Posts Tagged ‘co-infection’

As the Obama Administration re-jiggers US foreign assistance policy in general and global health in particular, this op-ed by Dr. Robin Wood, a leading South African physician-researcher, highlights a growing—but little-noticed—explosion in tuberculosis in Cape Town. His startling research there, focusing on TB rates among young children, is a sign of the escalating threat posed by this ancient scourge—a threat that requires high-level attention from Washington.

Below are a few key points from the op-ed, which you can read in full here.

“My research at a clinical trial site outside Cape Town is finding TB infection rates of children at the highest levels ever recorded since the onset of TB chemotherapy in the middle of the last century,” Dr. Wood writes.

“By the time children enter school at age 5, 20 percent are already infected with TB. By the time they reach the age of sexual maturity, 13 years, 50 percent are infected. And between the ages of 24 and 28 — the years of peak prevalence of HIV — 80 percent are infected.

That’s why what is happening in Washington now is so important to me, to all of those fighting TB in Africa, and really to all of us: No area of the world is immune from this contagious airborne infection, which passes on the wings of a sneeze or cough.”

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Dr. Robin Wood, director of the Desmond Tutu HIV Centre in Cape Town, has many startling slides to illustrate the astronomical problem of tuberculosis in South Africa—from photos of desperately poor, overcrowded shantytowns in the Western Cape to graphs that document the escalating rates of HIV/TB co-infection in his native country.

But there’s one image that gets at the crux of a perplexing problem in this epidemic:  A photo of a TB clinic door plastered with awards for successfully implementing the DOTS strategy, or Directly Observed Treatment, Short-course. Juxtaposed to that is a graph showing exponential growth in TB rates in the clinic’s community.

“Why is TB control failing in South Africa?” asks Dr. Wood, a renowned physician-scientist who has been on the front lines of HIV/AIDS treatment, research and prevention for two decades and has recently done cutting-edge research on the deadly intersection of HIV & TB in South Africa.

It is obviously not a failure to implement DOTS, a strategy at the heart of most TB control programs in the developing world. Instead, Dr. Wood suggested at a briefing with USAID staff today in Washington, it’s an overreliance on DOTS in settings where transmission is a “pressure infection” being transmitted at nearly unprecedented rates. He said the situation today in South Africa is similar to what happened in New York in the 1840s, when Irish immigrants with very little natural TB immunity came to the U.S., and the epidemic spread like wildfire.

“If you live in a sea of TB,” as so many South Africans do, DOTS is just not enough to control the disease, Dr. Wood said.

So what is needed? Dr. Wood isn’t calling for anything radical. (more…)

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When it comes to health-related news, South Africa is usually a source of grim tales and bleak statistics, from the declining life expectancy rates to the escalating threat of HIV/TB co-infection.

A just-published series of articles in The Lancet documents, in relentless detail, the health challenges that South Africa currently faces. But the Lancet articles also spell out the potential for change, writing in an opening commentary: “Not since the first democratic elections in 1994 has there been so much hope and expectation for a better health system, with improved health outcomes for all, in South Africa. The country is at an important crossroads.”

The Lancet series probes the state of maternal and child health, HIV/TB co-infection, and chronic non-communicable diseases, among other problems, and it is a goldmine of startling facts and interesting analysis, as well as some solutions and “urgent action points.”

In the article on co-infection, Salim S Abdool Karim and colleagues write that the twin threats of HIV and TB present one of “the greatest challenges facing post-apartheid South Africa.”

And they don’t sugar coat the reasons: “Until recently, the South African Government’s response to these diseases has been marked by denial, lack of political will, and poor implementation of policies and programmes,” they write. “Nonetheless, there have been notable achievements in disease management, including substantial improvements in access to condoms, expansion of tuberculosis control efforts, and scale-up of free antiretroviral therapy (ART).”

