TB is Common and Uncommonly Hard to Treat The isolation ward appeared to be empty.

But then a nurse emerged from one of the patient rooms, turned her masked face in our direction and waved. A few of us on the other side of the flimsy glass and wood doors waved back. In the U.S., the nurse probably would have been wearing a N95 respirator, latex gloves and a disposable gown. The quarantine doors would have been airtight and the ward’s air pressure would have been less than the surrounding building pressure in order to keep airborne germs from escaping. But the 800-bed tuberculosis clinic outside of Riga, Latvia was not built or budgeted for the types of cases they now have to treat. Our visit over, my colleagues and I stood in the parking lot breathing in the cool October air and wondering about a common menace that seems to be uncommonly deadly in many parts of the world. Tuberculosis is an ancient disease. In fact, it may be older than modern-day humans. A recent genetic analysis of the bacterium Mycobacterium tuberculosis suggests this respiratory pathogen may have existed among East African hominoids three million years ago. Much later, Egyptian pharaohs contracted it. Later still, it burned through centuries of urban slum dwellers, earning names like “the white plague” and “consumption.” By the late 19th century, TB killed one out of every seven people in the U.S. and Europe. Yet, as the next century rolled around, rates of tuberculosis began to decline in the West. Better food, better housing, better education, and better public health services probably helped to reduce the number of new cases, and post-war antibiotics quickly finished off the rest. Everyone soon forgot about the white plague. Then AIDS appeared.

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The AIDS virus targeted cells of the immune system, breaching the defensive walls that separated us from the microbial horde. A variety of unusual, or “opportunistic,” pathogens quickly entered the breach. One of them was the TB bug. Beginning in the late 1980’s, New York City had a TB epidemic. Infection rates tripled over 15 years and many area hospitals experienced outbreaks of hard to treat cases caused by multidrug-resistant TB (MDR-TB). The TB resurgence seemed to catch public health officials completely off guard. Evidently, they had forgotten that one third of the world is infected (“colonized” might be a better word) with latent TB, and that a crippled immune system will allow latent TB to become active, infectious TB. A TB epidemic in New York was bad enough, but the real problem was the emergence of MDR-TB. There are only a handful of antibiotics to treat TB. Most of those drugs are more than 40 years old and need to be taken ‘religiously’ for six to nine months. What if TB strains emerged that were resistant to all of the standard TB drugs? That happened in a very dramatic fashion earlier this year when an outbreak killed 52 AIDS patients in Kwazulu-Natal district in South Africa. The outbreak was caused by a strain of extremely drug-resistant TB (XDR-TB). XDR-TB is defined by the World Health Organization as TB that is resistant to two standard TB drugs (rifampicin and isoniazid); a fluroquinolone; and one or more of the common injectable drugs. That kind of resistance doesn’t leave doctors with many treatment choices. XDR-TB also is beginning to appear in Europe, particularly in some of the old Soviet republics. The Baltic countries (Estonia, Latvia, and Lithuania), for example, already had high rates of MDR-TB. A recent survey of strains in Latvia found 19% of the

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strains were XDR-TB. That’s not good news for Latvians, the Europe Union, or anyone else because bugs travel. More effective TB drugs are needed, but they are being tested and licensed at about the same speed as TB’s growth rate in a test tube: very, very slow. There is a vaccine for TB, but it is about a hundred years old and not particularly effective. The vaccine is used widely in Europe and India, but it makes the standard TB diagnostic skin test useless. This is one reason why the U.S. does not use the vaccine. Efforts are underway to produce more effective vaccines, but the research is difficult. In 2005, three researchers in Seattle infected guinea pigs—and themselves—with TB while working on a new vaccine. Maybe they should have held their breaths. Maybe that’s what we should have done in that Latvian TB clinic. Maybe it’s time I got another TB skin test.

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