ECDC: Tuberculosis Rates Declining, But Not Fast Enough

Credit ECDC Tuberculosis monitoring and surveillance 2015

 

 

# 9837

Although we tend to focus mostly on new and emerging health threats, old scourges like Tuberculosis continue to impact global health, and claims over a million lives each year.

 

Each March, we observe World TB day on the anniversary when Dr. Robert Koch announced his discovery of Mycobacterium tuberculosis in 1882.

 

First some quick facts about TB from the World Health Organization, followed by a press release from the ECDC on their annual TB surveillance and progress report, and a joint statement between the ECDC and WHO.

 

Tuberculosis

Fact sheet N°104
Reviewed March 2015

---

Key facts

• Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent.
• In 2013, 9 million people fell ill with TB and 1.5 million died from the disease.
• Over 95% of TB deaths occur in low- and middle-income countries, and it is among the top 5 causes of death for women aged 15 to 44.
• In 2013, an estimated 550 000 children became ill with TB and 80 000 HIV-negative children died of TB.
• TB is a leading killer of HIV-positive people causing one fourth of all HIV-related deaths.
• Globally in 2013, an estimated 480 000 people developed multidrug resistant TB (MDR-TB).
• The estimated number of people falling ill with TB each year is declining, although very slowly, which means that the world is on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015.
• The TB death rate dropped 45% between 1990 and 2013.
• An estimated 37 million lives were saved through TB diagnosis and treatment between 2000 and 2013.

 

 

This from the ECDC.

 

Tuberculosis cases down by 6% in 2013 – pace too slow to reach elimination this century

17 Mar 2015

​In 2013, 64 844 tuberculosis cases were reported by 30 EU/EEA Member States, according to new data published today by the European Centre for Disease Prevention and Control and the WHO Regional Office for Europe. The notification rate of 12.7 per 100 000 population observed in 2013 constitutes a 6% decrease compared to the previous year, when some 68 000 cases were notified.

The overall downward trend within the European Union and European Economic Area (EU/EEA) is influenced by a marked decline of TB in high-incidence countries such as Romania, which accounts for 26% of all reported cases in the EU/EEA, whereas in some low-incidence countries like Denmark, Norway and Sweden, notification rates are actually going up.

“Our data show a Europe in need of tailored interventions which target each country’s settings”, says ECDC Director Marc Sprenger ahead of World TB Day. Despite historically low numbers and a significant decline over the last ten years, the EU/EEA countries are not all progressing in the same way and face specific challenges in their TB control efforts. In most low-incidence countries, rates are stable or going down only very slowly and the majority of patients are of foreign-origin. Countries with high incidence overall face higher rates of re-infection and relapses and report many more multidrug-resistant (MDR TB) cases.

According to the new data, only 4% of TB cases tested for drug-resistance are MDR TB. However, treatment success rates for these cases are very low and have remained unchanged over the past 10 years.

TB elimination still too far away
“At the current pace of an annual 6% decline, the EU/EEA will only be free of tuberculosis in the next century. In order to achieve elimination by 2050 for example, we would have to cut down cases at least twice as fast”, warns Sprenger. In order to achieve TB elimination, current tools and interventions like early diagnosis, correct treatment and contact tracing have to be used more efficiently. In a next step, the currently available tools have to be complemented by new and more effective ones, including better diagnostic tools, shorter treatment and an effective vaccine.

ECDC working with countries
The goal of TB prevention and control will be one of the main topics of the first Ministerial Conference on TB and MDR TB, to be held in Riga on 30-31 March under the Latvian EU Council Presidency, and where ECDC will be participating. On 1-2 April, a technical meeting organized by ECDC and the Centre for Disease Prevention and Control of Latvia will discuss how to address TB and MDR TB in high-priority countries.

Tuberculosis monitoring and surveillance 2015

Credit ECDC – Warning LARGE PDF

Joint Press Release ECDC/WHO Europe: Every day, 1 000 people get sick with tuberculosis in the European Region

Every day, 1 000 people get sick with tuberculosis in the European Region

Stockholm/Copenhagen 17/3/2015

An estimated 360 000 Europeans developed tuberculosis (TB) in 2013 – 1 000 people on a daily basis. According to new data published today by the European Centre for Disease Prevention and Control and the WHO Regional Office for Europe, the number of TB cases dropped by about 6% compared to 2012, continuing a sustained decline over the last decade across the Region. But rates of multidrug-resistant (MDR) TB remain at very high levels, particularly in the so-called 18 high priority countries which see 85% of all new TB cases in the Region. These countries also account for most of the 38 000 TB-related deaths in 2013.

(Continue . . . )

PHE: Transmission Of Bovine TB From Felines To Humans - UK

 

 

# 8410

 

Readers with good memories will recall that back in 2010 I wrote a blog called Badgers? We Don’t Need No Stinkin’ Badgers!, that looked at a controversial plan to cull badgers in the UK in an attempt to reduce the wildlife reservoir of Mycobacterium bovis which is the cause of tuberculosis in cattle (known as bovine TB).

 

M. bovis is also capable of infecting humans (mainly through unpasteurized milk), although famers in contact with infected cattle are at risk as well.