One element that does not get a lot of attention in the series is the role of donor countries in helping South Africa at this “crossroads.” That’s an important question at a time when there is some uncertainty about the Obama Administration’s vision for the US global AIDS program.

The series is available online at http://www.thelancet.com/series/health-in-south-africa.

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How could the world dramatically lower the incidence of tuberculosis and save millions of lives? 

An effective TB vaccine would revolutionize the response to TB, which kills about 5000 people each day, and eliminate the need for lengthy and often difficult drug treatment.   

An effective vaccine would be of tremendous benefit all over the world, including in the United States, where there were 13,299 cases of active TB reported in 2007 and about 11 million people with latent TB. 

Of course, there’s no question that much more can be done to prevent TB using existing methods, notably the Three I’s.  But, imagine what an effective vaccine could do.  Vaccination of newborns with a successful TB vaccine could decrease global TB incidence by 39 percent to 52 percent by 2050, and mass vaccination could result in a nearly 80 percent decrease of TB by 2050, according to a recent estimate. 

What’s exciting is that the effort to develop such a vaccine is proceeding rapidly and could produce results in just a few years — that is, if the United States government and other donors provide the funding necessary for large-scale clinical trials. 

Right now, that’s a very big “if.”

A vineyard near Worcester, on the road to Barrydale

A vineyard near Worcester, on the road to Barrydale

South Africa is a leader in TB vaccine research, and I recently had the opportunity to visit a tuberculosis vaccine facility in Worcester, 120 km northwest of Cape Town, and to take some photos.  The facility has the strong support of the US-based Aeras Global TB Vaccine Foundation, and it is a terrific example of capacity building and international cooperation.

In fact, Aeras is supporting this kind of capacity building and healthcare infrastructure strengthening (including laboratories and disease detection) not only in South Africa but at partner sites in Kenya, Mozambique, Uganda, Cambodia and India as well.

The area called the Boland, where facility is located, is one of the most beautiful places I have ever visited.  It is the source of world-class wine as well as those delicious Ceres fruit juices you can find in supermarkets in the US and other countries.

Unfortunately, this rural area also has one of the highest rates of TB in the world.

TB incidence in the research area is about 100 times that which we have in the United States. The level of TB incidence in this area is at 1400 cases per 100,000 people, even higher than the overall South Africa rate of 900 per 100,000.  

This is the view directly oppostite the SATVI research facility.

This is the view directly oppostite the SATVI research facility.

The situation in South Africa is aggravated by unemployment, poor housing conditions (cramped and with inadequate air circulation), extreme inequity in access to medical care, and HIV/AIDS. 

As we explored in Deadly Synergy, TB is having an enormous and deadly impact on people who are living with HIV/AIDS.  Since 2007, HIV and TB co-infection has been the most significant cause of premature death in the province of Western Cape. 

However, it is also worth noting that, globally, most people with TB disease are not HIV positive. 

The woman on the left runs a local saloon, in Gugulethu, where people drink beer made from corn.  TB can spread in such enclosed spaces.

The woman on the left runs a local saloon, in Gugulethu, where people drink beer made from corn. TB can spread in such enclosed spaces.

In fact, in the Western Cape, HIV prevalence is less than the overall rate in South Africa as a whole.  Hassan Mahomed, the SATVI Clinical Director, told us that there are other factors in addition to HIV which are driving the TB problem in the area, which predates the escalation of HIV. 

He told us that the long, cold and rainy winters in the area lead people to staying indoors where they can become infected by TB.  He said poverty and alcoholism were also major factors, with many of the people receiving low wages for seasonal work on the many farms in the area.  

Many people live in cramped quarters, as in this photo from Gugulethu, near Cape Town

Many people live in cramped quarters, as in this photo from Gugulethu, near Cape Town

Children can suffer terrible forms of TB disease, such as TB meningitis, which can lead to severe brain damage and paralysis. 

While children in South Africa receive some protection from the BCG vaccine, developed about 90 years ago, this does not protect them against pulmonary TB and the protection does not last into adulthood.

