TB tests for all.....

Should Britain test all immigrants for TB? It’s a disease almost eradicated in the native population. Yet several hundred thousand immigrants a year come, many from countries where not only active TB rates are higher in the UK, but where up to a third of the population has latent TB. That is to say they have been infected, have a few hundred of the rod-shaped bacteria in their lungs contained by their immune systems: they are asymptomatic and non infectious. In ten percent of cases, however, these latent carriers go on to develop full blown TB.
Statistically that’s about three thousand arrivals a year who will eventually develop the disease . It wouldn’t be so bad if all these cases were of normal TB, which is easy and cheap to treat, inconvenient mostly for the patient, who has to endure a six month cocktail of antibiotics even after he has begun to feel well.
But about 2-3percent of TB cases these days are multidrugs resistant (MDR) – the result of pooor drugs compliance further back in the transmission chain – and this TB is expensive and massively inconvenient to treat, susceptible only to second line drugs which are expensive, take a long time to work and have terrible side effects. There are periods when these MDR TB patients have to be kept in isolation chambers, seen to by a phalanx of doctors and nurses. The cost of treating such a patient has been estimated at £250,000 for a three year programme, and statistically Britain should be seeing about 60-80 MDR patients a year (3% of the 3,000 TB cases), as indeed it does.

To get an idea of what treatment for MDR is like, I spoke to one of few native Brits who did catch it – while in hospital (a depressingly common route), from another patient with active MDR:
Paul Thorn was a young HIV positive nurse treated for his HIV in an open ward at Westminster and Chelsea hospital in 1995 when a Brazilian came in, coughed up his sputum – the standard test – and, because the nurses failed to take precautions, infected the others. Six died. Paul survived –by enduring a painful three year course of chemotherapy, part of that period spent in an isolation room in hospital. He sent me a copy of his diary of the period.
“For some time experts had been predicting that it was only a matter of time before an outbreak of TB/MDR-TB occurred in such a way. Three months after exposure to the deadly bacteria, I was told of the outbreak. My health had already been deteriorating prior to my knowledge of the exposure. During that time the bacilli multiplied slowly in my lungs without me knowing. My slowly advancing chest pain and breathlessness were finally explained. Then without warning I lost my liberty and found myself locked away from society in a negative pressure isolation room so that I didn’t infect anyone else.”
Paul couldn’t leave the room – “you might not get out alive”, one doctor told him - and his contact with visitors was restricted. He found himself being visited by a succession of doctors and nurses in masks, and was given medication that made him woozy, confused and angry. When his story appeared in the media; he started getting letters of support – but also critical letters, asking why the taxpayer should pay for he mistakes owning to his lifestyle choice, since HIV exacerbated his condition.
But things got better: by October 1995 he was putting on weight, and had started a fitness routine.
When he was set free, he had to comply with several conditions: Though he was sputum negative and therefore very unlikely to be infectious, he still had to be careful. His doctors told him:
“You should sleep in a single room with the door closed at night, and should spend the majority of your time inside. It is relatively safe for you to go out for short periods assuming you will not be in close contact with anyone for longer than quarter of an hour or so. This means you will not be able for example, to go to restaurants, clubs, or use public transport. The flat should be properly ventilated. You will need to comply with daily direct observed therapy and will be advised to attend our out-patients' clinic once monthly. You should have no new social contacts and should not have contact with anyone who is HIV positive or otherwise immuno-compromised. You should also not have any contact with pregnant women or children."

Over the next three years Paul lost a lot of friends. His MDR TB course continued, a daily dose of five drugs taken under supervision at his local medical centre, under the internationally recognised standard of DOTS treatment, for which he says he was glad. “These drugs represent really powerful chemotherapy. I was vomiting, my lips became numb, I became paranoid because the drugs seemed through my brain membranes. I would have stopped taking the drugs.” He never did though- thanks to the support of his consultant – and now speaks regularly at conferences as well as having published a book on how to survive TB.

There are several hundred individuals being treated in the above manner, in a lowokey way, in centres in London, Liverpool and elsewhere – under John Moore Gillon at Bart’s; under prof Peter Davies at the Liverpol cardiothoracic centre. Though invidious to question the dedication of staff or the determination to be cured of MDR patients, Paul did admit that he was often tempted to quit: to walk out and disappear into the community, with his uncured MDR.

It’s not that easy catch someone else’s TB, you have to spend hours in their company in an environment saturated with cough droplets, so catching it on the tube is unlikely. But there have been outbreaks – in Leicester, London, in the former a school, among former residents of a squat, from where it rippled out to 67 friends, relatives others. These have not been any multidrugs resistant outbreaks, yet.
The MDR treatment bill in the UK may only run into the tens of millions of pounds a year – these are the decisions policy-makers have to make all the time. Prof Davies does not think screening worthwhile = for a start the detection test s for MDR are complex and beyond the capabilities of embassy staff, at least until electronic kit becomes available, Then it raises the questions: if immigrants, why not all visitors? Students, tourists, temporary workers, since they could equally well –albeit at lower risk – be carriers. .No other country has gone down that route, ever..
But it’s worth awareness raising. Paul told me of one case in West London where a GP took a year to diagnose his patient with TB, having done tests for cancer as well as the usual respiratory diseases. Prof Davies blamed the drugs companies for pushing asthma drugs in the medical journals, with their slogans aimed at doctors “Cough..Think asthma” The drugs firms have long found it more profitable to invest in such western world ailments than in TB. (Though that is slowly changing.)
For while it must be a surprising fact to many that not only is disease associated with Victorian “romantic” death not eradicated but is the world’s second biggest infectious killer, it remains overwhelmingly disease of poor countries.