 

In fact, of the three type of Tuberculosis bacteria (Mycobacterium bovis, M. avium, and M. tuberculosis – the most prevalent strain in humans), M. bovis has the largest host range – being capable of infecting just about all warm-blooded vertebrates.

 

Last year, a study appeared in the CDC’s EID Journal that attempted to estimate the global burden of M. bovis infection in humans (see Zoonotic Mycobacterium bovis–induced Tuberculosis in Humans), and found that while the number was small (roughly 1 per 100,000 pop.) - it was not insignificant – particularly in areas of the world where unpasteurized milk is still widely consumed.

 

DEFRA calls Bovine TB one of the biggest challenges facing UK cattle industry, and cites the following key facts:

• 5.5 Million – total number of TB tests on cattle in England in 2011.
• 28,000 – approximate number of cattle slaughtered for TB control in England in 2012.
• 3,900 – approximate number of new TB incidents in 2012 (herds where at least one animal tests positive for bovine TB, when the herd had previously been TB free).
• 11.5% of cattle herds in England were under cattle movement restrictions at some point in 2011 (the 2012 statistics will be published once additional quality assurance checks have been completed).
• 23.6% of cattle herds in the South-West were under cattle movement restrictions at some point in 2011 (the 2012 statistics will be published once additional quality assurance checks have been completed).
• £500 million – the amount it has cost the taxpayer to control the disease in England in the last 10 years.
• £1 billion – estimated cost of TB control in England over the next decade without taking further action.
• £34,000 – the average cost of a TB breakdown on a farm, of which around £12,000 falls to the farmer.

 

While many farmers see badgers as the primary source of their bovine TB woes, and blame them for reintroducing the disease into their herds each year, conservation and animal rights groups strongly disagree, and argue that the badger is the victim here.

 

They maintain that cow-to-cow transmission is the primary route of infection, and that badgers usually get the disease from cattle – not the other way around.

 

Four years, and a pilot culling program later, and the controversy still reigns. Recent media coverage has run the gamut from TB strategy about much more than badger culling – Paterson -Farmers Guardian to MPs vote overwhelmingly to halt badger cull in England – The Guardian.

 

Adding a new dynamic to an already complex and contentious debate, yesterday Public Health England released a report on two rare human infections with M. bovis – both associated with an outbreak in cats – which likely became infected via contact (directly or indirectly) with badger setts (dens). 

 

The feline outbreak is described in a letter published in the BMJ’s Veterinary Journal called Mycobacterium bovis infection in cats by Nigel Gibbens, which prompted a full epidemiological investigation.  A brief excerpt:

 

BETWEEN December 2012 and March 2013, a veterinary practice in Newbury (west Berkshire) diagnosed nine cases of Mycobacterium bovis infection in domestic cats. In seven of those cases the diagnosis was confirmed by bacteriological culture. The nine affected cats belonged to different households and six of them resided within a 250 metre radius. The animals presented with mycobacterial disease of variable severity including anorexia, non-healing or discharging infected wounds, evidence of pneumonia and different degrees of lymphadenopathy. The latest information is that six of the cats have been euthanased or have died. The three surviving animals are undergoing treatment and are reported to be responding. At the time of writing, no new cases had been detected in local cats since March 2013.

 

PHE published the following press release on their website yesterday regarding the epidemiological investigation that turned up two probable cases where humans contracted M. bovis from cats.

 

Cases of TB in domestic cats and cat-to-human transmission: risk to public very low

Published 27 March 2014

Two people in England have developed tuberculosis after contact with a domestic cat infected with ‘Mycobacterium bovis’ (‘M. bovis’), Public Health England (PHE) and the Animal Health and Veterinary Laboratories Agency (AHVLA) have announced.’‘M. bovis’ is the bacterium that causes tuberculosis (TB) in cattle (bovine TB) and in other species.

Nine cases of ‘M. bovis’ infection in domestic cats in Berkshire and Hampshire were investigated by AHVLA and PHE during 2013. PHE offered TB screening to 39 people identified as having had contact with the infected cats as a precautionary measure. 24 contacts accepted screening. Following further investigations, a total of 2 cases of active TB and 2 cases of latent TB were identified. Latent TB means they had been exposed to TB at some point but they did not have active disease. Both cases of active TB disease have confirmed infection with ‘M. bovis’ and are responding to treatment.

There have been no further cases of TB in cats reported in Berkshire or Hampshire since March 2013. PHE has assessed the risk of transmission of ‘M. bovis’ from cats to humans as being very low.

Dr Dilys Morgan, head of gastrointestinal, emerging and zoonotic diseases department at PHE, said:

“It’s important to remember that this was a very unusual cluster of TB in domestic cats. ‘M. bovis’ is still uncommon in cats - it mainly affects livestock animals. These are the first documented cases of cat-to-human transmission, and so although PHE has assessed the risk of people catching this infection from infected cats as being very low, we are recommending that household and close contacts of cats with confirmed ‘M. bovis’ infection should be assessed and receive public health advice.”

The findings of the animal health aspects of this investigation are published in The Veterinary Record today, 27 March 2014.

 

Molecular analysis at AHVLA showed that ‘M. bovis’ isolated from the infected cats and the human cases with active TB infection were indistinguishable, which indicates transmission of the bacterium from an infected cat. In the other cases of latent TB infection, it is not possible to confirm whether these were caused by ‘M. bovis’ or the source of their exposure.

