Hawkridge, highlighted the critical role of scientists in Africa and other developing countries, saying they had been "at the forefront of the basic science underpinning vaccinology".
The Switzerland-based non-profit organisation Foundation for Innovative New Diagnostics (FIND) will receive US$62 million to develop rapid, point of care TB diagnostic tests for developing countries.
Giorgio Roscigno, chief executive officer of FIND, said that they already had ten new diagnostic technologies in development, and hoped to gain WHO approval for at least three of them in the next five years.
Peter Small, senior program officer for TB at the Gates Foundation, said he hoped that pharmaceutical companies would take notice of the grants for drug development. He said that one of the reasons that TB drugs have not kept up with changing situations —— such as drug resistance —— is that in the last 50 years "no one has really tried".

Friday, 21 September 2007

Moxifloxacin vs Isoniazid

Moxifloxacin performed as well as isoniazid in treating pulmonary tuberculosis (TB) in a multinational phase. Subjects were randomized to receive 400 mg/day of moxifloxacin or 300 mg/day isoniazid, given 5 days per week for 8 weeks. All patients also were treated with rifampin, ethambutol and pyrazinamide on the same schedule. The primary measure of treatment success was two consecutive sputum cultures negative for TB organisms. Time to first negative culture was a secondary endpoint. Based on earlier clinical studies, the investigators were hoping to see a treatment success rate of 88% among moxifloxacin patients completing the study protocol. The differences between drugs were not significant.

Anthropo-zoonotic transfer of tubercle bacillus

Human tuberculosis caused the partial paralysis in the young baboon, Marcus, that was put down in June. But TB experts have warned that, rather than baboons being viewed as a health threat to humans, the diagnosis should sound the alarm about the transfer of human disease to wild animals. It was initially feared that Marcus, a research baboon, had been poisoned and a battery of tests were performed to determine the cause of his paralysis and eventual death.
Revealing the news of Marcus's autopsy results, the multirepresentative Baboon Management team's Esme Beamish said they were concerned about the appearance of human TB in a baboon. Paul van Helden, professor of medical biochemistry at Stellenbosch University and a TB expert, said human disease was transferred to wild animals through close contact with them and inappropriate management of refuse. Beamish said the Peninsula's baboon population of 384 180 was already stressed due to isolation, ring fencing by urbanisation and conflict with humans. "A health risk introduced by humans is a serious threat to their continued presence in the Peninsula," she warned.

More on Moxifloxacin; and good news for mice!

A team of Brazilian and US TB experts reported at a meeting of the American Society for Microbiology that adding the drug moxifloxacin to a standard cocktail of antibiotics increased by 17 percent the number of patients who cleared active TB infection from their lungs, from 68 to 85 percent. The drug mixture shortened by two months the time needed to cure the dreaded lung ailment which kills some 1.5 million people each year, mostly in developing countries, experts reported at a meeting of the 47th Interscience Conference on Antimicrobial Agents and Chemotherapy (ICAAC).
The new combination drug therapy uses moxifloxacin in the place of an older, more traditional anti-TB drug, ethambutol.
"This is the most compelling evidence in nearly 25 years that a novel antibiotic drug combination works better than the current gold standard at curing active TB infection," said study senior author Richard Chaisson, a professor of medicine, epidemiology and international health at The Johns Hopkins University School of Medicine.
"Beyond the obvious value of healing patients more quickly, a shorter treatment time could also cut down on transmission of the disease to others and make it easier for health care workers worldwide, who are overwhelmed by large numbers of patients, to treat more people and to treat them faster" said Chaisson, who also heads Hopkins's Center for Tuberculosis Research. He noted nearly nine million new cases of TB are diagnosed each year in the world, and more than one-and-a-half million people die from the disease.
"Better vaccines, diagnostics, and drugs could dramatically improve the fight against TB, especially in poor countries where large numbers of people are affected by the disease," said Peter Small, senior program officer for Tuberculosis at the Gates Foundation.
Another study on mice performed by Johns Hopkins researchers and released at the conference found that replacing the antibiotics rifampin and isoniazide with moxifloxacin and rifapentine allow lab mice to get over TB in 10 weeks rather than six months


