Tuberculosis, or TB, a pestilence thought by many to be a relic of a bygone era, is once again a threat to public health, particularly in the former Soviet Union, where experts fear it could overwhelm increasingly overburdened health care systems. However, there is hope for a reversal, as correspondent K.P. Foley reports in this special edition of the RFE/RL Health Report.
Washington, 1 February 2001 (RFE/RL) -- Just two decades ago, Tuberculosis (TB) was another disease that modern medicine believed it had conquered, but the United Nations reports that the "white pestilence," as TB is sometimes called, is once again an epidemic -- especially in Eastern Europe and the former Soviet Union.
The UN's World Health Organization (WHO) says tuberculosis kills two million people every year. The WHO says the epidemic is growing and becoming more dangerous each year.
In the 51 countries that make up WHO's European Region -- which includes the Caucasus and Central Asia -- experts say TB is spreading at an alarming rate. Eva Nathanson, a TB specialist at the WHO's Copenhagen office, says that most of the 370,000 new TB cases reported in the European Region in 1999 occurred in Central and Eastern Europe and the former Soviet republics.
"In most countries of the former Soviet Union, TB has doubled, and more than doubled in ten years. So we see a sharp increase in the epidemic in these countries."
She told RFE/RL that within the former Soviet Union, the greatest numbers of new cases are reported in the Central Asian states. However, she said Russia and Ukraine have also seen dramatic increases in numbers of new cases of TB since the collapse of the Soviet Union in 1991.
Tuberculosis is an infection caused by a bacterium called "Mycobacterium tuberculosis." The disease is transmitted through the air. It primarily affects the lungs but other organs and tissues may be infected. A person who is infected spreads the germs by coughing and sneezing, or even by laughing and singing.
The American Lung Association (ALA) says repeated exposures to a TB-infected person are usually necessary for another person to become infected.
There are two classifications for tuberculosis: latent TB infection and active TB disease. For example, the ALA says millions of people harbor the bacterium, but they are not sick. In the United States alone, an estimated 10 million to 15 million people are carrying the TB germ.
Nathanson said that throughout the world, the percentage of people carrying the germ is much higher.
"One third of the world's population do have a latent infection but only ten percent of those cases will develop active TB during their lifetime."
A person with latent TB infection does not show any signs of illness and cannot infect another person, but that person carrying the germ could develop TB disease later on.
According to the WHO, the most important factor that determines whether latent TB infection will lead to active disease is the condition of the person's immune system -- the body's natural protection against infections. Nathanson says the people most at risk for developing active TB disease are the malnourished, the very young or the aged and people infected with the Human Immune Deficiency Virus (HIV), the infection that can lead to the development of the fatal condition known as AIDS.
Those with active TB disease feel sick or weak or very tired. They cough frequently and develop fevers or sweat profusely while sleeping. Weight loss is also a symptom. If the infection is in the lungs or throat, it can be more easily spread by the droplets coughed or sneezed into the air by the victim.
Nathanson says many factors have contributed to the TB epidemic in the former Soviet Union.
"Since tuberculosis is a disease of poverty, the major cause of this alarming increase is, of course, the socio-economic instability and the problems this region has had since the collapse of the Soviet Union." She said alcoholism and homelessness are also influential factors in the spread of TB. She said TB also flourishes where there is armed conflict -- Nathanson cited Tajikistan and the northern Caucasus as examples. The movement of large numbers of refugees also gives rise to problems with TB, she said.
TB is also a particular problem in prisons, Nathanson said.
"In Russia and in Ukraine one-third of all TB patients are in prisons. So the prisons are really a breeding ground for TB."
While there is a strong connection between TB and HIV, Nathanson said that for the moment, there is not a serious problem with HIV and TB in the former Soviet Union.
"TB is actually the main cause of death among HIV-positive people in the world, but luckily we do not have a TB-HIV co-epidemic in the region right now."
She said that could change because of the concurrent rise in HIV infections, especially among intravenous drug users in Russia, Belarus and Ukraine.
According to WHO European Region statistics, it would appear that, in general, the farther east a person travels in Europe, the worse the TB problem becomes.