 

Transmission of ‘M. bovis’ from infected animals to humans can occur by inhaling or ingesting bacteria shed by the animal or through contamination of unprotected cuts in the skin while handling infected animals or their carcasses.

 

Professor Noel Smith, Head of the Bovine TB Genotyping Group at AHVLA, said:

“Testing of nearby herds revealed a small number of infected cattle with the same strain of ‘M. bovis’ as the cats. However, direct contact of the cats with these cattle was unlikely considering their roaming ranges. The most likely source of infection is infected wildlife, but cat-to-cat transmission cannot be ruled out.”

Cattle herds with confirmed cases of bovine TB in the area have all been placed under movement restrictions to prevent the spread of disease.

 

Local human and animal health professionals are remaining vigilant for the occurrence of any further cases of disease caused by ‘M. bovis’ in humans, cats or any other pet and livestock animal species.

(Continue . . . )

 

The PHE also released a HAIRS Risk Assessment, where they characterized the risk to public health as:

 

A Very low risk of transmission of M. bovis from cats to humans.

 

Although the risk of acquiring TB from a domestic cat in the UK is exceedingly low, and even less likely here in the United States, this report illustrates how animals – both wild and domestic – can carry and transmit zoonotic infections to humans.

 

This intersection of man and other species, and their sharing of viruses (zoonotic transmission), has increasingly been recognized as a driving factor in emerging infectious diseases, and even the creation of pandemics.

 

The age of emerging infectious diseases in humans really began in earnest about 10,000 years ago when humans began to domesticate – and live in close proximity to – other animals (see The Third Epidemiological Transition).

   

Measles probably evolved from canine distemper and/or the Rinderpest virus of cattle. Tuberculosis, which now infects 1/3rd of humanity, likely jumped from domesticated goats and cattle.  And influenza’s all seem to have an origin in waterfowl.

 

Other zoonotic nasties include Babesiosis, Borrelia (Lyme), Nipah, Hendra, Malaria, Hantavirus, Ebola, Leptospirosis, Q-Fever, bird flu . . . the list is long and growing.

 

Roughly 70% of the infectious diseases that afflict man today are believed to have begun in some other species, and new ones (think MERS-CoV, H7N9, H5N1, SFTS, etc. ) continue to show up each year. We live in an amazingly complex and interconnected world, where what happens in a live poultry market in China, a camel stable in Saudi Arabia, or a pig farm in Mexico can ultimately impact the health of people around the world.

 

So we watch these spillovers of diseases from animals to humans – no matter how rare, or small they may be – with considerable interest.

WHO: Global Tuberculosis Report – 2013

 

Credit WHO

 

# 7889

 

Nearly twenty years ago the World Health Organization declared tuberculosis a public health emergency, and that organization (along with many others) has been working towards a goal of reducing the number of TB related deaths in half by 2014.

 

Today, WHO has today release their 18th global report on tuberculosis,  which outlines the progress to date, and the challenges ahead in the global battle.  Using their @WHO twitter account, WHO began tweeting details early this morning.

 

A few excepts from the Executive Summary, and then links to and excerpts from the press release follow:

COUNTDOWN TO 2015: key findings

On track:

• The rate of new TB cases has been falling worldwide for about a decade, achieving the MDG global target. TB incidence rates are also falling in all six WHO regions. The rate of decline (2% per year) remains slow.
• Globally by 2012, the TB mortality rate had been reduced by 45% since 1990. The target to reduce deaths by 50% by 2015 is within reach.
• Two WHO regions have already achieved the 2015 targets for reduced incidence, prevalence and mortality: the Region of the Americas and the Western Pacific Region.
  
• Of the 22 high TB burden countries (HBCs) that account for about 80% of the world’s TB cases, seven have met all 2015 targets for reductions in TB incidence, prevalence and mortality. Four more HBCs are on track to do so by 2015.

Off track:

• By 2012, the level of active TB disease in the community (prevalence) had fallen by 37% globally since 1990. The target of a 50% reduction by 2015 is not expected to be achieved.
• The African and European regions are currently not on track to achieve the mortality and prevalence targets.
• Among the 22 HBCs, 11 are not on track to reduce incidence, prevalence and mortality in line with targets. Reasons include resource constraints, conflict and instability, and generalized HIV epidemics.
• Progress towards targets for diagnosis and treatment of multidrug-resistant TB (MDR-TB) is far off-track. Worldwide and in most countries with a high burden of MDR-TB, less than 25% of the people estimated to have MDR-TB were detected in 2012.
• Many countries have made considerable progress to address the TB/HIV co-epidemic. However, global-level targets for HIV testing among TB patients and provision of antiretroviral therapy (ART) to those who are HIV-positive have not been reached.

 

And the press release:

 

Gains in tuberculosis control at risk due to 3 million missed patients and drug resistance

Progress in TB control can be substantially accelerated by addressing these challenges

News release

23 October 2013 | LONDON/GENEVA - Tuberculosis (TB) treatment has saved the lives of more than 22 million people, according to the WHO "Global tuberculosis report 2013" published today. The report also reveals that the number of people ill with TB fell in 2012 to 8.6 million, with global TB deaths also decreasing to 1.3 million.