Bayer AG's Avelox, set to become the first new type of medicine for tuberculosis in 30 years, may shorten treatment time by two months and slow the development of deadly, drug-resistant strains. Combining the antibiotic with three other therapies might cure the disease in four months instead of six, according to research funded by the Gates Foundation and the U.S. government. As a result, the number of patients who stop treatment too early may fall, slowing the spread of a disease that infects about 2 billion people, scientists say.
TB approval for Avelox, already used to treat pneumonia, may help contain lethal multidrug-resistant TB, the germ carried by Atlanta lawyer Andrew Speaker when he boarded a flight to Paris in May. Doctors at an infectious disease meeting this week in Chicago will hear results of a clinical trial. The findings will be crucial to the drug's approval as early as 2011.
The chemical structure of the drug, also known by the generic name moxifloxacin, can attach to both fatty and watery molecules, allowing it to penetrate TB efficiently, he said.
The Seattle-based Gates Foundation, the world's largest charitable fund, has given $140 million to the Global Alliance to develop new TB drugs. Without that support and direction, along with funds from the U.S. Food and Drug Administration for trials of Avelox, new TB drugs would never get approval, public researchers said. The market is small and treatment trials are so expensive and lengthy that most companies won't touch them.
Most patients carry TB in a dormant, non-infectious form. Even when active, the germ grows slowly, dividing about once a day, compared with other bacteria that might replicate every 20 minutes. The plodding pace gives antibiotics few opportunities for bacterial sabotage, and the organism also has a fatty outer coat that keeps most drugs out entirely.
Multi-drug resistant TB affects about 400,000 people worldwide. Speaker, the lawyer who put hundreds of airline travelers at risk of exposure by taking transatlantic flights, underwent surgery in a Denver hospital to remove infected tissue. Public health officials have spent decades trying to find the best ways to make sure TB patients finish their typical six- month treatments, which once lasted at least 18 months. Skipping doses allows resistant strains to thrive and spread to other people, said David Ashkin, the tuberculosis controller for Florida. Ashkin confines dozens of TB patients to a secure hospital in Lantana annually to make sure they take all their drugs and don't spread germs.
`Six months of therapy is very hard for some patients, with a shorter regimen, more people might complete therapy.'' About a third of patients drop out in the final two months of treatment, the TB alliance's Spigelman said. His group will use Gates Foundation support to begin testing four-month treatment with the Bayer drug later this year. He plans eventually to test whether other drug combinations can beat TB in three months or even two.

Saturday, 15 September 2007

Treatment of TB in Rural China

China's healthcare system has been swept up in the country's tide of capitalism, and it is the rural poor who are paying the price
The richest man in one of the poorest villages in China is the "barefoot doctor" Hua Wanxiang, who sells cigarettes, beer and antibiotics. It was an easy move. The only medical equipment he owns is a stethoscope, some tweezers and a sterilising bowl. He can now sell tobacco while referring locals to hospital for lung diseases; flog crates of beer one day and painkillers the next.
This shift from public service to market principles is entirely in keeping with the wider transformation of healthcare in China, which is now among the most market-driven in the world. Surveys suggest that health problems account for between a third and a half of all cases of destitution. The health ministry says three-quarters of the rural patients who declined to undergo recommended hospital treatment did so because they could not afford it.
A peasant saying has it that a pig must be taken to market every time an ambulance siren wails, a year's work is ruined as soon as you sleep in a hospital bed, and if you are struck with a serious disease, 10 years of savings go up in smoke. For Mo Wangfa, the cost of contracting spinal tuberculosis has been even higher. Since 1999, the farmer has spent more than 10,000 yuan on check-ups and treatment. With no support from the government and no insurance, he had to borrow most the money, much of it from loan sharks who charge 6% interest. What passes for family treasures now are his x-ray charts and medical reports, all of which cost far more than he could ever earn. He is still too sick to work his fields. "Before the illness, I was doing reasonably well. I wasn't rich, but I wasn't poor. Now I have big debts," he says. "I plan to ask my children to go the cities to find work so we can pay back the money."
Aside from compassion, doctors have few incentives to reduce costs or pursue long-term public health goals. In some areas, tuberculosis and other preventable diseases are making a comeback because vaccination programmes are under-funded. Meanwhile, the privatisation of medicine is blamed for the rampant over-prescription of drugs, which has created new strains of TB and other diseases that are resistant to antibiotics.
Sarah Boseley,,2168522,00.html

