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Over the past 48 hours, news has broken in India of the existence of at least 12 patients infected with tuberculosis that has become resistant to all the drugs used against the disease. Physicians in Mumbai are calling the strain TDR, for Totally Drug-Resistant. In other words, it is untreatable as far as they know.

News of some of the cases was published Dec. 21 in an ahead-of-print letter to the journal Clinical Infectious Diseases, which just about everyone missed, including me. (But not, thankfully, the hyper-alert global-health blogger Crawford Kilian, to whom I hat-tip.) That letter describes the discovery and treatment of four cases of TDR-TB since last October. On Saturday, the Times of India disclosed that there are actually 12 known cases just in one hospital, the P. D. Hinduja National Hospital and Medical Research Centre; in the article, Hinduja’s Dr. Amita Athawale admits, “The cases we clinically isolate are just the tip of the iceberg.” And as a followup, the Hindustan Times reported yesterday that most hospitals in the city — by extension, most Indian cities — don’t have the facilities to identify the TDR strain, making it more likely that unrecognized cases can go on to infect others.

Why this is bad news: TB is already one of the world’s worst killers, up there with malaria and HIV/AIDS, accounting for 9.4 million cases and 1.7 million deaths in 2009, according to the WHO. At the best of times, TB treatment is difficult, requiring at least 6 months of pill combinations that have unpleasant side effects and must be taken long after the patient begins to feel well.

Because of the mismatch between treatment and symptoms, people often don’t take their full course of drugs — and from that (and some other factors I’ll talk about in a minute) we get multi-drug resistant and extensively drug-resistant, MDR and XDR, TB. MDR is resistant to the first-choice drugs, requiring that patients instead be treated with a larger cocktail of “second-line” agents, which are less effective, have more side effects, and take much longer to effect a cure, sometimes 2 years or more. XDR is resistant to the three first-line drugs and several of the nine or so drugs usually recognized as being second choice.

As of last spring, according to the WHO, there were about 440,000 cases of MDR-TB per year, accounting for 150,000 deaths, and 25,000 cases of XDR. At the time, the WHO predicted there would be 2 million MDR or XDR cases in the word by 2012.

That was before TDR-TB.

The first cases, as it turns out, were not these Indian ones, but an equally under-reported cluster of 15 patients in Iran in 2009. They were embedded in a larger outbreak of 146 cases of MDR-TB, and what most worried the physicians who saw them was that the drug resistance was occurring in immigrants and cross-border migrants as well as Iranians: Half of the patients were Iranian, and the rest Afghan, Azerbaijani and Iraqi. The Iranian team raised the possibility at the time that rates of TDR were higher than they knew, especially in border areas where there would be little diagnostic capacity or even basic medical care.

The Indian cases disclosed before Christmas demonstrate what happens when TB patients don’t get good medical care. The letter to CID describes the course of four of the 12 patients; all four saw two to four doctors during their illness, and at least three got multiple, partial courses of the wrong antibiotics. The authors say this is not unusual:

The vast majority of these unfortunate patients seek care from private physicians in a desperate attempt to find a cure for their tuberculosis. This sector of private-sector physicians in India is among the largest in the world and these physicians are unregulated both in terms of prescribing practice and qualifications. A study that we conducted in Mumbai showed that only 5 of 106 private practitioners practicing in a crowded area called Dharavi could prescribe a correct prescription for a hypothetical patient with MDR tuberculosis. The majority of prescriptions were inappropriate and would only have served to further amplify resistance, converting MDR tuberculosis to XDR tuberculosis and TDR tuberculosis.

As their comment suggests, the other TB challenge is diagnosis, especially of resistant strains, and here again the news is not good. The WHO said last spring that only two-thirds of countries with resistant TB epidemics have the lab capacity to detect the resistant strains. As a result, only one MDR patient out of every 10 even gets into treatment, and when they do, cure rates range from 82 percent down to 25 percent. That’s for MDR. None of the TDR patients have been recorded cured, and at least one of the known Indian patients has died.

Meanwhile, health authorities estimate that one patient with active TB can infect up to 15 others. And thus resistant TB spreads: XDR-TB was first identified just in 2006, and it has since been found in 69 countries around the world.