The new data confirm that the world is on track to meet the 2015 UN Millennium Development Goals (MDGs) target of reversing TB incidence, along with the target of a 50% reduction in the mortality rate by 2015 (compared to 1990). A special "Countdown to 2015" supplement to this year’s report provides full information on the progress to the international TB targets. It details if the world and countries with a high burden of TB are “on-track” or “off-track” and what can be done rapidly to accelerate impact as the 2015 deadline approaches.

(Continue . . . )

You can download the 2013 report (either in sections, or in its entirety) at the following link:

Global tuberculosis report 2013

This is the eighteenth global report on tuberculosis (TB) published by WHO in a series that started in 1997. It provides a comprehensive and up-to-date assessment of the TB epidemic and progress in implementing and financing TB prevention, care and control at global, regional and country levels using data reported by 197 countries and territories that account for over 99% of the world’s TB cases.

WHO/ECDC: 1 In 5 TB Patients With Extrapulmonary TB

Credit ECDC

 

# 7013

 

While many are unaware of it, tuberculosis infections can spread far beyond the lungs. When that happens it most often involves the lymph nodes (Tuberculous lymphadenitis), or  pleural, and skeletal/joint areas, although any organ can be involved.

When the TB bacillus infects areas outside of the lungs it is considered an extrapulmonary infection. Diagnosis of extrapulmonary TB can be difficult, and is easily missed.

 

Today, in advance of next Sunday’s World TB Day, the ECDC and the World Health Organization have released a joint report on the treatment of TB. While reductions in pulmonary TB were reported in EU/EEA countries in 2011, the same cannot be said for extrapulmonary TB infections.

 

New ECDC/WHO Euro report: One in five TB patients has extrapulmonary tuberculosis

19 Mar 2013

Every day, around 200 people fall sick with tuberculosis (TB) across the EU/EEA, signalling that there is no room for complacency when it comes to TB prevention and control even in times of financial austerity. To mark World TB Day on the 24 March, ECDC and the WHO Regional Office for Europe release new surveillance data today.

 

The data show that the EU/EEA countries reported over 72 000 cases of TB in 2011, which is a 4% decrease compared to 2010. The average notification rate - 14.2 per 100 000 population - also represents a decline of pulmonary TB notifications. Notification rates vary significantly across Europe, from 2.8 in Iceland to 89.7 in Romania.

 

ECDC contributes to TB control by raising awareness and supporting  EU countries, as director Marc Sprenger points out: “Our primary aim is to further reduce TB transmission by timely diagnosis and adequate treatment of pulmonary TB. This is essential for TB elimination. But we should not forget about the patients with extrapulmonary TB: this group is often neglected in TB control strategies. In 2011, 22% of all notified patients in the EU/EEA had extrapulmonary TB, which can affect any organ of the body making the diagnosis particularly difficult for both physicians and patients”.

Extrapulmonary TB: a challenging diagnosis

A case with TB outside the lungs is considered an extrapulmonary TB case. Symptoms may be diffuse and mimic other pathologies, delaying the diagnosis or making it particularly difficult. In 2011, globally 6.2 million TB cases were notified, 0.8 million with extrapulmonary TB. In the European Union, one in five tuberculosis patients has extrapulmonary TB and unlike pulmonary TB, this form of the disease does not show a downward trend. Extrapulmonary TB is rarely infectious but contributes significantly to TB-related morbidity and can cause complications, lifelong sequelae and disabilities.

 

For World TB Day 2013, ECDC is launching a video documentary that focuses on extrapulmonary tuberculosis (TB). Two patient stories illustrate how difficult the diagnosis of extrapulmonary TB can be before proper treatment and care can start:

Winnie, 39 years old, living in Stockholm (Sweden)

After the first symptoms of abdominal pain started, Winnie visited her family doctor. With increasing swelling of the abdomen, the 39 year-old mother of two was later referred to Stockholm’s Karolinska Hospital gynaecological clinic. The suspected diagnosis of ovarian cancer made Winnie fear for her life and the future of her family.
Seven months after the first symptoms, Winnie was finally told she had extrapulmonary tuberculosis. Treatment started almost immediately: it was just the beginning of Winnie’s battle against the disease.

Italian patient, 54 years old, living in Brescia (Italy)

Nothing indicated that it could be tuberculosis causing the painful swelling in the chest of one Italian patient. For months, her family doctor and several speciality doctors struggled to find a diagnosis that matched her elusive symptoms.
Only after a full clinical investigation did the 54 year-old housewife learn that she had tuberculosis, not in her lungs, but in her chest. For her, the word “tuberculosis” still carries stigma and discrimination. That’s why she decided to share her story but not her identity.

TB treatment

Adequate treatment is essential to prevent the development of the drug-resistant forms of the disease, the multidrug-resistant TB (MDR TB) and the extensively drug-resistant TB (XDR TB). In 2011, cases of MDR TB have decreased but continue to be prevalent especially in the Baltic countries.

 

The ECDC/WHO surveillance report highlights that for the patients with known treatment outcome, only 74% were treated successfully. For 17%, treatment outcome is unknown. This is especially serious given that one untreated TB or MDR TB patient can infect 10-15 other individuals per year.