Friday, 14 September 2007

Bovine TB in Elk

Officials from Riding Mountain National Park say just three of more than a thousand elk and deer tested have bovine tuberculosis.
During the winter and spring of 2007, 128 elk were captured and blood tested as part of the park’’s surveillance and monitoring program. Three of these animals tested positive for bovine TB on culture. The animals were captured from a helicopter using a net fired from a netgun, a blood sample was taken, and then were released wearing collars for research and tracking purposes.
Manitoba Conservation, in co-operation with Parks Canada and Manitoba Agriculture, Food, and Rural Initiatives, also continued its surveillance of hunter-killed elk and deer continued during the 2006-07 hunting seasons. Approximately 950 elk and deer samples were collected from hunters and then examined at the Riding Mountain National Park lab.
None of these animals tested positive for bovine TB.

More efforts on drugs for orphan diseases

A group of leading drug researchers today announced the formation of a non-profit international institute to channel top talent and drug candidates from the world’’s leading research labs into a major, new global assault on tuberculosis (TB), malaria, and HIV/AIDS.
Founders of the International Drug Discovery Institute (iDDi) ( hope to fill a gap in commercial drug development that has left large populations in developing nations exposed to epidemic diseases with no new or affordable cures. In effect, iDDi’’s innovative model seeks to skirt barriers that have hampered the development of new therapeutic agents for scourges like malaria or TB for the past 40 years.
""Through my long career in drug discovery, I have found it incredibly frustrating that every year, millions of human beings still perish from diseases that could and should be curable,"" said Dr. Alan Kozikowski, founder and chief science officer of iDDi. ""We know that the world’’s best scientific minds –– collaborating on promising, new drug candidates –– and empowered by new machine-based screening technologies, could launch a Manhattan-style project that would wipe these diseases from the face of the earth.""
Explained John McCall, an iDDi director and former vice president of drug development at Pharmacia & Upjohn, Inc., ""iDDi is the embodiment of this new approach to drug discovery and development. We will empower an innovative network of global scientific talent to break through organizational, national, and economic barriers to deliver new drugs more expeditiously to the people who need them.""
IDDi is being formed specifically to accelerate drug discovery and development for neglected and orphan diseases, and has already begun outreach to major philanthropic foundations with similar goals.
Its founders and collaborating scientists include research luminaries, such as Scott Franzblau, Ph.D., Director of the Institute for Tuberculosis Research at the University of Illinois at Chicago; Geoff Dow, Ph.D. a malaria researcher at the U.S. Army’’s Institute at Walter Reed Army Hospital; and Paul Wender, Ph.D., of Stanford University.
In addition to its technical resources, iDDi is developing a novel operational model aimed at making practical and affordable medicines available to those in need. To this end, Mohsen Marefat of The Althing Group has been retained to head the development and management of business operations for the Institute.
To date, iDDi has been funded by donations from angel benefactors. The Institute plans to launch an aggressive fundraising campaign to attract foundation support.
About iDDi
iDDi is a non-profit institute that will accelerate and streamline drug discovery by harnessing the power of technology and the expertise of select scientists, worldwide, to identify and bring to market effective and practical therapies for diseases afflicting millions. For more information, please visit

