“Tuberculosis is an illness that goes along with poverty”

An interview with Tuberculosis expert, Prof. Timo Ulrichs

by LKO,  2015/08/07

More than nine million people contract tuberculosis every year, about 1.5 million of them died of this illness, which in fact is curable, in 2013. That’s why tuberculosis is one of the three biggest killers of human lives, besides HIV and malaria. Professor Timo Ulrichs from Berlin is an expert in the field of infection biology and has talked to us about the rise and the dangers of this worldwide epidemic.

Professor Ulrichs, in underdeveloped countries more and more people contract tuberculosis. Why is this infectious disease on the rise there again?

Tuberculosis is an illness which goes along with poverty. In poor countries, there are much more TB patients than in industrialized countries. Undernourishment, bad hygienic living conditions and a generally higher risk of contagion because of the many patients in the surroundings with open tuberculosis, often untreated, facilitate the spreading of this infectious disease.

Why are people there not being treated adequately? There are therapies, though.

Tuberculosis can be treated. A combined therapy of four medicines can eliminate the pathogen of the body. But in underdeveloped countries, the health systems are equipped only insufficiently to be able to diagnose and treat TB patients adequately. Also the necessary screening of all close contacts of an index case is insufficiently or not at all conducted.

Diagnostics, therapy and preventive measures provided by public-health measures are very demanding and need a good infrastructure in the health system. Here, international aid can help sensibly in all the mentioned points.

Is tuberculosis a problem in the whole of the society or are only certain social groups concerned, especially in the underdeveloped states?

Tuberculosis is always also a social problem. It preferably spreads amongst disadvantaged groups, like the homeless, the unemployed, alcohol addicts etc. But it can also concern all social classes. The group of age most concerned is the one of the 25 to 45 year olds, which also causes direct socio-economic consequences which are reflected in the GDP and other economic measuring parameters.

What are the biggest problems in the fight against tuberculosis?

There are two big problems worldwide, which prevent us from controlling tuberculosis effectively. The first one is its combined appearance with HIV, especially in southern Africa. Both infectious diseases favor each other – an HIV patient has got a weak immune system and contracts tuberculosis more easily. Tuberculosis is considered being an HIV defining, opportunistic infection; a TB patient contracting HIV will reach the full AIDS scale much faster, because the immune system is active fighting TB and is such more vulnerable to the HV virus.

The second problem is the rapid increase in resistances, especially in Eastern Europe, Russia and Central Asia. Especially in the years immediately after the fall of the Soviet Union, insufficient combination therapies, the patients’ lacking compliance and undersupply of necessary medicine have led to an increased spreading of multi-resistant strains.

The movement of these strains from east to west has, moreover, been accompanied by even more resistances per clinical isolate. We call them multidrug resistant (MDR), if there are resistances against first line drugs. Extensive multidrug TB (XDR) are also resistant against second line drugs. Not long ago, pathogens have been found in South Africa, which are named TDR, totally drug resistant.

And how do these resistances develop?

If the treatment is done “blindly”, that is to say without any information about probably already existing resistances, it is possible that the combined therapy is in fact a mono-therapy. And against this kind of therapy, a pathogen easily develops a resistance. Thus, a forth resistance has unintentionally been added to the existing three resistances.

That’s why the microbiological drug sensitivity testing is absolutely necessary for an adequate diagnosis. However, this test is very complicated and can only be executed by experienced staff. That’s why the WHO has been promoting laboratory partnerships, in order to dispose of the necessary know-how within a network of national reference laboratories.

Is tuberculosis also a real danger for Germany and the rest of the industrialized countries?

Many immigrants coming from Eastern Europe or from Russia can bring in an (often already multi-resistant) tuberculosis. However, the number of such cases are rather limited, especially also in Berlin as first contact place. But resistances may develop also in Germany itself due to insufficient treatment because of gaps in doctors’ knowledge. In Germany, there is only a small number of new TB cases and therefore TB diagnosis, therapy and prevention are only marginal fields of study.

What’s the current state of research? Are there any promising research approaches, which give hope for a better treatment of this disease?

In 2014, after decades without any progress, two new drugs with new modes of action came on the market. These are urgently needed, as ever less drugs can be used because of the growing number of multi-resistances. Now it is important to make sure that the new drugs are being implemented wisely in the high-prevalence countries, in order to avoid immediate new resistances.

During the last years, there has also been significant progress in the improvement of TB diagnosis, especially for the biomolecular methods. This has led to time reduction until the diagnosis. Moreover, there are some vaccines, which are also being tested clinically. However, it’s a moot point whether if these vaccines will really provide a protection (before or after exposure). That’s why the worldwide TB control should continue working with the classic public health methods for the containment of tuberculosis.

Thank you very much for these insights. We wish you the very best for your future!

Professor Timo Ulrichs is the co-founder (2006) of the Koch-Metschnikow-Forum, an NGO which promotes the scientific cooperation between Germany and Eastern Europe in the fields of Medicine and Health Science. Professor Dr. Ulrichs is head of the division tuberculosis and runs a lot of partner projects aiming at the improvement of tuberculosis diagnosis, therapy and prevention, especially in Russia, the Georgian Republic and the Republic of Moldavia.
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