With no medicine on hand, a father and his infant who have just been diagnosed with multidrug-resistant tuberculosis go untreated, the delay prolonging their recoveries as well as the time they will remain infectious. The delay adds to the risk that they will get sicker and resistant to more drugs, increases the odds that those around them will get sick too with an illness that won’t respond to medicine, and is especially life-theatening to the child, who also could suffer permanent brain damage without immediate treatment.
It sounds like, and is, something that happens daily in resource-poor countries, where efforts to control the ancient disease struggle with burgeoning drug-resistant epidemics that are the outcomes of long neglect.
But the particular example above comes from an article this week from the Centers for Disease Control and Prevention on “Interruptions in Supplies of Second-Line Antituberculosis Drugs — United States, 2005-2012” detaling the results of surveys of local, state and territorial health departments in this country.
According to the article, in this week’s Morbidity and Mortality Weekly Report, the 26 health departments handling about 75 percent of the United States tuberculosis caseload have confronted multidrug-resistant tuberculosis, with 21 of those departments — more than 80 percent — facing obstacles to getting the medicine necessary to treat it. According to the survey, 19 — or 90 percent — of those departments reported “adverse outcomes or other problems” resulting from those obstacles — including treatment delays, interruptions, or incomplete regimens. The report notes the consequences of those failures on communities — sicker patients, increased drug resistance, longer periods of infectiousness and increased transmission of drug-resistant tuberculosis. It also describes the toll on health systems, including drug rationing, higher costs, overburdened staff, and errors.
And as in neglected tuberculosis outbreaks anywhere, shortages of appropriate treatment here clear a path for for the challenges to worsen, as Coco Jervis, senior policy advisor for Treatment Action Group (TAG) told Science Speaks.
“TB state and local programs are under incredible stress,” Jervis said. “It is setting the stage for resurgence.”
TAG, along with PATH, RESULTS, American Thoracic Society and the Center for Global Health Policy, which produces this blog, will hold a meeting Friday to discuss the problem of U.S. and global TB drug shortages with congressional and organizational advocates, state tuberculosis controllers, federal agency officials, and industry representatives. It will be the first in a series of meetings, Jervis said.
While the immediate causes of tuberculosis drug shortages in United States differ from the causes of drug shortages in resource poor settings where disease burdens are higher, the origins and consequences end up being similar, Erica Lessem assistant director of TAG’s TB/HIV Project told Science Speaks. While fragile health care infrastructures struggle to keep up with the demands of tuberculosis epidemics overseas, one problem here, she says can be described as “low incidence paradox.” Here, the perception that tuberculosis incidence is under control leads to its own vicious circle with uncoordinated and ultimately an inaccurate assessment of disease burden.
“We can’t let TB get so far off the radar that we end up where we were in the early 90s,” Lessem said. She was referring to New York, where after tuberculosis incidence dropped sharply in the middle of the century, resources to care for patients and ensure they were able to complete treatment dropped too. Then, between 1978 and 1992 the number of tuberculosis patients nearly tripled, and the numbers of patients who did not respond to first-line treatment doubled.
In the end, she points out, treatment shortages are at least partly driven by the same issues: “Demand isn’t appropriately pooled, and we don’t have accurate surveillance.”
The result also is the same, Lessem notes.
“The fewer resources we invest in TB now, the greater the problem is going to be later on,” she says. “It’s going to be much more expensive later on.”