Thursday, 13 September 2007

XDR-TB in Western Pacific Region

A top World Health Organization (WHO) official urged Asia-Pacific countries on Wednesday to step up their fight against growing outbreaks of multidrug-resistant tuberculosis.
Shigeru Omi, regional director for the Western Pacific, also called for immediate action to prevent the development of extensively drug resistant-TB or XDR-TB in the region.
"There is an urgent need to scale up the management of multidrug resistant-TB, which has emerged across the region, including the Pacific," said Omi.
The region has about a third of the global multidrug resistant-TB burden, mostly in China and the Philippines, and to some extent in Mongolia, South Korea and Vietnam, according to the WHO.
Tuberculosis of all kinds continues to be a major public health problem in the Western Pacific with an estimated 1.9 million new cases in 2005.
"The potential magnitude of the threat of multidrug-resistant TB in the region requires countries to urgently develop a response and thus prevent the development of extensively drug resistant-TB or XDR-TB," Omi said.
Omi also drew attention to "increasing concern" about HIV-related TB, saying that in the region TB is the main opportunistic infection that kills people living with HIV/AIDS.
He called for comprehensive infection control strategies to prevent the spread of TB among HIV sufferers.
The meeting heard that access to HIV treatment continues to expand in the region but significant obstacles to universal access must still be overcome.
In the Western Pacific 1.3 million people were living with HIV at the end of 2006 and almost 80,000 died of HIV/AIDS that year.
"Despite some success in scaling up prevention interventions, the epidemic continues to grow, with an estimated 167,000 new HIV infections occurring in the region in 2006," a statement said.

From Northern Canada

Members of a major health project in Nunavut are holding a ceremony on Tuesday to remember Inuit who lost their lives to tuberculosis in the 1950s and '60s.
The Nunavut Inuit Health Survey —— known as Qanuippitali?, which is Inuktitut for, "How about us, how are we?" —— is hosting a commemoration ceremony in Apex, near Iqaluit, at 2 p.m. ET. The event is expected to include a drum dance, speeches by elders, and an unveiling of a plaque.
During the project, 40 doctors, nurses, lab technicians and interpreters, along with 40 coast guard personnel, have been travelling to 19 coastal communities around the territory in August and September aboard a "floating health lab" on the icebreaker Amundsen.
They bring Inuit on board the Amundsen for three-hour medical appointments. Randomly selected participants are asked fill out questionnaires and undergo medical tests for diseases such as diabetes and stroke.
Survey lead Prof. Dr. Grace Egeland of McGill University said the project raised memories of the C.D. Howe medical ship in the 1950s, which gathered about 1,600 Inuit tuberculosis patients and transported them to sanatoriums in southern Canada. Many of those patients never returned.
"As we were planning this survey using the ship, the memories of C.D. Howe have come back to people in communities," Egeland told CBC News on Monday. "There's been no closure, no healing, no group ceremony where we can collectively come together to recognize the loss and the tragedy and the suffering of families."
Egeland said she hopes Tuesday's event will emphasize a positive change in working relationships with Inuit.

More on XDR-TB and Andrew Speaker

At the request of Committee on Homeland Security Chairman Bennie G. Thompson (D-MS), the Majority Staff of the Committee on Homeland Security published a comprehensive report which analyzes the federal government's trouble with handling an XDR-TB case and the government's ability to manage incidents like it.
The report concludes that many of the problems associated with the conducting of the case have still not been resolved.
Specifically, the report looks into the interactions between the Department of Homeland Security and the Centers for Disease Control and Prevention (CDC) regarding public health security issues, while identifying weaknesses in homeland security processes designed to prevent "persons of interest" from entering the United States and making recommendations for improvements to the federal handling of national security on the nation's home soil.
"This was a real world incident, and there was a breakdown at the intersection of homeland security and public health. The government has numerous plans and policies in place to secure our communities, but they just didn't follow the playbook. This certainly raises questions about our homeland security if the government had this much trouble countering TB, let alone countering terrorism," said Thompson.
The case in question centers on a 31-year-old American Lawyer named Andrew Speaker.
Speaker learned he had tuberculosis, or TB, in January of this year. In May, his doctors realized that he had XDR-TB, which is a fiercely drug-resistant strain of the illness. He was permitted to board a commercial flight to Paris on May the 12th , and returned from Europe 12 days later on a flight into Canada from Prague in the Czech Republic.
Speaker said that he had begun feeling better by the time of his flight and never realized he had something in his body that could infect or harm anyone else.
His doctors told Speaker not to travel, but Speaker maintains that while the Centers for Disease Control and Prevention as well as other health organizations advised him against travel, they did nothing to stop him and did not describe to him in detail what he was carrying.
XDR-TB is "extensively drug-resistant tuberculosis". One in three people in the world is infected with dormant TB germs (bacteria). The bacteria have to become active before people become ill with TB.
The bacteria become active as a result of anything that can reduce a person's immunity, such as HIV, aging into advanced years, or certain pre-existing medical conditions. TB can typically be treated with a course of four standard or "first-line" anti-TB drugs However, multidrug-resistant tuberculosis (MDR-TB) takes longer to treat and demands the use of second-line drugs, which are more expensive and have more side-effects than first-line drugs. If drugs get misused or misapplied in treating TB, then XDR-TB can develop.
Due to the fact that XDR-TB is resistant to first- and second-line drugs, treatment options are severely limited, and a person with the illness has to be strictly managed to prevent the spread of the potentially fatal illness.