Press Release “Adequate treatment essential to stop TB across Europe - ECDC/WHO new report”

Watch

Extrapulmonary Tuberculosis: a challenging diagnosis - video documentary

Download

ECDC/WHO TB Surveillance and Monitoring Report 2013
ECDC/WHO TB Surveillance and Monitoring Report 2013 Slide presentation - main findings

Join
Joint twitter chat on Tuberculosis - 22 March 11:00 CET
Use #TBchat
Follow us on @ECDC_EU

 

A few recent blogs on the spread of TB, and particularly the threat posed by MDR-TB, you may wish to revisit:

 

Study: Substandard & Falsified TB Drugs

Lancet: TB Vaccine Trial Disappoints

EID Journal: The Emergence Of `Totally Resistant TB’

EID Journal: XDR-TB/HIV Treatment Outcomes

Study: Substandard & Falsified TB Drugs

(From the 2011 TB Progress Report)

# 6914

 

A topic we’ve looked at before – the proliferation of substandard or fake medications – is back in the news today with the publication of a field analysis of the quality of first line anti-Tuberculosis drugs (isoniazid and rifampicin) collected from pharmacies from 17 low- and middle-income countries.

 

The results are reminiscent of those we saw a year ago in an report in The Lancet that looked at the quality of Malarial drugs (see Lancet: 1/3rd Of Malaria Drugs Fake Or Sub-Standard).

 

Not only can using substandard (or fake) drugs endanger the person taking them, their use can lead to the rise of greater drug resistance.

 

And that endangers everyone.

 

Last October, in Interpol & FDA: Operation Pangea V, we looked at some of the International efforts to curb the trafficking in counterfeit drugs.

FDA PSA on Counterfeit Drugs

 

Today’s study, published this month in the International Journal of Tuberculosis and Lung Disease, found  9.1% of the drugs tested failed to have the requisite levels of API (Active Pharmaceutical Ingredients) or failed a disintegration test. 

 

The abstract was published on PubMed last month.

 

Substandard and falsified anti-tuberculosis drugs: a preliminary field analysis

R. Bate, P. Jensen, K. Hess, L. Mooney, J. Milligan.

Abstract

SETTING: Pharmacies in 19 cities in Angola, Brazil, China, Democratic Republic of Congo, Egypt, Ethiopia, Ghana, India (n = 3), Kenya, Nigeria, Russia, Rwanda, Thailand, Turkey, Uganda, United Republic of Tanzania and Zambia.

OBJECTIVE: To assess the quality of the two main first-line anti-tuberculosis medicines, isoniazid and rifampicin, procured from private-sector pharmacies, to determine if substandard and falsified medicines are available and if they potentially contribute to drug resistance in cities in low- and middle-income countries.

DESIGN: Local nationals procured 713 treatment packs from a selection of pharmacies in 19 cities. These samples were tested for quality using 1) thin-layer chromatography to analyze levels of active pharmaceutical ingredient (API), and 2) disintegration testing.

RESULTS: Of 713 samples tested, 9.1% failed basic quality testing for requisite levels of API or disintegration. The failure rate was 16.6% in Africa, 10.1% in India, and 3.9% in other middle-income countries.

CONCLUSIONS: Substandard and falsified drugs are readily available in the private marketplace and probably contribute to anti-tuberculosis drug resistance in low- and middle-income countries. This issue warrants further investigation through large-scale studies of drug quality in all markets.

 

While the study appears to be available only to subscribers at the Journal, I found it available on the American Enterprise Institute website in its entirety at the link below:

 

Substandard and falsified anti-tuberculosis drugs: A preliminary field analysis

Roger Bate, Lorraine Mooney, Kimberly Hess, Julissa Milligan, Paul Jensen | The International Journal of Tuberculosis and Lung Disease

 

Roger Bate also authors a commentary that warns of the dangers of these drugs - published on Feb. 5th in the International Herald Tribune - called:

 

Feeding a Disease With Fake Drugs

By ROGER BATE

Published: February 5, 2013

EID Journal: The Emergence Of `Totally Resistant TB’

 

(From the WHO 2011 TB Progress Report)

 

# 6896

 

 

The existence of TDR-TB (Totally Drug Resistant Tuberculosis) has been fraught with controversy since the term first sprang into the headlines a little more than a year ago (see Crofsblog India: New TB strain is "totally drug-resistant" (updated)).

The story concerned at least 12 patients treated at an Indian hospital that had been diagnosed with `TDR-TB’. 

 

Not - as has been seen in the past - MDR-TB (multi-drug resistant tuberculosis), and XDR-TB (extensively drug resistant Tuberculosis), but tuberculosis that was supposedly resistant to all known drugs.

 

Varyingly resistant forms of TB have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients. Patient compliance for long-term treatment has consistently been a major obstacle.

 

Until now – as difficult as treatment might have been - there has always been some combination of antibiotics that could be used to treat even the most resistant of TB cases.

 

The emergence of a totally resistant form of the disease would be a game-changer, and so these reports began to set off alarm bells around the world.

 

A few days later, in ECDC Comment On Drug Resistant TB In India, we saw calls to avoid using the term TDR-TB until it could be better defined. 

