Global | New drug resistant form of tuberculosis reported in India
India | 12 Jan 2012
In a recent scientific article (Udwadia, F et al. Clin. Infect. Dis. 2011, Dec 21, Eprint) four cases of so-called total drug resistant tuberculosis (TB) were reported from India. According to the article, these patients have shown resistance to all the first line TB drugs (isoniazid, rifampicin, ethambutol, pyrazinamide, streptomycin) and to seven second line anti-TB drugs (ofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, para-aminosalcyclic acid and ethionamide).
ECDC comment (12 January 2012):
Drug-resistant tuberculosis is manmade and results from inadequate treatment management of TB cases like irregular treatment regimen prescription, poor compliance to treatment plans or sub-optimal dosing due to biological variations in drug uptake. The key to preventing the development of drug resistance, multi-drug resistance or extensively drug resistance is to provide patients with the correct multi-drug TB treatment regimen for the entire treatment time.
Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.
Successful treatment of TB is possible but requires full support from the health care system by offering optimal diagnostic services, high-quality drugs for the full time of treatment and support to the patient in fulfilling the treatment. To make this happen, strong TB diagnostic services and processes that ensure the rational use of TB drugs (1,2,3) are essential in order to be able to test all suspected TB cases for drug-resistance and to identify resistance as soon as possible to enable appropriate therapy. Furthermore, ensuring treatment outcome monitoring of all cases is vital.
In 2009, 1.450 MDR-TB cases were reported in the EU/EEA (5.3% of all TB cases) and 66 XDR-TB case were reported by 15 EU/EEA countries. Cases resistant to almost all anti-TB drugs have been reported in the EU, albeit not many. In 2007, two cases resistant to all the second-line TB drugs in Italy were also described in the literature (4). Both cases had acquired resistance to these multiple drugs as a result of mismanagement of treatment (this included erratic treatment prescription and poor treatment adherence).
Yet, the full extent of the XDR-TB burden in the EU/EEA is not known as to date not all countries report these results, and much less for TB forms resistant to almost all anti-TB drugs. However, MDR-TB and XDR-TB are clearly present in the EU/EEA and it is important to maintain and strengthen TB control programmes to assure all TB patients are rapidly identified, tested for drug-resistance, receive appropriate treatment and are supported to ensure full completion of treatment. It is every individual patient’s right to receive the best of care and in a public health view, this is essential to prevent the further spread/transmission of TB in the population.
To prevent further spread of TB, drug-resistant TB, MDR-TB, XDR-TB in the population, it is essential that appropriate infection control measures are in place.(5)
In response to the findings of a survey on MDR-TB case management in the EU (6,7), ECDC and the European Respiratory Society (ERS) jointly developed European Union Standards for Tuberculosis Care (ESTC)(8). These aim at providing EU-tailored standards for the diagnosis, treatment and prevention of tuberculosis (TB)(9). Effective TB, MDR-TB and XDR-TB prevention and control in the EU can only be achieved when all the three components function optimally. These ESTC have been developed on the basis of the existing International Standards for TB Care, to ensure conformity and comparability with the global standards.
To further support EU Member States in improving and maintaining strong TB control programmes, ECDC is coordinating the European Reference Laboratory Network for TB (ERLN-TB) with the aim to strengthen TB diagnosis, surveillance, drug susceptibility testing, and international coordination in the EU/EEA. Also, ECDC has been developing molecular surveillance of MDR-TB in the EU (through an open contract), aiming at developing molecular typing in EU Member States to enable the mapping of MDR-TB in the EU/EEA. In 2012, ECDC will be incorporating molecular typing in the ERLN-TB as well as introducing the Molecular Surveillance System for which MDR-TB reporting will be provided. This will be essential to further monitor MDR-TB in the EU and identify strengths and challenges.
1. Langendam MW, van der Werf MJ, Huitric E, Manissero D. Prevalence of inappropriate tuberculosis treatment regimens: A systematic review. ERJ. 2011 Oct 17; Epub ahead of print.