(Source: Wired)

A man in southern China has died of bird flu a week after being admitted to hospital with a fever, state media reports.

The 39-year-old bus driver from Guangdong province contracted the first human case of bird flu in China in 18 months.

The man from Shenzhen, just across the border from Hong Kong, developed symptoms last week and was admitted to a hospital on Christmas Day because of severe pneumonia, the official Xinhua news agency said.

The report added the man died in the early afternoon on Saturday (local time), after having tested positive for the H5N1 virus.

Guangdong’s official newspaper, the Southern Daily, said 120 people who had contact with the man had developed no signs of sickness.

About 10 days ago Hong Kong culled 17,000 chickens at a wholesale poultry market and suspended all imports of live chickens from mainland China for 21 days after a dead chicken there tested positive for the H5N1 virus.

The virus is normally found in birds but can jump to people who do not have immunity to it.

Researchers worry it could mutate into a form that would spread around the world and kill millions.

In recent years, the virus has become active in various parts of the world, mainly in east Asia, during the cooler months.

Authorities in China are worried about the spread of infectious diseases around this time when millions of Chinese travel in crowded buses and trains across the country to go home to celebrate the Lunar New Year.

The current strain of H5N1 is highly pathogenic, kills most species of birds and up to 60 per cent of the people it infects.

Since 2003, it has infected 573 people around the world, killing 336.

The virus also kills migratory birds but species that manage to survive can carry and disperse the virus to new, uninfected locations.

It transmits less easily between people but there have been clusters of infections in people in Indonesia and Thailand in the past.

Reuters/AFP

(Source: abc.net.au)

Fear of terrorism as university prepares to publish key details

A deadly strain of bird flu with the potential to infect and kill millions of people has been created in a laboratory by European scientists – who now want to publish full details of how they did it.

(Source: independent.co.uk)

Hong Kong has culled 17,000 chickens and suspended live poultry imports for 21 days after three birds tested positive for the deadly H5N1 strain of bird flu virus.

Health chief York Chow announced the measures after a dead chicken at the city’s main wholesale market and two wild birds tested positive for the virus, which can be fatal to humans.

Authorities raised the bird flu alert level to “serious” and suspended live imports while they trace the origin of the infected chicken, meaning major disruptions to poultry supplies over the busy Christmas period.

“It is unfortunate that an avian influenza case is detected before the Winter Solstice, necessitating a halt to the supply of live chickens,” Mr Chow said.

“I understand that it will cause inconvenience to the public and the poultry trade will also encounter losses.”

All chickens at the Wholesale Poultry Market were slaughtered and extra inspections were ordered at chicken farms and hospitals.

Authorities confirmed on Tuesday that an oriental magpie robin found dead in a secondary school at the weekend had tested positive for H5N1, the second such case in a week.

Another secondary school was ordered to close for a day for disinfection last Friday after a dead black-headed gull was found with the virus.

A school clerk who picked up the bird was taken to hospital with her son, who had developed flu-like symptoms, but both were cleared later.

Hong Kong was the site of the world’s first major outbreak of bird flu among humans in 1997 when six people died. Millions of birds were culled.

The virus, which does not pass easily from human to human, has killed around 350 people worldwide, with Indonesia the worst-hit country. Most human infections are the result of direct contact with infected birds.

In people it can cause fever, coughing, a sore throat, pneumonia, respiratory disease and, in about 60 per cent of cases, death.

Scientists fear H5N1 will mutate into a form readily transmissible between humans with the potential to cause millions of deaths.

Hong Kong is particularly nervous about infectious diseases after an outbreak of deadly respiratory disease SARS in 2003 killed 300 people in the city and a further 500 worldwide.

AFP

(Source: abc.net.au)

For almost two years, an infant school pupil has found himself losing muscle control and falling asleep at a moment’s notice due to a rare sleeping illness.

Six-year-old Josh Hadfield, from Frome in Somerset, had shown no symptoms of narcolepsy prior to February 2010, and it took another year for doctors to diagnose the condition.

Josh’s mother, Caroline, fears it could be linked to a swine flu vaccine called Pandemrix which he received three weeks before showing symptoms.