 

From the ECDC report New drug resistant form of tuberculosis reported in India.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

During this time, Maryn McKenna – Flublogia’s favorite scary disease girl – wrote extensively about these developments on her Superbug Blog:

 

Totally Resistant TB: Earliest Cases in Italy

• By Maryn McKenna January 12, 2012

India Reports Completely Drug-Resistant TB

• By Maryn McKenna January 9, 2012 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna January 14, 2012 

 

That same week, in Resistant TB: The Limits Of Surveillance & Reporting, I wrote about the World Health Organization’s initial response to these reports (they did not currently recognize TDR-TB due to reasons stated in their TDR-TB FAQ), along with an article in the Indian Express suggesting that TDR-TB cases may be more widespread than reported. 

 

By the end of January, India’s government was denying the existence of untreatable TB in their country (see Referral: McKenna On India’s Denial Of TDR-TB), a response not dissimilar to their denials of NDM-1.

 

In March of 2012, the World Health Organization  released a statement on the supposed TDR-TB, titled  More evidence and better diagnostics needed before redefining severe forms of drug-resistant TB says WHO.

 

The `TDR-TB’  story simmered quietly for the next few months, that is, until October of 2012, when in EID Journal: Challenges To Defining TDR-TB we looked at an EID Journal article called:

NOTE: Corrected Link

 

Challenges and Controversies in Defining Totally Drug-Resistant Tuberculosis

Peter Cegielski , Paul Nunn, Ekaterina V. Kurbatova, Karin Weyer, Tracy L. Dalton, Douglas F. Wares, Michael F. Iademarco, Kenneth G. Castro, and Mario Raviglione

(Excerpt)

Susceptibility tests for several drugs are poorly reproducible. Few laboratories can test all drugs, and there is no consensus list of all anti-TB drugs. Many drugs are used off-label for highly drug resistant TB, and new drugs formulated to combat resistant strains would render the proposed category obsolete. Labeling TB strains as totally drug resistant might lead providers to think infected patients are untreatable. These challenges must be addressed before defining a new category for highly drug-resistant TB

 

All of which brings us to a new EID Journal article (abstract reparagraphed for readability), published yesterday, called:

 

Emergence and Spread of Extensively and Totally Drug-Resistant Tuberculosis, South Africa

Marisa Klopper, Robin Mark Warren, Cindy Hayes, Nicolaas Claudius Gey van Pittius, Elizabeth Maria Streicher, Borna Müller, Frederick Adriaan Sirgel, Mamisa Chabula-Nxiweni, Ebrahim Hoosain, Gerrit Coetzee, Paul David van Helden, Thomas Calldo Victor, and André Phillip Trollip

Abstract

Factors driving the increase in drug-resistant tuberculosis (TB) in the Eastern Cape Province, South Africa, are not understood. Using a convenience sample of 309 drug-susceptible and 342 multidrug-resistant (MDR) TB isolates, collected July 2008–July 2009, we characterized them by spoligotyping, DNA fingerprinting, insertion site mapping, and targeted DNA sequencing.

 

Analysis of molecular-based data showed diverse genetic backgrounds among drug-sensitive and MDR TB sensu stricto isolates in contrast to restricted genetic backgrounds among pre–extensively drug-resistant (pre-XDR) TB and XDR TB isolates.

 

Second-line drug resistance was significantly associated with the atypical Beijing genotype. DNA fingerprinting and sequencing demonstrated that the pre-XDR and XDR atypical Beijing isolates evolved from a common progenitor; 85% and 92%, respectively, were clustered, indicating transmission.

 

Ninety-three percent of atypical XDR Beijing isolates had mutations that confer resistance to 10 anti-TB drugs, and some isolates also were resistant to para-aminosalicylic acid.

 

These findings suggest the emergence of totally drug-resistant TB.

 

 

For those unfamiliar with para-aminosalicylic acid (PAS), it’s an older drug discovered in 1944, and one of the first drugs to effectively treat TB.  Its use as a first-line drug treatment was discontinued when newer antibiotics – like Rifampin - became available.

 

PAS is still used in treating XDR-TB although its value is limited and there are problems with toxicity.

 

Whether we should label them XDR-TB or TDR-TB may be debatable, but what is not is that we continue to see an erosion in our arsenal of effective drugs as new, resistant forms of TB emerge and spread.

 

As reported in last week’s MMWR, getting the best drugs to treat resistant TB can be difficult, even here in the United States (Interruptions in Supplies of Second-Line Antituberculosis Drugs — United States, 2005–2012).

 

Semantics aside, if you are unlucky enough to be infected by one of these resistant TB strains - and no effective drug is available to you  – then the fine distinction over whether it is XDR or TDR TB is of little practical consequence to you.

Resistant TB: The Limits Of Surveillance & Reporting

 

 

 

# 6071

 

 

With practically any disease you’d care to mention the number of cases that we see, and are counted, generally represent only a small subset of the total.

 

As the chart from the CDC below indicates, public health officials are usually only aware of the `tip of the disease pyramid’.

 

 

Many people suffering an illness do not become sick enough to seek medical care (or may live in an area where such care, or testing is unavailable). Those that see a doctor may not be properly diagnosed.  And those that are diagnosed may not be reported to the health department.