2. van der Werf MJ, Langendam MW, Huitric E, Manissero D. Knowledge of tuberculosis treatment prescription of health workers: A systematic review. ERJ. 2011 Dec 19; Epub ahead of print
3. van der Werf MJ, Langendam MW, Huitric E, Manissero D. Multidrug resistance after inappropriate tuberculosis treatment: A meta-analysis. ERJ. 2011 Oct 20; Epub ahead of print]
4. Migliori et al. First tuberculosis cases in Italy resistant to all tested drugs. Eurosurveillance, volume 12(20)
5. Sotgiu, G et al. TB and M/XDR-TB infection control in European TB reference centres: the Achille’s heel? Eur Respir J. 2011 Nov;38(5):1221-3.
6. Migliori*, G.B., G. Sotgiu* et al. TB and MDR/XDR-TB in the EU and EEA countries: managed or mismanaged? Eur Respir J. accepted for publication (2012)
7. Sotgiu G, et al. Development of a standardised tool to survey MDR-/XDR-TB case management in Europe. Eur Respir J. 2010 Jul;36(1):208-11.
9. Migliori, G.B., et al. Towards the development of EU Standards for TB Care (ESTC). Eur Respir J. 2011 Sep;38(3):493-5.
Global | Tracking marine debris from the Japanese tsunami
Washington DC | Debris from the tsunami that devastated Japan in March could reach the United States as early as this winter, according to predictions by NOAA scientists. However, they warn there is still a large amount of uncertainty over exactly what is still floating, where it’s located, where it will go, and when it will arrive. Responders now have a challenging, if not impossible situation on their hands: How do you deal with debris that could now impact U.S. shores, but is difficult to find?
Federal Agencies Join Forces
To learn more about the tsunami debris, NOAA researchers have been working with the U.S. Environmental Protection Agency, U.S. Fish and Wildlife Service, and other partners to coordinate data collection activities.
NOAA and its partners are also coordinating an interagency assessment and response plan to address the wide-range of potential scenarios and threats posed by the debris.
“We’re preparing for the best and worst case scenarios — and everything in between,” says Nancy Wallace, director for NOAA’s Marine Debris Program.
As the tsunami surge receded, it washed much of what was in the coastal inundation zone into the ocean. Boats, pieces of smashed buildings, appliances, and plastic, metal, and rubber objects of all shapes and sizes washed into the water — either sinking near the shore or floating out to sea. The refuse formed large debris fields captured by satellite imagery and aerial photos of the coastal waters.
The Japanese government estimated that the tsunami generated 25 million tons of rubble, but there is no clear understanding of exactly how much debris was swept into the water nor what remained afloat.
What remains of the debris?
Nine months later, debris fields are no longer visible. Winds and ocean currents scattered items in the massive North Pacific Ocean to the point where debris is no longer visible from satellite. Vessels regularly traveling the North Pacific have reported very few sightings. Only two pieces have been clearly linked to the tsunami.
NOAA is coordinating new interagency reporting and monitoring efforts that will provide critical information on the location of the marine debris generated by the tsunami. Ships can now report significant at-sea debris sightings and individuals or groups can request shoreline monitoring guides at DisasterDebris@noaa.gov.
Where is it?
Computer models run by NOAA and University of Hawaii researchers show some debris could pass near or wash ashore in the Northwestern Hawaiian Islands (in the Papahānaumokuākea Marine National Monument) as early as this winter, approach the West Coast of the United States and Canada in 2013, and circle back to the main Hawaiian Islands in 2014 through 2016.
Researchers caution that models are only predictions based on location of debris when it went into the water, combined with historical ocean currents and wind speeds.
Conditions in the ocean constantly change, and items can sink, break down, and disperse across a huge area. Because it is not known what remains in the water column nor where, scientists can’t determine with certainty if any debris will wash ashore.
Worst- and Best-case Scenarios
The worst-case scenario is boats and unmanageable concentrations of other heavy objects could wash ashore in sensitive areas, damage coral reefs, or interfere with navigation in Hawaii and along the U.S. West Coast. Best case? The debris will break up, disperse and eventually degrade, sparing coastal areas.
Debris will not go away completely, even in a best-case scenario. Marine debris is an ongoing problem for Hawaii and West Coast states, where garbage and other harmful items regularly wash up on beaches, reefs and other coastal areas.
What Else is NOAA Doing?
