First Case of Highly Drug-Resistant TB Found in US

Margie Mason and Martha Mendoza, San Francisco Chronicle, December 27, 2009

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Then came the fevers. They bathed and chilled the skinny frame of Oswaldo Juarez, a 19-year-old Peruvian visiting to study English. His lungs clattered, his chest tightened and he ached with every gasp. During a wheezing fit at 4 a.m., Juarez felt a warm knot rise from his throat. He ran to the bathroom sink and spewed a mouthful of blood.

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Doctors say Juarez’s incessant hack was a sign of what they have both dreaded and expected for years–this country’s first case of a contagious, aggressive, especially drug-resistant form of tuberculosis. The Associated Press learned of his case, which until now has not been made public, as part of a six-month look at the soaring global challenge of drug resistance.

Juarez’s strain–so-called extremely drug-resistant (XXDR) TB–has never before been seen in the U.S., according to Dr. David Ashkin, one of the nation’s leading experts on tuberculosis. XXDR tuberculosis is so rare that only a handful of other people in the world are thought to have had it.

“He is really the future,” Ashkin said. “This is the new class that people are not really talking too much about. These are the ones we really fear because I’m not sure how we treat them.”

Forty years ago, the world thought it had conquered TB and any number of other diseases through the new wonder drugs: Antibiotics. U.S. Surgeon General William H. Stewart announced it was “time to close the book on infectious diseases and declare the war against pestilence won.”

Today, all the leading killer infectious diseases on the planet–TB, malaria and HIV among them–are mutating at an alarming rate, hitchhiking their way in and out of countries. The reason: Overuse and misuse of the very drugs that were supposed to save us.

Just as the drugs were a manmade solution to dangerous illness, the problem with them is also manmade. It is fueled worldwide by everything from counterfeit drugmakers to the unintended consequences of giving drugs to the poor without properly monitoring their treatment. Here’s what the AP found:

_ In Cambodia, scientists have confirmed the emergence of a new drug-resistant form of malaria, threatening the only treatment left to fight a disease that already kills 1 million people a year.

_ In Africa, new and harder to treat strains of HIV are being detected in about 5 percent of new patients. HIV drug resistance rates have shot up to as high as 30 percent worldwide.

_ In the U.S., drug-resistant infections killed more than 65,000 people last year–more than prostate and breast cancer combined. More than 19,000 people died from a staph infection alone that has been eliminated in Norway, where antibiotics are stringently limited.

“Drug resistance is starting to be a very big problem. In the past, people stopped worrying about TB and it came roaring back. We need to make sure that doesn’t happen again,” said Dr. Thomas Frieden, director of the U.S. Centers for Disease Control and Prevention, who was himself infected with tuberculosis while caring for drug-resistant patients at a New York clinic in the early ’90s. “We are all connected by the air we breathe, and that is why this must be everyone’s problem.”

This April, the World Health Organization sounded alarms by holding its first drug-resistant TB conference in Beijing. The message was clear–the disease has already spread to all continents and is increasing rapidly. Even worse, WHO estimates only 1 percent of resistant patients received appropriate treatment last year.

“We have seen a huge upburst in resistance,” said CDC epidemiologist Dr. Laurie Hicks.

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Tuberculosis is the top single infectious killer of adults worldwide, and it lies dormant in one in three people, according to WHO. Of those, 10 percent will develop active TB, and about 2 million people a year will die from it.

Simple TB is simple to treat–as cheap as a $10 course of medication for six to nine months. But if treatment is stopped short, the bacteria fight back and mutate into a tougher strain. It can cost $100,000 a year or more to cure drug-resistant TB, which is described as multi-drug-resistant (MDR), extensively drug-resistant (XDR) and XXDR.

There are now about 500,000 cases of MDR tuberculosis a year worldwide. XDR tuberculosis killed 52 of the first 53 people diagnosed with it in South Africa three years ago.

Drug-resistant TB is a “time bomb,” said Dr. Masae Kawamura, who heads the Francis J. Curry National Tuberculosis Center in San Francisco, “a manmade problem that is costly, deadly, debilitating, and the biggest threat to our current TB control strategies.”

Juarez underwent three months of futile treatment in a Fort Lauderdale hospital. Then in December 2007 he was sent to A.G. Holley State Hospital, a 60-year-old massive building of brown concrete surrounded by a chain-link fence, just south of West Palm Beach.

“They told me my treatment was going to be two years, and I have only one chance at life,” Juarez said. “They told me if I went to Peru, I’m probably going to live one month and then I’m going to die.”

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There are two ways to get drug resistant TB. Most cases develop from taking medication inappropriately. But it can also be transmitted like simple TB, a cough or a sneeze.

In the 1980s, HIV and AIDS brought an even bigger resurgence of TB cases. TB remains the biggest killer of HIV patients today.

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About 60 million people visit the U.S. every year, and most are not screened for TB before arrival. Only refugees and those coming as immigrants are checked. The top category of multidrug-resistant patients in the U.S.–82 percent of the cases identified in 2007–was foreign-born patients, according to the CDC.

The results are startling among those tested, said Dr. Angel Contreras, who screens Dominicans seeking to enter the U.S. on immigrant visas. The high rate of MDR-TB in the Dominican Republic coupled with high HIV rates in neighboring Haiti are a health crisis in the making, he said.

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“You’re really looking at a global issue,'” said Dr. Lee Reichman, a TB expert at the New Jersey Medical School Global Tuberculosis Institute. “It’s not a foreign problem, you can’t keep these TB patients out. It’s time people realize that.”

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His [Juarez’s] treatment cost Florida taxpayers an estimated $500,000, a price tag medical director Ashkin says seems like an astronomical amount to spend on someone who’s not an American citizen. But he questions how the world can afford not to treat Juarez and others sick with similar lethal strains.

“This is an airborne spread disease . . . so when we treat that individual, we’re actually treating and protecting all of us,” he said. “This is true homeland security.”

In July, at age 21–19 months after checking in–Juarez swallowed his last pills, packed a few small suitcases and wheeled them down the hospital’s long corridor.

The last time doctors saw him, he was walking out of the sanitarium into south Florida’s soupy heat.

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