The rate of development of a disease is expressed by the term 'incidence.' Incidence refers to the number of new cases of a disease, such as TB, within a population over a certain time period, such as a calendar year.
For example, Britain, which has a population of 58.2 million, reported 5,658 new cases of TB in 1998, for an incidence rate of 9.7 cases for every 100,000 people. In Holland, where the population is 15.7 million, the case rate was 7.7 per 100,000. In the Czech Republic, where the population totals 10.2 million, the case rate in 1998 -- the most recent year for published statistics -- was 17.2 per 100,000.
In Russia the figure was 82.5 new cases for every 100,000 people. In Ukraine the number was 61 per 100,000. Georgia reported 89.8 new cases per 100,000, while Azerbaijan reported 60.6 per 100,000. In Kazakhstan, the figure for 1998 was 122 per 100,000 and in Kyrgyzstan the number was 126.9 per 100,000. The case rate in Turkmenistan was 88.9 per 100,000.
There are exceptions. In Armenia, for example, the new case rate at the end of 1998 was 37.9 per 100,000. Nathanson attributed that to an aggressive and effective TB control program run by the Health Ministry and backed by the highest levels of government.
Without political will, she said, TB control efforts are doomed to fail.
The World Health Organization cites other causes for the rise in TB cases in the former Soviet republics and in Eastern and Central Europe. The WHO says poorly managed, under-financed and outdated control practices are common in most countries with high rates of new TB cases.
The agency also says that a lack of anti-TB drugs plus the use of treatments not up to international standards has led to rising levels of strains of TB that are resistant to drug therapy.
According to the WHO, 50 percent of the people who develop active TB disease will die within five years if they are not treated. Another 25 percent will remain ill with chronic, infectious TB, and 25 percent will regain their health on their own.
International agencies stress that curing TB is the best way to control its spread. The WHO and the International Union Against Tuberculosis and Lung Disease -- a non-profit foundation based in Paris -- and other groups have been recommending a TB control method known by its acronym DOTS. That stands for "directly observed treatment - short course."
In the DOTS method, patients with active TB disease take three, and sometimes four, medications to eradicate the TB bacteria. The key to the treatment lies in having the patient complete the entire course of treatment, usually six months, under the supervision of a health care worker. The supervision ensures that the patient takes all the necessary drugs for the requisite length of time.
One of the drawbacks to this method has been the number of pills required. Patients have had to swallow up to 14 pills a day. If patients do not complete the treatment, there is a real danger that the TB bacterium will become resistant to the anti-biotics and that this resistant strain will be spread.
Richard Laing, a TB specialist at Boston University in the northeastern U.S., told RFE/RL that the quantity of pills that must be taken has been a barrier to completion of the treatment for some.
"It's very difficult for people to keep taking drugs for eight months, particularly as they feel much, much better after about two weeks."
However, Laing and several of his colleagues have written in international journals that it is possible to drastically reduce the number of pills necessary to cure the disease.
In an article that Laing and several colleagues co-authored for this month's edition of the WHO Bulletin, this group of experts recommended adoption of what they call Fixed Dose Combinations for use in the DOTS regimen. This treatment substitutes one or two drug combinations in a single pill for the multiple pills.
The experts researched the benefits and disadvantages of the fixed dose method, which has been available for a number of years and which is in use in about 40 countries around the world. The doctors recommend adoption of the fixed dose method in all countries, particularly in countries with high rates of TB.
In an interview, Laing said the fixed dose method offers clear advantages for health ministries.
"The major benefits in going with this Fixed Dose Combination is convenience and simplicity."
He said that instead of taking anywhere from 8-14 tablets a day, patients need only four or five combinations. Laing stressed that the treatment would still have to be observed in order for it to be effective.
One of the major drawbacks to the fixed dose method, he said, is cost. Drug prices vary widely from country to country, he said. Laing believes that a price of between $20-$30 per patient for a six-month treatment program is a target most countries might be able to reach.
He said there is hope that fixed drug combination tablets will be more widely available in the near future. Laing said international drug prices have fallen, and he said the World Bank is making funds available to health ministries to help them strengthen their TB control programs.
(TB statistics and country profiles compiled by the WHO are available at the website http://cisid.who.dk/tb )