NOAA has convened experts to review available data and information from models and provide their perspectives on debris fate and transport. They are gathering information on significant sighting of marine debris in the North Pacific through NOAA’s Office of Marine and Aviation Operation’s Pacific fleet, the NOAA Voluntary Observing Ship Program, which includes industry long-haul transport vessels, as well as the NOAA Pacific Island Regional Observer Program and their work with the Hawaii longline fishing industry. NOAA is also working with the U.S. Fish and Wildlife Service and the State of Hawaii on shoreline debris monitoring in the Papahānaumokuākea Monument.
The risk of “warning fatigue” in disaster preparedness
Bangkok – IRIN — Weeks of flood threats during one of Thailand’s most destructive monsoon seasons on record have given residents in the capital of more than eight million people time to prepare for the worst.
But that extra time also allows for uncertainty, mixed messages, and “warning fatigue”, complicating how well people prepare and, ultimately, how many lives and livelihoods are spared, say disaster workers and researchers.
“It’s partially denial, it’s partially the information, it’s partially not knowing what information to believe,” said Jerry Velasquez, senior regional coordinator for the UN International Strategy for Disaster Reduction (ISDR) Asia Pacific. He likened the run-off from flooding in the north winding southwards to a “slow tsunami”.
When the government first reported potential flooding in parts of Bangkok in early October, some residents built flood walls. Others did little more than stock up on bottled water. When warnings escalated to include all 50 city districts, thousands packed bus terminals to leave the city, while others ignored the evacuation calls.
How people decide whether, how and when they prepare for a disaster is complicated, and in a slowly unfolding one such as in Bangkok, it is often made amid uncertainty and conflicting messages, said Douglas Paton, a psychology professor at Australia’s University of Tasmania.
“Nobody can say a flood with this amount of water will reach this suburb at 3:47pm and at a height of 1.2m,” he said. “Things are much more vague.”
Anxiety fatigue
Warnings generally stoke anxiety that cause people to act, Paton said. But weeks of alarm-raising without any calamity can cause distrust. “That anxiety means we take an instant dislike to the people who have created this bad feeling,” he explained.
People tend to give more weight to positive messages, particularly when predictions prove inaccurate and their personal experiences do not give them reason to fear, Paton said.
Residents in Bangkok have received numerous warnings from the national government through its flood relief operation centre and the city’s metropolitan authority, which have each issued varying predictions of flood damage.
Central Bangkok was mostly dry during the recent high-risk period, but surrounding areas have been submerged in run-off water from the north that is testing the city’s dams and waterways. Most of Thailand has been affected in this year’s monsoon, with 26 of the country’s 76 provinces still flooded, and more than 100,000 people displaced.
Saranya Sonthiratana, 44, lives 25km north of central Bangkok in Nonthaburi Province, where stretches of homes sit in 1m of water. The threat had been abstract – until her pipes burst.
“I do not live near a canal or the [Chao Phraya] river, so when we got the government order to evacuate, I had one day’s notice to get out,” she said. “I did not know my pipes could burst from the pressure.”
Ensuring people remain vigilant under a drawn-out threat is a challenge, said Matthew Cochrane, communications and advocacy manager for the International Federation of Red Cross and Red Crescent Societies (IFRC) Asia Pacific region.
Officials risk creating undue panic or becoming “the boy who cried wolf”, Cochrane said. With rapid-onset disasters, by comparison, officials can be more declarative about what needs to be done, he said.
“It’s a fine line between keeping people aware, and agitated to an extent, but not so overwhelmed or underwhelmed that you create confusion or prove yourself worthless,” he said. “It’s a very difficult balance, and it’s very difficult to get it right.”
One message
Agencies should reduce conflicting messages, especially when there is more time to sow confusion, said crisis communication practitioners and researchers.
But warnings alone are not enough to get people to act. “People don’t really need to have the information,” said Cochrane from IFRC. “They need to have the ability to act on the information.”
Approaches that ask people to consider how a risk might personally affect them are important for increasing levels of preparedness, Paton said. Not only does this process help people better understand otherwise abstract warnings, but it also allows for a shared understanding to form so that communities can work together to prepare.
Such engagement ideally happens ahead of an existing threat, but even without much time, “risk communication should be a partnership between experts and the people”, he said.
“We start with people themselves,” Paton said, “rather than making assumptions that telling people about a threat will get them to take action.”
Ads