Tests in the UK have not revealed a link between Pandemrix and narcolepsy, although the Medicines and Healthcare Regulatory Agency said “a similar risk had only been confirmed in Finland and Sweden”.

‘Dropping forward’

Mrs Hadfield said her son “became a different boy” soon after receiving the vaccination, and Josh was also found to have cataplexy which makes his muscles collapse whenever he laughs.

She said: “Initially, I put it down to being the end of term, coming up to half-term week.

“He was tired and then he started losing muscle control so he couldn’t hold things properly.

“He needed you to support his hand because it was just dropping forward. It was horrible.”

In Finland, investigators found 79 vaccinated children and adolescents had developed narcolepsy, 12 times more than they would expect.

The Finnish government said it accepted a link between Pandemrix and narcolepsy and has promised compensation and support for affected families.

Health Minister Paula Risikko said: “We have decided to take these measures because the decision to acquire the vaccine was ours under the threat of a pandemic, and therefore we want to take the responsibility for the outcome.”

‘Genetic link’

The vaccine is manufactured by GlaxoSmithKline, whose UK medical director Dr Pim Kon said: “There is currently no evidence at all to suggest there is a causal link between Pandemrix and narcolepsy.

“We are working very hard with the regulatory authorities to try to understand what is happening.

“At the end of day, patient safety is of utmost importance to us and we wouldn’t ever put out a drug or leave it out there if we believed that it actually was a true issue.”

The European Medicines Agency said in July studies had shown a six to 13-fold increased risk of narcolepsy in children and adolescents vaccinated with Pandemrix compared with unvaccinated children.

But it added there appeared to be a link but the vaccine “is likely to have interacted with genetic or environmental factors which might raise the risk of narcolepsy, and that other factors may have contributed to the results”.

And despite six million doses being administered, only seven children have been reported to have developed narcolepsy after taking Pandemrix in the UK.

But Mrs Hadfield believes there could be more families affected and has set up a Facebook campaign to try to track them down.

One such child is eight-year-old Lucas Carleton from Liverpool who has been off school for nearly a year and can sleep up to 20 hours per day.

His mother Pauline said: “He was a humorous little boy who used to make me laugh so much. He had a wicked sense of humour.

“All that’s gone and all that’s left is this angry frustrated little boy. It’s heartbreaking, absolutely heartbreaking.”

(Source: BBC)

Researchers in the Netherlands studying bird flu or avian influenza (H5N1) have reportedly developed a strain of the virus that’s just as lethal as the original virus.

According to the New Scientist magazine, research on the bird flu virus has resulted in the highly contagious strain that has some scientists worried about the possible development of a bioweapon.

Media reports say the US biosecurity committee is deciding whether the crucial research is too dangerous to publish since it might allow the H5N1 to cause a lethal human pandemic.

The research was initially submitted to the journal Science, but has now been passed to the US National Science Advisory Board for Biosecurity (NSABB).

“The benefits of publishing this work do not outweigh the dangers of showing others how to replicate it,” Thomas Ingelsby of the Center for Biosecurity was quoted as saying.

According to the US Department of Health & Human Services, the H5N1 kills more than half the people it infects, but cannot be readily passed from person to person.

It has so far infected more than 500 people in more than a dozen countries.

“The potential for escape of that virus is staggering,” says D A Henderson of the Center for Biosecurity.

“A catastrophe would result” if a highly contagious virus with a 50 per cent kill rate got loose.

The NSABB does not have the power to prevent publication of scientific findings, but it can request that journals not publish certain studies.

(Source: Yahoo!)

Parents who do not have their children fully immunised will be stripped of family tax benefits under a scheme announced by the Federal Government.

The Government says 11 per cent of five-year-olds are not immunised and has announced a shake-up of the system which will take effect from July 1 next year.

Under the changes, families who refuse vaccinations face losing up to $2,100 per child in benefits.

Families will need to have their children fully immunised to receive the Family Tax Benefit (FTB) Part A end-of-year supplement.

A new immunisation check will be introduced for one-year-olds to supplement the existing immunisation checks at two and five years of age.

The FTB supplement, worth $726 per child each year, will now only be paid once a child is fully immunised at these checks.

Families are already required to have their child fully immunised to receive Child Care Benefit and the Child Care Rebate.

