WHO/NEW YORK CITY PRESS BRIEFING ON TB

22 March 1996

Press Briefing

19960322 FOR INFORMATION OF UNITED NATIONS SECRETARIAT ONLY

An Associate Commissioner in the New York City Department of Health, Fred Winters, said at a joint press briefing with the World Health Organization (WHO) this morning on the occasion of the 1996 World Tuberculosis Day that the disease was a study in contradictions. While a cure for it had been discovered more than 10 years ago, few cities and nations had shown commitment and provided the means to control it. New York had about 2,445 cases in 1995, 18.4 per cent below the 2,995 reported in 1994. If Governments showed the commitments necessary and adopted the Directly Observed Therapy (DOT), they might be able to scale down the number of tuberculosis cases. The DOT, in which health-care workers observe patients taking their anti- tuberculosis medications, was a highly successful model credited with New York's dramatic advance against the disease.

Mr. Winters introduced other participants in the press conference. They were Thomas Frieden, Director of the Tuberculosis Control Bureau of the city's Department of Health; Richard Bumgarner, Senior Programme Management Officer of the WHO Global Tuberculosis Programme in Geneva, and Dr. Paul Nunn, Chief of the Programme's Research and Surveillance Unit. The WHO officials participated in the conference via satellite link-up.

Joining the conference, Mr. Bumgarner said, "the WHO would like to take its hat off to New York City for the excellent performance that it's demonstrated to the world in applying the DOT strategy". The people of New York were benefitting from having to pay far less because they were treating tuberculosis correctly. But, the same could not be said for most parts of the world where the disease continued to rage. Currently, about one third of the people in the world carried the germ, which attacked both the rich and the poor alike. Based on the inaction of governments, it seemed that much of the planet was unconcerned about stopping it. Also, unprecedented levels of neglect during the 1970s and 1980s helped to create the situation. In 1993, the WHO declared a global TB emergency, prompting some governments to increase their responses. But only about 500,000 cases were successfully receiving a DOT-based strategy of care. That left about 7.5 million people either receiving inadequate treatment, dying or risking the development of multidrug- resistant tuberculosis.

Dr. Nunn said that nearly 3 million people died from tuberculosis in 1995, surpassing the worst years of the epidemic around 1900, when an estimated 2.1 million people died annually. More people died from tuberculosis in 1995 than in any other year in history. It might take more than 30 million lives in the next 10 years, unless drastic efforts were made to control it. "The 3 million deaths in 1995 were approximately 10,000 times

as many as those caused by the ebola virus." It was a disease that killed the poorest people, women in developing countries, children and those infected with HIV. In some parts of Africa, for instance, about 35 per cent of the general population was HIV-infected.

Since TB spread through the air, "wearing condoms will not protect you against tuberculosis. Being a vegetarian in Britain will not protect you against tuberculosis", he said. Yet a highly effective and cost-effective treatment existed for the disease. That was a contradiction because governments had failed to introduce effective programmes such as DOT. Nations that follow the WHO-recommended DOT strategy, such as United Republic of Tanzania, China and Malawi, had discovered that they could double the number of patients they cured. An unfortunate result of inadequate treatment was the development of drug resistance and, in particular, multidrug resistance. "The big concern for the next decade must be the unholy alliance that we could see between drug resistance and HIV." There was plenty of both in the developing countries already, but with proper and well-organized tuberculosis control programmes, their threats could be reduced. "We therefore have a window of opportunity, a narrow space of time in which we can actually do something." If nothing was done in, for instance, Asia, where HIV was increasing and which accounted for two thirds of the world's TB cases, there would be a global catastrophe.

Mr. Frieden, of the New York City Department of Health, added that there was hope in the struggle against tuberculosis. It could be controlled by using the DOT strategy and the Mayor of New York, Rudolph W. Guiliani, would this afternoon announce the city's achievements, such as the fact that the number of new tuberculosis cases in 1995 had dropped, marking the third consecutive decline in new cases after a 14-year rise. Also, the city accounted for 35 per cent of the nation's decline in the number of cases between 1992 and 1995. Its tuberculosis rate was now 33.4 cases per 100,000 people. The number of multidrug-resistant cases in the city had gone down by about 40 per cent from 1994 and 75 per cent since 1992 -- from 441 in 1992 to 105. The decrease in TB had helped New Yorkers through the tax dollars they saved and in improvements in the quality of life. With 1,400 fewer cases in 1995 than 1992, the city had saved hospital costs of more than $40 million last year alone and more than $110 million since 1992.

