TB: A Killer's Return

For a disease that ravages the lungs, debilitating and often killing its victims, tuberculosis occupies an incongruously romantic place in the popular imagination. Perhaps that is because of its illustrious artistic affiliations: sufferers of "consumption," as it was termed in its 19th century heyday, include Keats, the Bronte sisters and the fictional heroines of La Boheme and Camille. Perceptions of the disease remain slightly sepia-toned, colored by images of wealthy consumptives strolling about scenic alpine sanatoriums. TB, in this view, is long ago and far away.

It is not. Endemic to poverty, tuberculosis is most prevalent in the developing world, and has in recent years been of particular concern in former communist-bloc nations like Romania. But health officials are now noticing an alarming spike in TB rates in Western Europe as well, especially in poor sections of large cities. While it is far from reaching epidemic proportions, Europe's increasingly porous borders, along with the appearance of multi-drug-resistant strains of the disease, are cause for enough concern that earlier this year the World Health Organization warned that unless governments act quickly, TB will make inroads in areas where it was once thought under control.

London, with an average of two deaths and 50 new cases reported each week, has become a hotspot for the disease, according to John Grange, co-author of a recent book on the disease. Though U.K. health officials dismiss the notion of a TB crisis, the current London rates of 32 per 100,000 are among the highest in Western Europe. "We certainly have some serious problems in the capital in terms of managing TB cases," says Francis Drobniewski, head of the U.K. Public Health Service's TB program. "The situation is bad and seems to be getting worse."

London is not an isolated case. In Portugal, where until the 1940s TB was the leading cause of death, the incidence of the disease remains higher than in any other European Union country, with 53 cases per 100,000. As in Britain, it tends to be concentrated in urban centers. The demographic profile is similar in France, where about 40% of the country's approximately 10 per 100,000 reported TB cases are in the Paris region. Pierre Duroux of the French National Committee Against Respiratory Diseases and Tuberculosis stresses that overall TB rates in France have been on the decline since a brief surge in the early '90s and says that the figures for Paris simply underscore the extent to which the disease is related to poverty.

For former colonial powers like Britain, Portugal and France, the disease is also linked to immigration from regions where TB is still at epidemic levels, such as Africa and the Indian subcontinent. But Drobniewski warns that poverty and immigrant status alone cannot be relied on to assess risk. "I have quite a few patients who are young, white and middle class. And frankly, their diagnosis has been delayed because people have said 'Well, they're not from Sierra Leone and they're not black, so they can't have TB.'"

Elizabeth Gray, a 37-year-old Londoner, is one of these anomalous cases. She first discovered she had the disease two years ago when she suddenly began coughing up blood during the 35th week of a pregnancy with twins. As a former nurse, she may well have contracted TB through patient contact years before and, with the stress to her immune system of a double pregnancy, the opportunistic infection was able to blossom into disease. Or, she says, "I could have picked it up standing in the queue at Woolworth's a few weeks earlier."

The disease's surreptitious path to its victims' lungs, even more than the current rise in cases, is worrying European health officials. TB is so infectious because the bacteria that cause it are carried by airborne particles. Sitting next to an infected person during a 15-minute bus ride probably won't lead to transmission, but repeated or prolonged contact — sitting near that person as part of a regular commute, or on a long-haul flight — could. Says Drobniewski, "Obviously people are far more worried about AIDS, but basically if you don't have sex and are not an IV drug abuser and don't have a blood transfusion, there's no other way you can get AIDS. But we've got to breathe."

In Eastern Europe, Romania is the worst hit, with 114 new cases of tuberculosis per 100,000 inhabitants reported last year, up from 56 per 100,000 in 1985. Says Ion Paul Stoicescu, director of the country's National Program Against Tuberculosis, "Life is bad in Romania and after the [1989] revolution the situation even deteriorated ... There is not enough money in the budget for health care." According to Stoicescu, each day seven people in Romania die of TB and 74 contract it. In the Baltic states, which could be included in the first tier of an enlarged E.U., the high incidence of TB is so troubling that in June several Scandinavian diplomats raised the issue with the Latvian Welfare Minister.

They may be too late: TB originating in Eastern Europe and other parts of the world is already beginning to take its toll in the E.U. Teresa Contreiras, an official at the Portuguese Ministry of Health, notes that there are an estimated 55,000 illegal immigrants from Eastern Europe in her country. Unlike citizens from Portugal's former colonies, who "are within the health care system and pose no risk," says Contreiras, most recent illegal immigrants do not come under the control of the authorities.

Conventional TB remains eminently treatable. Before antibiotics, the mortality rate was around 50%, but the introduction of anti tuberculosis drugs in the late 1940s and the development of various drug regimens lowered that rate in Europe to around 2%. Widespread inoculation has also kept the disease in check. In the U.K., however, the school TB vaccine program was suspended for nearly a year until last month because of manufacturing problems with the vaccine's sole U.K. supplier. A who-sponsored regimen, Directly Observed Therapy Short Course — or dots — relies on regular doses of powerful antibiotics, and at about $50 for a six-to-eight-month course, it is also cost-effective. But using the wrong drugs or combinations of drugs, or not completing the course of treatment, allows the disease to quickly become drug-resistant. Multi-drug-resistant strains — or MDR-TB — are the most deadly, and when transmitted to uninfected people, are drug-resistant from the outset.

According to the WHO, "Resistance to at least one TB drug has increased by 50% in both Denmark and Germany since 1996." In Russia, where 10% of the 1 million strong prison population is infected with TB, a third suffer from MDR-TB. In Estonia, the incidence of MDR-TB increased nearly 5% in one year to 18% of all TB cases. Central and Eastern Europe are an opportune breeding grounds for the drug-resistant strains because of the low quality of some of the antibiotics on the market there and shortages of others. "You have ad hoc combinations, interruptions and supplementations that are not appropriate," says Armin Fidler, health sector manager for Europe and Central Asia with the World Bank.

While there seems little danger of a Europe-wide outbreak along the lines of the MDR-TB strain that hit New York City in 1991, vigilance is essential. Spanish epidemiologist Mercedes Diez takes comfort in the fact that "we still have not noticed any rise in [TB] cases in Spain," but she is far from complacent. Spain has the E.U.'s highest number of AIDS cases, and HIV-weakened immune systems are particularly vulnerable to TB. Drug addicts, who account for many new AIDS cases, are also least able to exercise the discipline necessary to complete conventional TB treatment. "We realize that the disease is on the increase, and we must not allow ourselves to become lazy," Diez says. Health officials across the Continent should heed her words.

With reporting by Martha de la Cal/Lisbon, Francois Messier/Paris, Jan Stojaspal/Prague and Jane Walker/Madrid