 

When the World Health Organization announced the detection of the 571st human H5N1 infection, or the ECDC reports that 4,200 people were infected by the E. coli O104:H4 outbreaks in Germany and France, everyone in the public health arena understood that those numbers are unlikely to include all of the cases out there.

 

Reporting and surveillance – even in technologically advanced regions like the United States and Europe – are simply not that good. 

 

So when we learn – as we have this week – of a dozen cases of `totally resistant tuberculosis’ in India, it’s a pretty fair assumption that there are more cases out there, as yet undetected.

 

The question is:  How many?

 

While the answer to that question remains elusive, we’ve some troubling hints today from an article that appears in the Indian Express.  

 

The story revolves around an interview with Dr John Kenneth, Professor and Head, Infectious Diseases, St John’s Research Institute. The article can be accessed at the following link:

 

The new, deadly TB strain may be more widespread

Johnson T A : Bangalore, Sat Jan 14 2012, 03:47 hrs

 

 

While the headline, that this new form of resistant TB `may be more widespread’ is practically a given - what is worrisome are the percentages being reported.

 

Dr. Kenneth states that his group has unpublished data showing that out of one hundred TB patients they had randomly selected for drug susceptibility studies, six were found to be `totally drug resistant’.

 

Additionally out of these 100 cases, 30 were found to be multi-drug resistant (MDR), and 13 were defined as being extensively drug resistant (XDR).

 

Dr. Kenneth admits that there may be some selection bias in the 100 patients selected for this study, and that all cases tested were randomly selected from among TB patients at only one treatment facility.

 

Until this study is published, we are lacking details on how the screening for drug resistance was done, and exactly how `totally drug resistant’ was defined. This is an issue that the ECDC brought up earlier this week, when they cautioned against the use of the term TDR-TB (see ECDC Comment On Drug Resistant TB In India).

Whether these results reflect the prevalence of resistant TB across a wider region is – for now, at least – unknowable.

 

For more on all of this, you can’t do better than Maryn McKenna’s coverage on her Superbug Blog.   Her latest entry (which includes links to her radio interview yesterday) can be read at:

 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna
• January 14, 2012  |   

 

 

For some more background on Tuberculosis, which kills 1.7 million people each year,  last March I wrote a blog titled World TB Day: March 24th.

 

Some of the resources I cited that day may be of interest.

 

(From the 2011 TB Progress Report)

 

The World Health Organization  released a new report and a factsheet on MDR-TB & XDR-TB in advance of this yearly event on the the status of Tuberculosis around the world and the progress being made in its control.

 

WHO progress report 2011

Towards universal access to diagnosis and treatment of MDR and XDR-TB by 2015

 

 

While progress has been cited in the global fight against tuberculosis, the addition of a new supposedly `totally resistant’ form of TB to the mix complicates matters enormously. 

 

Yesterday the WHO published the following notice:

 

Tuberculosis that is “resistant to all drugs”

13 January 2012 | Geneva | WHO's Stop TB Department has just published a briefing note with "Frequently Asked Questions" to provide information on tuberculosis that is resistant to all drugs.

 

In 2006, the first reports of extensively drug-resistant tuberculosis (XDR-TB), an even more severe form of drug resistant TB than multidrug-resistant TB (MDR-TB), began to appear. Within a year of the first reports of XDR-TB, isolated cases were reported in Europe that had resistance to all first-line anti-TB drugs (FLD) and second-line anti-TB drugs (SLD) that were tested. In 2009, a cohort of 15 patients in Iran was reported which were resistant to all anti-TB drugs tested. The terms “extremely drug resistant” (“XXDR-TB”) and “totally drug-resistant TB” (“TDR-TB”) were given by the respective authors reporting this group of patients. Recently, another study has been published that describes 4 patients from India with resistance to all tested drugs.

• To access the Frequently Asked Questions please click here.

 

WHO: Blood Tests To Detect Active TB Unreliable

 

 

 

# 5703

 

Although following story was telegraphed earlier in the week by comments to the press by Mario Ravigli - the director of WHO's Stop TB Department – today we have the official announcement from the World Health Organization’s media centre, along with a detailed Policy Statement.

 

 

 

For the first time, the WHO has issued a “negative" policy recommendation against a well established practice used in Tuberculosis care. 

 

The World Health organization is calling for countries to immediately ban the use of blood tests designed to detect active TB, and rely instead upon microbiological or molecular tests for the diagnosis of Tuberculosis.

 

The two main measures of the accuracy of a diagnostic test are sensitivity and specificity.

 

• Sensitivity is defined as the ability of a test to correctly identify individuals who have a given disease or condition.

 

• Specificity is defined as the ability of a test to exclude someone from having a disease or illness.

 

And based on a year-long review by the WHO and global experts – which examined 94 existing studies – researchers found overwhelming evidence that these serological diagnostic tests produced an `unacceptable level of wrong results’  (compared to WHO sanctioned tests).

They found both `low sensitivity’, where the test failed to identify TB in patients (which can lead to patients not receiving the appropriate treatment).

 

And `low specificity’, where the test indicated TB when the patient was not infected (which could lead to unwarranted treatment and no treatment for the true cause of their illness).

