Tuberculosis makes a comeback

Yerevan, Armenia – In a barren hospital room, Arman lies on a messily made bed as a nurse administers one of two daily antibiotic injections into his forearm. The 35-year-old ex-soldier was admitted nearly 18-months ago, having suffered a relapse of the bacterial lung infection tuberculosis (TB).

“I felt very bad, I couldn’t talk, I couldn’t breathe, my temperature was 40 degrees Celcius upwards,” says Arman, who asked to be identified only by his first name. “I thought I would definitely die, I lost all hope.”  Before starting on this regimen he suffered from TB for four years and failed to respond to two rounds of treatment.

Arman is one of 450,000 people per year worldwide who are infected with a dangerous, mutated version of one of the world’s deadliest illnesses. TB kills 1.3 million people per year – more than any other infectious disease apart from HIV/AIDS.

A MDR TB patient takes her pills [Sylvia Rowley/Al Jazeera]

It’s caught by breathing in Mycobacteria tuberculosis, and is usually treated with a six-month course of antibiotics. But for many people, these decades-old drugs have simply stopped working. 

In Armenia, 9.4 percent of people newly infected with TB, and 43 percent of those who are re-treated, are now resistant to at least two of the main antibiotics used to treat the disease, according to the World Health Organisation (WHO).

Potential epidemic

The highest levels of resistance are concentrated in Eastern Europe and Central Asia, where in some countries more than 20 percent of new cases and 50 percent of previously treated cases are Multi Drug Resistant (MDR). But large numbers of people are infected with resistant strains around the world, including 64,000 people in India and 59,000 in China. In 2012, 170,000 people died from MDR TB, according to the WHO.

“Wrong prescriptions, incomplete regimens, not using the quality drugs necessary, not following patients to make sure they take all the drugs, all of these things are conducive to drug resistance” says Mario Raviglione, director of the Global Tuberculosis Programme at the WHO. “And if there is no infection control in place, if people are poor and live in congested housing, then the resistant strains spread from person to person. That’s what the disaster is about.”

With globalisation, the contagious airborne disease could affect anybody. “As we speak there is a small outbreak of extensively drug-resistant TB in Milan that has affected children,” Raviglione says. “A 12-year-old boy is seriously ill and has infected his classmate and possibly his siblings.”

Those diagnosed with Multi Drug Resistant TB are subject to a gruelling cocktail of toxic antibiotics every day for about two years. Side-effects from these second-choice drugs include extreme nausea, vomiting, deafness, depression and psychosis. Fewer than half of patients are successfully treated.

“It’s very difficult for me to prescribe these drugs,” says Dr Charles Ssonko, TB implementer for the international medical charity Doctors Without Borders. “The treatments are long, I’m aware of the side effects. I know how much it’s going to be for the patient [to cope with].”

On her blog about life with MDR TB, 23-year-old South African student Phumeza Tisile writes about her experience of taking more than 20,000 doses of toxic antibiotics. The treatment left her deaf, and damaged her kidneys.

“Those [little] things make you even sicker than you already are,” she says. “There are times where one would swallow his/her vomit [after throwing up the drugs] because you don’t want to repeat taking the medication.”

‘Hardy’ bacteria

One reason why TB poses such a public health challenge is that Mycobacterium tuberculosis does not behave like other bacteria. It is called a “mycobacterium” because it has a thick, waxy coating rich in mycolic acids that make it extremely hardy.

“There are only a few antibiotics that can actually get through that layer and get into the bacterium and kill it,” says the WHO’s Raviglione. “The vast majority of antibiotics don’t work.”

M. tuberculosis also has the ability to seemingly lie dormant in our bodies – possibly inside white blood cells or in a protective biofilm, where it cannot be killed – and emerge months later, says Raviglione. This and other complexities mean that even treatments for ordinary TB involve a combination of antibiotics taken for six months, leaving plenty of opportunities for missed doses.

New treatments are finally in development, but they are only just beginning to be used. In June 2013, the WHO issued interim guidance supporting the use of the first new TB drug in more than 40 years. The antibiotic, bedaquiline, works by interfering with the bacteria’s energy metabolism, and has been recommended for certain adults with MDR-TB, even though it has yet to finish clinical trials.

In Armenia, Doctors Without Borders has started giving bedaquiline along with other drugs to 40 patients – including Arman – who have no other options left. After five months on his new treatment, Arman tested negative for TB for the first time since his relapse in 2008, and is now in good condition according to his doctor.

“I hope to be cured,” says Arman. “I will be checked again in six months after the completion [of treatment], and if it is okay, I want to marry.”

In April 2014, the WHO’s expert committee is also set to consider a second new TB antibiotic, delamanid, and aims to publish its verdict on the drug this summer.

“It is an exciting and promising time, but at the same time those single drugs on their own are not going to beat MDR-TB,” says Dr Bern-Thomas Nyang’wa, a TB specialist at Doctors Without Borders UK. “They have been shown to improve the effectiveness of existing regimens, but those regimens are still long, toxic, expensive and difficult to take. We urgently need trials that combine the new drugs, to find regimens that are far shorter, less toxic, and able to be taken orally.”

New tests

As well as advocating for new treatments, doctors who work with drug resistant TB patients stress the need for better diagnosis. According to the WHO, fewer than one-third of MDR TB patients worldwide are accurately diagnosed, leading to delays in treatment that can be fatal, and that encourage the spread of the disease.

An Armenian patient  provides a doctor with a sputum sample [Sylvia Rowely/Al Jazeera]

A new rapid molecular test that identifies resistance to one of the main TB drugs, rifampicin, can reduce diagnosis times for MDR TB from weeks to hours, and offers “a lot of hope”, says Bertie Squire, of the Liverpool School of Tropical Medicine. But the “GeneXpert” machine is expensive to use and needs a stable electricity supply.

“It can be difficult to implement in post-conflict or poor countries,” adds Squire.

Late last year, against all expectations, South African blogger Tisile was finally cured of her TB, which had become resistant even to second-line drugs. Although she had major lung surgery, suffered TB in her brain and has been left permanently deaf, she is one of the luckier ones – many of her fellow patients died.

She is now a leading voice in Doctors Without Borders’ “Test me, treat me” manifesto for drug-resistant TB, calling for better diagnosis, improved drug regimens and greater investment from donors and governments.

As well as fighting for better treatment for others, Tisile can now focus on getting her life back after three gruelling years.

“I will resume those big dreams I had before – going to university, getting a degree and getting a job that I want,” she says. “But I’m not sure any more about studying business. Maybe now I’ll consider health.”

Doctors Without Borders’ work with people affected by drug resistant TB in Armenia will feature on the next series of Al Jazeera’s health Show The Cure, which starts on May 26, 2014.