Resistant TB strains spreading from Russia Attempts at control make disease deadlier

September 14, 1998|By Will Englund | Will Englund,SUN FOREIGN STAFF

MOSCOW -- Strains of tuberculosis that resist ordinary treatment, nurtured in Russia's crowded prison system, are reaching epidemic proportions, and Russian and Western efforts combat the disease here are making the problem worse, a panel of doctors said last week.

Millions of people are at risk, and the disease won't stop at Russia's borders. It is already spreading quickly into the general population as infected prisoners are released.

"And those people get on planes, they go to Moscow, they go to Baltimore, and it spreads even farther," said Dr. Lee B. Reichman, director of the U.S. National Tuberculosis Center.

Already, tuberculosis has been moving westward from Russia into Europe. Now the new resistant -- and therefore deadlier -- strains pose a threat that could, the doctors say, get out of hand in two years or less.

"A time bomb waiting to go off? It already went off," said Dr. Paul Farmer, a Harvard Medical School expert in what is called multidrug-resistant tuberculosis.

Reichman and Farmer were among a group of specialists who spent last week visiting prisons and tuberculosis treatment centers in Siberia. They came away impressed by the dedication of local health care workers but shaken by the extent to which resistant strains have taken hold.

"It's extraordinarily scary," said Reichman.

Resistant forms of tuberculosis are difficult and expensive to cure. But as Russia falls deeper into economic collapse, resistant strains have mushroomed because of the fitful and erratic care that patients receive.

Even in pilot programs run by Western organizations, which provide more thorough treatment, an indiscriminate use of "first-line" drugs against tuberculosis has helped give rise to resistant bacteria.

At least 20,000 Russian inmates have contracted multidrug-resistant strains; there were 15,000 new cases in the civilian population last year.

Each person with the disease can be expected to infect 10 to 12 others within a year, Farmer said. That's a minimum of 3.5 million people infected within the next two years. Without proper treatment, they will all die.

"This is probably the worst situation for multidrug-resistant tuberculosis ever documented in the world," said Dr. Richard O'Brien of the Centers for Disease Control and Prevention.

The three Western medical organizations that have been providing tuberculosis treatments at Russian prisons -- the Public Health Research Institute, Doctors Without Borders, and Medical Emergencies Relief International -- issued a joint appeal Friday for $100 million in foreign donations to provide the drugs and lab equipment needed to fight resistant tuberculosis


"If we wait a year or two more, not even the richest country in the world would be able to cope with this situation," said Dr. Malgosia Grzemska, of the U.N. World Health Organization.

Since the fall of the Soviet Union in 1991, Russia has seen an alarming rise in tuberculosis, with the health care system in disarray and poor nutrition a growing problem. The health ministry reports 3 million cases nationwide.

In the United States, by contrast, the CDC reported 19,855 cases in 1997. Multidrug-resistant strains accounted for 1.3 percent of those. Tuberculosis is a bacterial infection that most commonly lodges in the lungs, where it forms lesions. It is easily spread to others by coughing.

For several years, the argument was whether to follow traditional Russian treatments, which can involve lengthy hospitalization, or use a Western regimen called "direct observed therapy short-course," or DOTS, which involves giving infected persons modern antibiotics daily while a medical worker watches to make sure there is no backsliding.

At five prisons and surrounding communities, the Western agencies established DOTS programs, along with nutritional support. Death rates went down, but people weren't being cured. And cases of tuberculosis that resisted the drugs are going up.

In essence, the antibiotics killed off the easily susceptible bacteria, leaving a clear field for resistant strains to prosper.

"The patients with multidrug-resistant tuberculosis are getting the standard DOTS regime, which will not cure them," O'Brien said.

The Western agencies organized last week's tour of experts. They have agreed that they need to change their treatment plans so as to fight resistant tuberculosis rather than inadvertently encouraging it.

About 10 percent of the patients come already infected by resistant tuberculosis, said Dr. Alexander Goldfarb of the Public Health Research Institute. Another 5 percent to 10 percent, infected with strains that are somewhat resistant, develop a fully resistant tuberculosis because of the treatment.

But these pilot programs account for only a small proportion of inmates.

"The rest of the penal system is engaged in a massive program of creating multidrug resistance," Goldfarb said

Russian prisons are horribly overcrowded and nutrition is atrocious. They are perfect breeding grounds for tuberculosis.

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