Tuesday, 11 September 2007

Tuberculosis in Africa -- incomplete data

The World Health Organisation said lack of regional data for Tuberculosis (TB) prevalence in Africa is hampering the monitoring and evaluation of TB control programmes there and was hampering health officials in efforts to estimate the disease prevalence, unlike HIV, which has regional records to facilitate planning to control the spread of the pandemic.
Some 590,000 Africans die from Tuberculosis annually, this is 35% of the world total. Africans living with TB are estimated to be around 4 million.
Despite the significant progress by member states in the implementing of the Direct Observed Therapy Short (DOTS) course, TB remained the most important communicable disease in the Region. Other challenges faced by the region to control TB were low or non-participation of the private sector, limited laboratory facilities for diagnosis, human resource capacity, slow country TB/HIV implementation and the expansion of community and civil society Organizations involvement.
Outlining some strategic ways to address the challenges, WHO African Regional Office suggested pragmatic actions to accelerate population DOTS coverage to increase case detection, reduce patient default to improve treatment success rates and strengthening health systems for TB laboratory networks as well as mobilising additional resources for TB. WHO Africa Regional Office would ensure the reduction of the gap created between policy and implementation, advocate for correct approach to programme implementation, undertake special studies on TB prevalence and DOTS implementation and make available simple treatment guidelines and charts. These strategies would help to achieve the global target of stopping TB by at least 70 per cent case detection rate and 85 per cent treatment success rate among new cases by 2015.

Tuberculosis in Central Asia Prisons

In the majority of Central Asia's prisons and colonies, inmate access to even basic medical care is severely limited. Rights activists and former convicts say sick prisoners often get only one-half or even one-quarter of a pain-relief tablet, regardless of what illness they have. Prison facilities are considered the epidemiological pump behind the high rate of infectious diseases there.
The rates of HIV/AIDS and tuberculosis (TB) are high among inmates. The Brussels-based International Crisis Group reported last year that cases of TB among prisoners has more than doubled in Kazakhstan, tripled in Uzbekistan, and increased fivefold in Tajikistan since 1990.
In Kyrgyzstan, the rates of TB among prison inmates are said to be 40 times higher than in the general population and mortality rates are some 60 times higher, the ICG reported.
In response to this alarming situation, Kyrgyz authorities seem to be taking steps to address the problem. Observers have said that TB -- particularly its drug-resistant strains -- is rampant, two of the three prisons for men that have TB hospitals in Kyrgyzstan. (The women's and juveniles' colonies also house TB treatment centers.)
Kyrgyz authorities have demonstrated commitment and maturity in dealing with contagious diseases in the penal system. "Like all other prisons in this region, the situation [in Kyrgyz prisons] and the conditions of sick [convicts] are very bad, however, Kyrgyzstan does much more compared to other countries of the region in order to reduce the threat of the penitentiary system as a source of tuberculosis and HIV/AIDS."
Kyrgyzstan was the first country in Central Asia to receive the Global Fund's financial aid to start treatment of people with multidrug-resistant tuberculosis.
Central Asian countries are situated on a transit route of narcotics from Afghanistan to Russia and on to Europe. All of them, including Kyrgyzstan, have seen a sharp increase in the number of drug addicts -- particularly heroin users -- in recent years. The trend has led to the rise of HIV/AIDS among the general population, as well as in prisons.
"Yesterday, when we visited it, there were 52 people in a place suited for only 30 people. Their conditions were hard. There was neither fresh air, nor natural light [in the cells]. Food was provided for 30 people; the other 22 people did not receive any."
In general, convicts lack basic medical care as well. Specialized services, like oncological, gynecological, mental, and dental services are virtually unavailable in most prisons in the region. Nutritious food -- a key in treating TB -- is also in very short supply.
Furthermore, prisoners who receive treatment for TB in prisons and who require further therapy do not receive follow-up care. Thus, they are likely to spread TB among the general population after their release from prison.