But research is advancing rapidly.  There are now 10 new TB vaccine candidates in clinical trials worldwide, and four of them are being tested in Worcester, at the field site of the South African Tuberculosis Vaccine Initiative (SATVI).

We happened to arrive at the site on a day when mothers were bringing in their babies to receive an already-proven vaccine against pneumococcal disease.  Children in the TB vaccine study area are provided with other vaccinations free of charge, whether or not their parents choose to enroll them in the study. 

This mother of three had brought her daughter in for the free pneumococcal vaccination.  She said her uncle had suffered from TB.

This mother of three had brought her daughter in for the free pneumococcal vaccination. She said her uncle had suffered from TB.

I asked one of the mothers if the 150 Rand (about $19 USD) payment she receives for each clinic visit was a help to her, and she said yes but the even more important benefit was that as a study participant her baby also receives regular medical check-ups.

On our visit to the site, I got a chance to meet four month old Janenique Pienaar of Worcester.  Her mother was beaming, clearly delighted that her daughter is making history as the first baby in 80 years to be vaccinated in a proof-of-concept efficacy trial (Phase IIb) of a candidate TB vaccine. 

Child receiving his pneumococcal vaccine.

Child receiving his pneumococcal vaccine.

This vaccine candidate, called MVA85A/AERAS-485, would be a booster to the BCG vaccine, and it has already been shown to be safe in a number of Phase I and Phase II clinical trials. 

 To study this vaccine candidate, SATVI is enrolling 2783 healthy, already BCG vaccinated, babies, at about 4 months of age to participate in the trial. Half the babies will be given the new vaccine, and the other half a placebo. 

The children will then be monitored for two years to compare the incidence of TB in the two groups. If successful, the vaccine would proceed to a much larger, and more costly, Phase III clinical trial in 2011. 

A sleepy-eyed baby Janenique, with Dr. Michele Tameris, clinical manager of the South African Tuberculosis Vaccine Initiative

A sleepy-eyed baby Janenique, with Dr. Michele Tameris, clinical manager of the South African Tuberculosis Vaccine Initiative

This vaccine could be ready for wide-scale use by 2016, if the trials are successful.  Unfortunately, funding for later stage clinical trials for TB vaccines is at present very much in doubt, and the funding shortfall could significantly delay progress.

While the NIH and CDC have funded some early stage TB vaccine research and epidemiology studies, funding for the kind of late-stage trials conducted in South Africa is authorized under the PEPFAR law (Lantos-Hyde) to come through USAID. 

USAID is already investing significantly in AIDS and malaria vaccine research, but unfortunately it has not provided funding for TB vaccine research, whether through Aeras or another program.

The Obama Administration supported a tiny increase of only $10 million for USAID’s TB program in 2010.  Congress is now on course to provide a larger increase for 2010, but it will be roughly a $150 million increase at best — far less than the increase of about $500 million we and other advocates had sought for implementation of TB programs and research.  

The Aeras Global TB Vaccine Foundation needs over $30 million per year in additional funding to support a late stage clinical trial of a TB vaccine candidate.

Proud mom, with baby Janenique, the first baby to receive the candidate vaccine in this trial

Proud mom, with baby Janenique, the first baby to receive the candidate vaccine in this trial

We hope that the Administration proposes a substantial increase for TB in its 2011 budget proposal, yet the signs so far are not good. 

TB is not just any disease.  It’s the third leading cause of morbidity and mortality combined in women of reproductive age in developing countries. India’s national TB program estimates that some 100,000 women in India alone are rejected by their families every year because of TB.

Yet, the Administration’s draft, 6-year strategy on TB omits any reference to the TB funding levels “authorized” last year in the Lantos-Hyde bill, now US law. 

That bill specified $4 billion over 5 years for TB, or $800 million per year, including for vaccine development.  But, to become a reality, this funding level needs annual support from Administration and from the Budget Chairmen and Appropriators in Congress. 

