Can we beat Koch’s bacillus?

March 24 is World Tuberculosis Day. Battling this disease is not just a series of losses but also a chronicle of great discoveries. The first in this line is obviously the turn-of-the-19-century French genius Rene Laennec. It is he who invented the stethoscope and studied tuberculosis extensively. Laennec lived for 45 years and also died of tuberculosis — well before Chekhov, Lesia Ukrainka, Nadson, Platonov, and Ilf also perished of this disease.

But the wheel of discoveries and disappointments kept on gaining momentum. In 1882 Robert Koch isolated a microbiological agent that caused the relentless disease, which was then named after him. Bacteriology and immunology seemed to be making tremendous strides. Great hopes were pinned in this connection on tuberculin, a toxic extract of Koch’s bacilli intended as an immune remedy, sort of a shield against infection. It turned out to be a double-edged sword, though it remained important in terms of diagnostics… On the other hand, the BCG Calmette-Guerin vaccine, the result of the years of re-sowing weakened bacilli strains, which is intended to produce primary immunity against TB in children, has been in wide use since 1921.

Thanks to the efforts of self-denying national scientists, Ukraine occupies quite an important place in this long-term defensive effort. It is symbolic that, thanks to Feofil Yanovsky and other noble figures of medicine, an anti-TB society was organized in Kyiv in 1900, when so much trust was placed in the new century. Indeed, Selman Abraham Waksman, a Ukrainian-born US microbiologist, was awarded the Nobel Prize in 1952 for inventing streptomycin, and the disease really loosened its grip for the first time. Yet we have entered the current century with an outbreak of tuberculosis. What are the causes and the ways of harnessing the danger of infection?

“Before the 1990s, the incidence of tuberculosis and its mortality rate looked rather optimistic against the backdrop of wide-scale organizational, medical and social measures taken,” says Prof. Vasyl Petrenko, Doctor of Medicine, head of the Phthisiology and Pulmonology Department at National Bohomolets Medical University. “A tendency to timely identify and assiduously treat tuberculosis, without being tempted by initial success, worked like a true compass. Unfortunately, in the following years economic troubles and social problems not only slowed down the effectiveness [of the program] but also triggered a major growth of TB incidence in Ukraine in 1996.”

The national anti-tuberculosis program, underway in the past few years, has really caused some changes in this face-off. Free supply of anti-TB medications to patients remains uninterrupted, various frontal projects are being carried out, and TB-induced mortality has been gradually falling since 2006, which is so far not the case with other indicators. But what really matters is a clear-cut concept of the new national anti-tuberculosis program for 2012-16. Prime Minister Mykola Azarov recently signed an instruction to this effect.

Can you please comment on the importance of this act.

“It should be noted that the order of the head of the government states: the Ministry of Health of Ukraine is to elaborate and provide by July 30, 2011, and submit for the consideration of the Cabinet of Ministers of Ukraine, the project of the given program. It’s clear that a huge amount of analytical work has been accomplished to realize these steps and the document is actually formed. Here are some basic statements. The spread of tuberculosis, first of all its multi-resistant form (resistant to major anti-tuberculosis medicine), is a threat to the country’s national security; it is one of the reasons for the loss of working capacity and health, for the levels of disability and mortality in Ukraine. The situation demonstrates the topicality of the problem of poverty and social inequality, requiring a constant growth of expenditures from the state budget.

Ukraine takes the second place after the Russian Federation among European countries in the spread of tuberculosis. In 2010 these figures were considerable. According to the WHO estimates, 16 percent of new cases and 44 percent of recurring ones, are caused by multi-resistant forms of the disease. Cases of almost incurable tuberculosis with increased drug resistance occur in the country, and their number is growing. Given the growing HIV/AIDS epidemic, increasingly transmitted via sexual contacts, in 2010 people suffering from both diseases constituted 11 percent of the overall number of new incidents of tuberculosis. The combination of multi-resistant tuberculosis with HIV within the groups particularly threatened by HIV is especially dangerous. For example, according to the information of a WHO pilot project, in the Donetsk region (in 2006) 58 percent of prisoners with co-infection had a multi-resistant form of tuberculosis.”

These threatening statements require relevant measures from a number of state and social organizations, including the Committee of Counteraction to HIV/AIDS and other socially dangerous infections. Are global measures necessary?

“The goal of the program we are talking about lies exactly in improving the epidemic situation, by decreasing the absolute numbers and mortality rates of tuberculosis patients, first of all those with co-infections; this is to be done by counteracting the spread of HIV and tuberculosis through state policy, which is based on the principles of ensuring universal and equal access to quality aid oriented toward the prevention, diagnostics and treatment of tuberculosis. At this, the methods have really improved.”

Obviously your chair is involved in this effort, also considering that you were recently chairman of the Committee to Combat HIV Infection.

“That’s right. Our chair has good traditions. We recently published a textbook on tuberculosis in Ukrainian, Russian, and English, based on one of the first such textbooks written by our teacher, Dr. Pylypchuk, M.D. We are preparing a textbook on a subject that’s getting increasingly complicated. Toward the end of March, the international conference “Tuberculosis and HIV” will be held at the University, on its Rector, Academician Moskalenko’s, initiative. Last year, the National Medical University founded the journal Tuberculosis, Lung Diseases, HIV Infections. Several issues have come off the presses. The Editorial Board is made up of scientists from various countries.”

All NMU students study modern TB treatment methods at your chair, but you apparently focus on the training of phthisiatricians. Would you care to specify?

“That’s an acute issue. We lack trained phthisiatricians; there are more than a thousand vacancies, considering that this isn’t a prestigious but risky and, most importantly, unrewarding profession. Ukraine badly needs these specialists, considering that we register 92 TB cases every day. Significantly, the Cabinet’s resolution of February 16, 2011, increased the phthisiatricians’ wages by 60 percent when treating contagious cases and 40 percent for active cases.

“However, I think this is only part of the measures that must be taken. Phthisiatricians and specialists in the preventive field need effective protection. In 2009, a total of 580 medical personnel contracted TB, so our chair is paying special attention to the training of students in this sphere, that they may follow in the footsteps of our predecessors, albeit in new, complex conditions. This is one of our traditions. A great many problems have to be solved, including effective diagnosis, considering that half of the TB patients prove to be eliminators of bacilli, so they have to be under controlled treatment using five to six medical drugs.”

The subject of our conversation is extremely topical, although some of its aspects aren’t discussed at sufficient depth. Therefore, my last question is about the TB age and social profile.

“Most patients at Kyiv’s TB prophylactic centers that are the core of the chair are able-bodied but jobless males. However, our statistics aren’t accurate enough because we lack data concerning our society’s flotsam and jetsam. Another problem is that our medical network cannot make patients with open tuberculosis undergo a programmed course of treatment. I’d also add that TB is a treacherous disease; it starts and evolves unnoticeably, manifesting itself as the common cold in the early phase, so timely medical checkups, including sputum tests and photofluorograms, are the alpha and omega.”

Listening to him, I was reminded of Dr. Petrenko who has dedicated over 30 years to this profession. Mikhail Bulgakov, who graduated from the Kyiv Medical School, said about the country’s doctors: “Here come all the king’s men.”

One can only hope that the ranks of phthisiatricians will expand thanks to the dedicated efforts of the National Medical University, because these specialists are so badly needed by our society.