Monday, 10 September 2007

Memories of Sanatorium life in Wales

The exhibition has been organised by a former patient at the Adelina Patti Hospital in the Swansea Valley, better known as Craig-y-nos Castle, it housed TB patients from 1922-59.
Craig-y-nos Castle was the estate of the world-renowned opera singer Adelina Patti until her death in 1919.
Two years later, it was bought by an organisation founded to combat TB in Wales and was reconstructed as a sanatorium before admitting its first patients in August 1922.
The exhibition is part of an oral history project supported by the Heritage Lottery Fund and the Sleeping Giant Foundation charity.
"It will be the first ever collective account by patients and staff of life inside a tuberculosis sanatorium and is therefore a unique heritage project."
"The time period, from the 1920s to the 1950s, is also crucial because of the tremendous activity by medical professionals and other groups to understand the nature of tuberculosis.
"The real treatment breakthrough came in 1947 when the first effective medicine, an antibiotic called streptomycin, became available in Britain. The children of Craig-y-nos were among the first to receive this new 'wonder' drug. "

Failure of follow-up in Taiwan -- Is it any better in America?

A doctor with the Department of Health's Chest Hospital in Taipei warned on Wednesday that the country's efforts to battle tuberculosis have a weak link because 90 percent of those in close contact with TB patients are not thoroughly tested. He said new regulations on TB control that took effect in June require anyone who has been in contact with an infectious TB patient for eight hours in a single day to be tested for infection. Between August 2005 and July, there were 1,069 people who required such testing. However, after having an initial chest X-ray taken, 969 never returned for a second check-up. Only 89 had a second chest X-ray taken within the next year, while just 11 returned for a third test.
The bacteria that causes TB can remain dormant for many years, and that those who are infected have a 10 percent to 20 percent chance of developing the disease, while half of these will become symptomatic within five years.
TB is the most prevalent communicable disease in Taiwan. Approximately 15,000 persons are infected every year.
Statistics show that there were 24,161 people with TB in 2004, including 16,784 new cases, an incidence rate of 74.11 per 100,000 people. About 92.3 percent of the cases were pulmonary TB. That year 957 people died of the disease.

Nepalese student dies of TB in Colorado

Local health department officials are urging Colorado State University-Pueblo students and staff who had close contact with a student who died of tuberculosis in June to be tested again for the communicable disease. The follow-up TB test is only for those individuals who have been identified as having close contact with the victim and who tested negative on the first test administered in late June.
On June 8, CSU-Pueblo international student Kalpana Dangol died of tuberculosis at Memorial Hospital in Colorado Springs. Dangol, a native of Nepal, attended CSU-Pueblo for three semesters, including spring 2007. She never lived on campus and at the time of her death, she was living with her sister in Colorado Springs.
In late June, the Pueblo and El Paso county health departments hosted free TB clinics for the 160 individuals who were identified as having close contact with Dangol. The first clinic was well-attended but those needing the follow-up test have not responded as health officials would like them to. Enough time has passed that if an individual is carrying TB, a test now will show a positive result. "If it shows positive, that doesn't necessarily mean that you have active TB but that you may have been exposed to someone with active TB, a positive result does not necessarily mean a person is contagious, but would indicate the need for further testing and precautionary treatment."
"These services are all free of charge and it's so important, not only for your health but also for your peace of mind."

Tuberculosis control in the Philippines

The Philippine Government is doubling its tuberculosis control budget to P280 million next year to combat a resurgent disease which is said to infect six in ten Filipinos and claims one life every 20 minutes in the country. 100-percent hike in funds of the Department of Health TB Control Program this year which is P139 million has been included in the proposed national budget. This would allow the government to procure more anti-TB drugs, which are mainly administered to patients through the proven Directly-Observed Treatment Short Course (DOTS).
The Provincial Health Office here has taken a more vigorous approach to combat tuberculosis, like early detection through sputum examination, laboratory and x-ray services.
The Multi-Drug-Resistant (MDR) cases are also covered by the program (DOTS). These are TB cases that despite the medication, patients when subjected to sputum examination were still found to be positive of the disease.
More attention would be given to this category as these were described to be expensive to treat or cure, very contagious and noted to be responsible for spreading TB resistant bacilli. TB cases of this nature qualify for referral to Makati Tropical Disease Foundation Clinic, so patients could be subjected to thorough medication, but the process entails enormous amount of money, a longer period of treatment as Out-Patient.