What we have heard from government insiders is that the Administration feels the amount of TB funding now provided through PEPFAR, which directs some of its funding to addressing TB-HIV coinfection, in effect addresses the TB funding need.  Would that were the case!

President Obama just awarded the Presidential Medal of Freedom to Archbishop Emeritus Desmond Tutu.  He, like Nelson Mandela, is a TB survivor, and both have called for bold action to confront TB.  Tutu has appealed for funding for TB and HIV programs, even in these difficult times.

South African Archbishop Emeritus Desmond Tutu

South African Archbishop Emeritus Desmond Tutu

We must heed their call to action. TB is estimated to deplete the incomes of the world’s poorest communities by $12 billion per year. South Africa has made progress in the fight against TB, but there is still much to do.  As Tutu has stated, “As we have overcome apartheid, so we shall defeat TB and HIV/AIDS, these ungodly twin killers.”

— David Bryden, Senior Program Policy Officer, Center for Global Health Policy 

The floor of the District Six Museum in Cape Town has this quote from Langston Hughes

The floor of the District Six Museum in Cape Town has this quote from Langston Hughes


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Global health may not have been at the top of the agenda at the Group of 8 summit in Italy today, but it wasn’t ignored either.

In their declaration today, G8 leaders noted that progress on global health has not been as significant as hoped and they reaffirmed previous commitments, most notably the $60 billion investment to fight infectious diseases and strengthen health system by 2012. In addition, the declaration specifically mentions the need to better coordinate HIV & TB care, a coup for those concerned about the threat of HIV/TB co-infection.

“We will implement further efforts towards universal access to HIV/AIDS prevention, treatment, care and support by 2010, with particular focus on prevention and integration of services for HIV/TB,” the declaration states. (Click here for the full statement; the global health section starts on p. 33.)

Some critics expressed disappointment that the G8 leaders did not offer any new initiatives or articulate the less-than-impressive progress toward meeting previous commitments. And it’s hard to say whether the G8 leaders will live up to the goals outlined in this meeting. But at least they did not try to renege on the Heiligendamm promise or stay mum about the issue entirely. (more…)

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Leading disease experts will call on President Obama and Congress to mount a concerted and comprehensive response to the deadly alliance between HIV/AIDS and tuberculosis at a Capitol Hill briefing this Thursday, June 25

The call to action from America’s top HIV/TB scientists and physicians comes in conjunction with the release of a new report, “Deadly Duo: The Synergy Between HIV/AIDS and Tuberculosis,” from the Center for Global Health Policy.

The Center’s report highlights the scope of TB/HIV co-infection and warns that, without a well-coordinated effort to address these co-joined epidemics, lives rescued from AIDS through access to life-saving HIV drugs will be lost to TB. So far, policymakers have not treated HIV-TB co-infection as an issue in need of an emergency response, despite an enormous death toll from these twin scourges.


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As policymakers in Washington make vital funding and program decisions on global health, we need to showcase the work of global HIV/AIDS and TB scientists and physicians who are on the front-lines of preventing and treating these twin global epidemics.


We’re looking for compelling stories about what’s happening in the research labs, the clinical trials, the field programs, to help inform decisions made at the White House and in Congress on spending and other key issues. The center will use your stories to develop program profiles and brief reports that highlight innovative approaches to HIV prevention in the developing world, to global TB, and to HIV/TB co-infection.


We are particularly interested in programs that merit scale-up. Submissions should be grounded in research, clinical practice, training or program activity relevant to resource-poor settings that hold implications for US government policy or practice.


You will have a chance to review all completed program profiles before they are made available publicly. The Center’s staff may request a brief phone interview to clarify issues and program components with you or a member of your team.


So please consider sending us descriptions of your programs or research, either by email or snail mail.


Send information to globalhealth@idsociety.org or IDSA, Attn: global health, 1300 Wilson Boulevard, Suite 300, Arlington, VA  22209

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