Despite that progress, he said, the epidemic was far from over, as the city was a place which had nearly four times as many TB cases as the national average. The disease primarily affected the newest New Yorkers and HIV patients. In 1992, at the peak of the recent tuberculosis epidemic, foreign- born patients accounted for 18 per cent of the city's caseload. While new cases among HIV suffers had been cut by using DOT, those related to immigrants were rising. Preliminary data indicated that foreign-born patients accounted for about 40 per cent of all cases.

TB Briefing - 3 - 22 March 1996

Since no one immune to TB and international travel could not be slowed down, he said more efforts should be made to check the disease through the DOT strategy. Such a strategy would include the creation of a human bond between the patient and the health worker and the monitoring of patients to ensure that they took their meditations until they were cured. Since such a simple method proved to be effective in fighting tuberculosis, it should be widely adopted and used.

In response to a question on whether the disease's multidrug resistance was being exacerbated by the growing loss of biodiversity, Dr. Nunn, of the WHO, said that there was no evidence of that. Rather, the growth of multidrug resistance was due to human incompetence. Doctors and hospitals were failing to ensure that patients took their medications for the six months it usually took to be fully cured. In many instances, they stopped taking their drugs once they felt better even though the germs had not been killed. That was quite common with poor people who might not be able to afford the entire treatment. When they fell ill again, they would then resume taking their prescription. But by then, the germs might have become resistant to the drugs.

Asked whether there were ways to screen out and prevent carriers from crossing borders, Dr. Nunn said that the best way to do so would be to ensure introduction of global programmes to control the disease and prevent it from spreading. Mr. Bumgarner added that the entire world should work together to control the disease for as little as 10 United States cents per capita and with a wider use of the DOT. There were about 2 billion tuberculosis-infected people all over the world. Many had not yet developed the disease, though.

Asked for comments on the spread of drug resistance, Mr. Frieden, said that it was not new but that the use of the DOT strategy had reduced its emergence and even reversed it.

In response to a question as to why tuberculosis cases had doubled in some periods, he gave the following four main reasons: it attacked those infected with HIV; immigration, with foreign-born New Yorkers accounting for 40 per cent of new cases; cuts in tuberculosis control efforts; and social changes. Social changes included overcrowding, homelessness and incarceration. The DOT strategies had helped control the spread of the disease.

Speaking from Geneva, Mr. Bumgarner, of the WHO, added that China, for instance, had a large number of patients. Up to 1992, the DOT strategy had not been followed and China had had 1.5 million patients. Then, half of the country, about 12 provinces, introduced the DOT strategy, treating 350,000 patients and curing 90 per cent of them. If the other parts of China joined in the programme, the country would experience the dramatic improvements being witnessed in New York.

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Asked whether, with the United Nations financial crisis, there was evidence that money would be available for global efforts to check the disease, Mr. Bumgarner said there was not. But since the global emergency was declared in 1993, several donor countries had increased their allocations for a global fight against tuberculosis. They included Japan, United Kingdom and Germany. The World Bank had increased its commitments to health projects over the last seven years to a point where total commitments for tuberculosis control were nearing $100 million. However, the sums were far below what was needed to help poor countries import the antibiotics they needed.

"Foreign aid to the poor countries to help them purchase the high- quality drugs ... which can be made in the rich countries is, indeed, a very good thing for the world," he said. "It saves lives. It creates employment. It returns shareholder investment. It makes good use of tax dollars ... to reduce an air-borne, infectious threat which will inevitably spread from the poor world to the rich world if we continue to neglect it the way it has been in the last decade."

Mr. Winters added that the 18.4 per cent drop in new cases in New York had saved the city about $40 million in health-care costs in 1995 alone and more than $110 million since 1992.

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