Tuberculosis in Zaire province of Northern Angola

Health authorities in the northern Zaire Province recorded at least 766 cases of tuberculosis in the first semester of this year, including three deaths caused by that disease.
According to an official, in comparison to the second semester of last year there was a decrease of 50 TB cases, with the most affected age group being those between 24 to 45 years old. As factors that contribute to the high number of TB cases in the province, he pointed out the poor social conditions of many families and the excessive use of alcoholic drinks.

Control of neonatal tuberculosis in Africa

The call to action in Prevention of Mother to Child Transmission (PMTCT) aims to reduce the risk of mother to child transmission of HIV through integrated HIV/Aids education, routine counselling and testing as well as administration of a prophylaxis single dose Nevirapine therapy to mother and infant.
It goes without saying then, that the need to protect infants or the unborn from the possibility of contracting Tuberculosis, including the Multi-Drug Resistant (MDR) and Extremely Drug Resistant (XDR) TB, which is closely linked to the HIV epidemic, becomes of paramount importance.
During the last decade, there has been an increase of TB infections as an opportunistic infection in people with HIV because of their weakened immune systems. This is causing concern in the light of MDR and XDR-TB surfacing because interventions such as the prevention of mother to child transmission of HIV may be challenged where the mother is living with HIV and found with Tuberculosis.
Communications Officer of National TB Control Programme, Henry Chimbali, told Health Check that most healthy people do not get TB unless they are in very close contact with people infected with Tuberculosis as it is spread through droplets in the air.
"The infection of XDR-TB is transmitted the same as the standard TB and could be prevented the same way ordinary Tuberculosis is prevented," Chimbali said.
The international medical humanitarian organisation, Medicines Sans Frontieres (MSF) is quoted by Health Check calling for approaches and new tools to treat multi-drug resistant (MDR) Tuberculosis in Southern Africa.
"MDR, and now XDR-TB, are the tip of an iceberg of failing strategies to control TB," said Dr.. Eric Goemaere of MSF "We desperately need new tools and new approaches and we need them now - we cannot just sit and wait. Despite all the international fanfare created by XDR, efforts to treat drug resistant TB in high HIV prevalence settings are moving at a snail's pace and investments to develop new drugs and diagnostics to improve management of all forms of TB are terribly inadequate. This situation is unacceptable."
Chimbali told Health Check, however, that any development of TB could be averted if regular TB is treated effectively and if Malawi succeeded in controlling the XDR-TB transmission, then the risk of infection would not be there.
Country Director for UNC Project at Kamuzu Central Hospital, Dr.. Francis Martinson, says there is need for a prophylaxis regimen to protect mother/infant pairs from tuberculosis just as there is a Nevirapine dose to facilitate the prevention of mother to child transmission of HIV.
In this regard, University of Northern Carolina (UNC) Project has embarked on a randomized, placebo-controlled trial to determine the efficacy of Isoniazid (INH), a component drug in the combination of TB treatment in preventing Tuberculosis disease and latent TB infection among South African infants with peri-natal exposure to HIV.
Dr. Martinson told Health Check that the trial would have an initial sample size of 1,300 study participants consisting of 500 infected and 800 uninfected exposed study participants.
"The objective of the trial aims to determine whether INH prophylaxis increases TB disease survival for HIV infected participants; to determine whether INH prophylaxis increases TB infection-free survival for peri-natal-exposed HIV uninfected study participants," said Dr.. Martinson.
"Among both peri-natal-exposed HIV infected and HIV uninfected study participants we are also trying to assess the toxicity and safety of INH prophylaxis."
The fact that once one is HIV positive and having Tuberculosis, one is automatically placed on antiretroviral therapy, puts the mother/infant pair at risk of not accessing medical care if they infect one another and do not get diagnosed in time.