... XDR-TB, defined as MDR-TB with additional resistance to a fluoroquinolone and a second-line injectable agent, is often considered untreatable and was responsible for a well-publicised outbreak in South Africa . Karakalpakstan is a semiautonomous region in the west of Uzbekistan, characterized by poverty, severe environmental degradation and slow reform of health services [8,9]. In response to an identified need, the medical aid agency Médecins Sans Frontières (MSF), in cooperation with the Ministry of Health, began the progressive implementation of a DOTS program for TB Funding: The MDR-TB program is funded primarily by Médecins Sans Frontières, Holland, with contributions in kind from the Ministry of Health in Karakalpakstan and the National Reference Center for Mycobacteria in Germany. ...
A pilot programme to treat multidrug-resistant TB (MDR-TB) was implemented in Karakalpakstan, Uzbekistan in 2003. This region has particularly high levels of MDR-TB, with 13% and 40% among new and previously treated cases, respectively.
This study describes the treatment process and outcomes for the first cohort of patients enrolled in the programme, between October 2003 and January 2005. Confirmed MDR-TB cases were treated with an individualised, second-line drug regimen based on drug susceptibility test results, while suspected MDR-TB cases were treated with a standardised regimen pending susceptibility results.
Of 108 MDR-TB patients, 87 were started on treatment during the study period. Of these, 33 (38%) were infected with strains resistant to at least one second-line drug at baseline, but none had initial ofloxacin resistance. Treatment was successful for 54 (62%) patients, with 13 (15%) dying during treatment, 12 (14%) defaulting and 8 (8%) failing treatment. Poor clinical condition and baseline second-line resistance contributed to treatment failure or death. Treatment regimens were changed in 71 (82%) patients due to severe adverse events or drug resistance. Adverse events were most commonly attributed to cycloserine, ethionamide and p-aminosalicylic acid. Extensively drug resistant TB (XDR-TB) was found among 4 of the 6 patients who failed treatment and were still alive in November 2006.
While acceptable treatment success was achieved, the complexity of treatment and the development of XDR-TB among treatment failures are important issues to be addressed when considering scaling up MDR-TB treatment.
The routine recommendation to women to count fetal movements daily during late pregnancy for the prevention of antepartum late fetal death in normally formed singletons has been evaluated. 68,000 women were randomly allocated within thirty-three pairs of clusters either to a policy of routine counting or to standard care, which might involve selective use of formal counting or informal noting of movements. Antepartum death rates for normally formed singletons were similar in the two groups, regardless of cause of prior risk status. Despite the counting policy, most of these fetuses were dead by the time the mothers received medical attention. The study does not rule out a beneficial effect, but at best, the policy would have to be used by about 1250 women to prevent 1 unexplained antepartum late fetal death, and an adverse effect is just as likely. In addition, formal routine counting would use considerable extra resources.
The Aral Sea area in Central Asia has been encountering one of the world's greatest environmental disasters for more than 15 years. During that time, despite many assessments and millions of dollars spent by large, multinational organizations, little has changed. The 5 million people living in this neglected and virtually unknown part of the world are suffering not only from an environmental catastrophe that has no easy solutions but also from a litany of health problems. The region is often dismissed as a chronic problem where nothing positive can be achieved. Within this complicated context, Medecins Sans Frontieres, winner of the Nobel Peace Prize in 1999, is actively trying to assess the impact of the environmental disaster on human health to help the people who live in the Aral Sea area cope with their environment. Medecins Sans Frontieres has combined a direct medical program to improve the health of the population while conducting operational research to gain a better understanding of the relationship between the environmental disaster and human health outcomes. In this paper we explore the health situation of the region and the broader policy context in which it is situated, and present some ideas that could potentially be applied to many other places in the world that are caught up in environmental and human health disasters.