Children will also be required for the first time to be vaccinated against meningococcal C, pneumococcal and chicken pox.

Children will also be immunised against measles, mumps and rubella earlier, at 18 months instead of the current four years of age.

Health Minister Nicola Roxon is also announcing today a new campaign to advise parents and healthcare providers on what they can do to protect babies from whooping cough.

All parents of newborns will receive letters providing information on immunising against whooping cough and how to identify the disease and prevent it spreading.

“We know that immunisation is fundamental to a child’s lifelong health and that’s why we want to make sure children are immunised at the right time,” Ms Roxon said.

The Government says the changes will deliver savings of $209.1 million over four years.

(Source: abc.net.au)

The World Health Organisation is warning of the potential for an untreatable form of tuberculosis to develop on Australia’s doorstep.

It says infections of multi-drug resistant tuberculosis (MDR TB) in Papua New Guinea’s remote south-west have reached crisis levels.

The country’s health minister says tuberculosis is now a greater health emergency than HIV/AIDS.

Dr Catharina Van Weezenbeek, from the World Health Organisation, says it is now clear the problem is in a state of emergency.

“If you just look at the numbers of MDR TB cases, it’s clear that we’re dealing with a crisis,” she said.

“Children 14-years-old infected with MDR TB in a family with already five patients dying.”

A research team from WHO found the rural health centres are rundown with very limited or no medical supplies.

There is no TB coordinator in the region so no one is monitoring patients to ensure they stick to the lengthy treatment of drugs required to beat the disease, meaning many do not.

WHO’s Dr Donald Enarson says that has led to the emergence of MDR TB.

“Multi-drug resistance has passed from being created from bad treatment to now being established in a community by itself and spreading among community members,” he said.

Local medical records show 94 people have contracted MDR TB in Western Province since 2005.

But the records are incomplete and WHO suspects those cases are just the tip of a much bigger iceberg.

The organisation’s MDR TB expert, Dr Ernesto Jaramillo, says the situation has the potential to get much worse.

“When treatment is delivered under the current conditions which many patients are having, then it’s a matter of months or years before we have forms of TB that cannot be cured,” she said.

Clinics closed

Half the identified cases of MDR TB were treated at tuberculosis clinics in the Torres Strait which is just a short boat ride across the maritime border with Australia.

Earlier this year Queensland’s Department of Health said it would close the clinics because of a funding dispute with the Federal Health Department.

Australian tuberculosis experts have criticised the move as irresponsible.

But Dr Van Weezenbeek says despite the best of intentions, the treatment of PNG nationals across the border has contributed to the emergence of MDR TB.

“The cross border is, in fact, is complicating the situation. In fact most of those patients are being lost,” she said.

PNG’s health minister Jamie Maxtone-Raham responded to WHO’s report by saying TB is now a greater health risk than the country’s HIV/AIDS epidemic.

“It’s very frightening,” he said. “HIV/AIDS is more confined to people who are active, sexually active. But multi-drug resistant TB, the whole home is all at risk.”

Australia’s aid agency AusAID has provided $1 million to improve health facilities in Western Province before the Torres Strait clinics close.

The money is being used to train and recruit medical staff, to purchase a boat for outreach programs, and to construct a TB ward at the hospital on Daru Island.

A gradual clinical handover of PNG patients being treated in the Torres Strait is underway but an AusAID spokesman says they won’t be transferred if there’s no treatment support in their local area.

A decision on whether to keep the clinics open will be made in January.

Despite the dire warning of the potential for an untreatable form of tuberculosis to develop, Dr Van Weezenbeek is confident MDR TB can be contained.

“We have the measure and momentum now,” she said.

“We have Australian Aid assisting. We have technical assistance of all the partners. We have commitment of the PNG government. We have very committed and competent people now in place.”

(Source: abc.net.au)

The latest scandal to hit the CDC is explosive: what appears to be a deliberate cover-up of damning scientific data.

Thimerosal, a controversial mercury compound used as a preservative in certain vaccines, was removed from all vaccines in Denmark in 1992. A subsequent Danish study showed a marked decline in autism rates following the removal of thimerosal, indicating a clear link between mercury in vaccines and the development of autism.

