State of the Planet

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Celebrating World TB Day: Private Donations Pave Way for Progress on Multidrug-resistant Tuberculosis in Mali

To celebrate World Tuberculosis Day, the Earth Institute has linked with Becton Dickinson to improve the diagnosis of the disease in regions where it is needed most and to continue a partnership to fight multidrug-resistant tuberculosis in Africa.

When I met with the Global Health team from Becton Dickinson (BD) in November of 2007 at the World Tuberculosis Conference in Cape Town, South Africa, they announced a critical offer their company was ready to make to the Earth Institute (EI) and more specifically, to the Millennium Villages Project I was working for. BD’s offer could not have been more timely: to provide a MGIT 960™machine (1)  and one year worth of reagents to operate it to one of the 14 sites where the Millennium Villages Project (MVP) was implanted and where it would be most needed. Becton Dickinson’s goal through this partnership was to increase MVP’s capacity to accurately and timely diagnose not only tuberculosis (TB), but also its more dangerous form: multidrug-resistant tuberculosis (MDR-TB).

A stocked clinic in the Millennium Village of Tiby in Mali.

Every year, more than nine million people worldwide develop tuberculosis, the devastating illness, which is easily transmitted by sustained casual contact. Close to 1.8 million people die of TB each year—5,000 every day on average—and their deaths are for the most part preventable, because most cases are drug susceptible and TB is therefore almost always curable. Unfortunately, as the World Health Organization (WHO) reported, drug resistant strains, which are more difficult to treat, are on the rise: multidrug-resistant TB, defined as strains of TB resistant to at least the two most potent TB antibiotics (2) , account for approximately 500,000 new cases yearly. The vast majority of these cases occur in the developing world, but people with the infection can travel easily.

Becton Dickinson’s offer was not an isolated case: when Millennium Villages, a unique project that offers a holistic, innovative model for empowering rural communities to lift themselves out of extreme poverty was initiated in 2005, BD proposed to visit the first site, Sauri in Kenya, to assist the local health team undergo various performance assessments, both at the village clinic and district hospital level. After determining the gaps in diagnostic services, one of BD’s many strengths in the Global Health arena, a series of in-kind donations ensued in the forms of laboratory equipments and supplies, mostly oriented around the provision of HIV services that were not available in the Sauri cluster at the time.

As the Director of the Tuberculosis and HIV/AIDS Initiative at MVP, I had a difficult choice to make: which one of the 14 sites in the 10 countries, ranging from Senegal and Mali in West Africa to Ethiopia, Kenya and Rwanda in East Africa would benefit from the much needed tool? Coincidentally, around the time of the meeting in Cape Town, my colleagues and I were reviewing the state of MDR-TB in Africa. Based on the latest report from the World Health Organization at the time, published a few years before, Africa was not as hardly hit by high MDR-TB burdens as other countries in Latin America or countries from the former Soviet Union. This seemed odd. MDR-TB, as we now know, is man-made and results from poor or suboptimal management of TB cases who undergo treatment. The disease, which has a long and strenuous 6-month treatment regimen, requires daily direct observation of the patient’s antibiotics intake by a nurse or community health worker to verify the patient’s compliance. Without supervision, patients usually stop their medication when their TB symptoms alleviate, and when the side effects of the drugs become more debilitating than the symptoms from the disease.

That’s when MDR-TB strains are created, by interrupted courses of TB treatment. Every year, WHO reports the TB performance of each country by measuring a series of predefined indicators. This includes treatment success, a proxy to estimate the MDR-TB burden in a country. The reason why the alleged absence of MDR-TB in Africa was so puzzling is that countries in Africa had systematically, since 1999, performed at similar or worse levels than their counterparts in Latin America or countries from the former Soviet Union where levels were already considered high.

A closer examination of the WHO report unveiled a different picture: only 6 of the 46 countries in Africa ever had a drug susceptibility survey, a systematic, nationwide study of the estimated MDR-TB burden. And most of the studies were outdated! With my colleagues at Columbia University, we gathered evidence from several published and unpublished sources and mapped (see map above) what we believed to be the real MDR-TB problem in Africa (our work was subsequently published in Emerging Infectious Diseases, and drew a significantly gloomier picture of the underreported threat of MDR-TB in Africa.

While reviewing the various MVP sites to determine the best location for the MGIT 960™, I took many factors into consideration: national TB rates, alleged MDR-TB rates on the basis of the WHO report, MDR-TB rates on the basis of our study, whether a MGIT 960™ machine was already available in the country and whether there was local capacity to operate the equipment without on-site supervision. While undergoing this selection process, I decided the machine would be more beneficial to the general public of the host country if it were housed at a national, reference facility, indeed serving the whole country, rather than at one of our MVP sites, limiting its accessibility.

One country stood out in the decision process: with only 20% of the estimated cases of TB diagnosed every year, Mali desperately needed a tool to increase its diagnosis capability. Furthermore, Mali had never undergone a national MDR-TB survey, yet our estimates classified the country as “moderate” (see map), a more worrisome classification than the “No MDR-TB” one stemming from the WHO report. Mali did not have access to a MGIT 960™ in the whole country (3)  and there was a laboratory at the University of Bamako that had the technical capacity to efficiently run the equipment and protocols, following a basic series of training to be provided by BD.

And this is how on October 24th, 2008, Becton Dickinson, the University of Bamako, the National TB Control Program of Mali and the Earth Institute entered a partnership to both increase case detection rates of TB in the country, and provide the tools to undergo the first national MDR-TB survey.

In the lab.

Our initial work focused primarily on determining MDR-TB rates in Bamako, the capital of Mali. So we mapped the 6 communes and for over one year, systematically checked the rates of drug resistance in all patients attending the various clinics in the city for TB. And our findings, to be published soon, are even more worrisome than we anticipated!
As the partnership is coming to an end this month, and to mark World TB Day on March 24th, Becton Dickinson has extended yet another generous offer to the Earth Institute, and our project in Mali. Every time you click on this link, BD will donate 1 tube of reagents to continue operating the MGIT 960™ at the University of Bamako, and hopefully extend our MDR-TB survey nationally!

(1) (Mycobacterial Growth Indicator Tube, the World Health Organization recommended tool for liquid culture of the tuberculosis pathogen)
(2) Rifampicin and Isoniazid
(3) One machine was available in a research facility, but was not used for public health and diagnostic purposes, which was the goal of the partnership between EI and BD

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