Documents obtained by the Coalition for Mercury-free Drugs (CoMeD) through the Freedom of Information Act (FOIA) suggest that officials at the US Centers for Disease Control and Prevention were fully aware of the Danish data, yet published an article about the study in the journal Pediatricswhich excluded this information, manipulated the data to misrepresent the decline as an increase, and propagated the erroneous conclusion that thimerosal in vaccines does not cause autism.

As CoMeD noted, one of the Danish study’s co-authors was aware of the omission in the initial draft of the Pediatrics article, and alerted CDC officials in a 2002 email: “Attached I send you the short and long manuscript about thimerosal and autism in Denmark. I need to tell you that [your] figures do not include the latest data from 2001, but the incidence and prevalence are still decreasing in 2001.”

The lead author of the Pediatrics article seemed to be aware of the missing autism data, because he replied in an email, “I am not currently at the university but I will contact you and <names withheld> tomorrow to make up our minds.” Despite this, the data from 2001 showing a decline in autism was not mentioned in the draft of the Pediatrics article, and in a 2002 letter to the editor of Pediatrics, CDC officials encouraged expedited review and publication of the article. The misleading article was published by Pediatrics in 2003.

CoMeD, led by biochemist Brian Hooker, PhD, is demanding that the CDC launch an immediate investigation of the officials involved to determine if there was scientific fraud. CoMeD is also calling for a full retraction of the deceptive Pediatrics article.

The CoMeD work and other elements of this scandal have also been brilliantly reported by Tim Bolen on his must-read Bolen Report.

This is not the first scandal to hit the CDC in recent years. Earlier this year, Dr. Poul Thorsen, one of the co-authors of the Pediatrics article and “scientist-in-residence” at the CDC from 2000 to 2002, was indicted in Atlanta for fraud and money laundering in relation to his $11 million grant from the CDC. And just last week, Dr. Kimberly Quinlan Lindsey, a top CDC official, was arrested and charged with two counts of child molestation and one count of bestiality.

While thimerosal has been removed from most vaccines in the US, it is still routinely used in vaccines given to children in the Third World— in other words, to kids who may have compromised immune systems to start with, if their diet has been poor or the quality of the water they drink is bad. They need more protection, not less. In the US, thimerosal is still found in many flu shots, which are becoming increasingly routine for adults and strongly encouraged for the elderly and children.

Speaking of flu shots, a new study on the effectiveness of flu vaccines has been published in the British medical journal Lancet Infectious Diseases. The media is reporting that the study says flu shots are “only about 60% effective”—a lower percentage than the public had been told previously. Unfortunately, even the 60% figure is misleading.

In the study, test subjects were divided into two groups. The control group was not vaccinated; only 2.7 percent of them caught the flu. The treatment group received the vaccine, and of them, only 1.2 percent caught the flu. That means that for every 100 adults vaccinated, only 1.5 of them will avoid influenza as a result. Mike Adams has a fascinating analysis that reveals where the misleading 60% figure comes from (hint: it’s called “massaging the numbers,” and it’s an old statistical trick that the vaccine and pharmaceutical industries use to inflate their reports on the drug’s effectiveness).

Even the CDC admits, on its own website, that flu shot immunity is at best temporary. Why the shot does not confer the kind of immunity provided by other vaccines is not explained, but it presumably has to do with the changing nature of the flu virus. What is also not explained is why the CDC may recommend exactly the same shot two years in a row, which suggests that the agency does not think the flu virus has significantly changed, but the shot a year earlier is not expected to confer any remaining immunity. What is never explored is the possibility that the shot simply fails to confer much immunity at all, which could be tested by seeing if immunized people actually do get the flu, something that the government refuses to do.

Regular readers will know about vitamin D as a natural way to prevent and treat influenza viruses—including Swine Flu. A Japanese study last year showed that schoolchildren who were given vitamin D3 supplements were three times less likely to develop cold or flu symptoms as children who did not take the vitamin.

Speaking of Japan, an article in a respected medical journal points out that infants there get twelve vaccines, not the twenty-six that US infants are supposed to get. Infant mortality is also less than half what it is overall in the US. Clearly it needs more research. The same article states that the US administers more infant vaccines than any other developed nation and ranks behind 33 developed nations in infant mortality.