 

First, some excerpts from the WHO’s media centre press release, followed by a link to the Policy Statement, and the strongly worded conclusion from its executive summary.

 

 

WHO warns against the use of inaccurate blood tests for active tuberculosis

A substandard test with unreliable results

News release

20 July 2011 | GENEVA - The use of currently available commercial blood (serological) tests to diagnose active tuberculosis (TB) often leads to misdiagnosis, mistreatment and potential harm to public health, says WHO in a policy recommendation issued today. WHO is urging countries to ban the inaccurate and unapproved blood tests and instead rely on accurate microbiological or molecular tests, as recommended by WHO.

TB can be wrongly diagnosed

Testing for active TB disease through antibodies or antigens found in the blood is extremely difficult. Patients can have different antibody responses suggesting that they have active TB even when they do not. Antibodies may also develop against other organisms which again could wrongly indicate they have active TB. In addition, different organisms share the same antigens, making tests results unreliable. These factors can result in TB disease not being identified or wrongly diagnosed.

A blood test for diagnosing active TB disease is bad practice

"In the best interests of patients and caregivers in the private and public health sectors, WHO is calling for an end to the use of these serological tests to diagnose tuberculosis," said Dr Mario Raviglione, Director of WHO Stop TB Department. "A blood test for diagnosing active TB disease is bad practice. Test results are inconsistent, imprecise and put patients' lives in danger."

 

Today's policy recommendation applies to blood tests for active TB. Blood tests for inactive TB infection (also known as dormant or latent TB) are currently under review by WHO.

(Continue . . . )

 

 

 

Commercial Serodiagnostic Tests for Diagnosis of Tuberculosis - Policy Statement pdf, 809kb

 

EXECUTIVE SUMMARY

Conclusions:  Commercial serological tests provide inconsistent and imprecise findings resulting in highly variable values for sensitivity and specificity.

 

There is no evidence that existing commercial serological assays improve patient-important outcomes, and high proportions of false-positive and false-negative results adversely impact patient safety.

 

Overall data quality was graded as very low and it is strongly recommended that these tests not be used for the diagnosis of pulmonary and extra-pulmonary TB. 

 

For some background on Tuberculosis, which kills 1.7 million people each year,  last March I wrote a blog titled World TB Day: March 24th. 

 

Some of the resources I cited that day may be of interest.

 

(From the 2011 TB Progress Report)

 

The World Health Organization  released a new report and a factsheet on MDR-TB & XDR-TB in advance of this yearly event on the the status of Tuberculosis around the world and the progress being made in its control.

WHO progress report 2011

Towards universal access to diagnosis and treatment of MDR and XDR-TB by 2015

MMWR: Tuberculosis Trends In The United States

 

# 5440

 

Today’s MMWR from the CDC, released on this World TB Day, contains two reports on the incidence of Tuberculosis in the United States.

 

I’ve pulled some excerpts from each report (and reformatted for readability), but follow the links to read them in their entirety.

 

The first takes a closer look at an unexpected drop in TB cases in two states – Georgia and Pennsylvania – in 2009, and concludes that these reductions were real, and not the result of surveillance artifacts, health-care provider under diagnoses, or underreporting.

 

Assessment of Declines in Reported Tuberculosis Cases --- Georgia and Pennsylvania, 2009

Weekly

March 25, 2011 / 60(11);338-342

What is already known on this topic?

In 2009, tuberculosis (TB) incidence in the United States decreased to 3.8 cases per 100,000 population, the lowest recorded rate since national TB surveillance began in 1953. The 11.4% decrease from 2008 was the greatest single-year decrease ever recorded.

What is added by this report?

Findings from systematic investigations in Georgia and Pennsylvania, two states that experienced unexpectedly large decreases in TB incidence in 2009, indicate that the decline in new TB disease in those states appeared actual and not attributable to surveillance artifact, health-care provider underdiagnosis, or underreporting.

What are the implications for public health practice?

The TB surveillance systems in Georgia and Pennsylvania appear to be functioning appropriately. Current efforts to diagnose, treat, and report TB cases should be vigorously maintained as the United States moves closer to the goal of TB elimination.

 

 

The second report looks at the trends in Tuberculosis in the United States, and finds that while significant reductions in TB have been made, the stated goal back in 1989 of reaching an incidence rate of < 0.1 per 100,000 population by 2010 has not been met.

 

Trends in Tuberculosis --- United States, 2010

Weekly

March 25, 2011 / 60(11);333-337

In 2010, a total of 11,181 tuberculosis (TB) cases were reported in the United States, for a rate of 3.6 cases per 100,000 population, which was a decline of 3.9% from 2009 and the lowest rate recorded since national reporting began in 1953 (1). This report summarizes provisional 2010 data from the National TB Surveillance System and describes trends since 1993.

 

Despite an average decline in TB rates of 3.8% per year during 2000--2008, a record decline of 11.4% in 2009 (2), and the 2010 decline of 3.9%, the national goal of TB elimination (defined as <0.1 case per 100,000 population) by 2010 was not met (3).

 

Although TB cases and rates decreased among foreign-born and U.S.-born persons, foreign-born persons and racial/ethnic minorities were affected disproportionately by TB in the United States. In 2010, the TB rate among foreign-born persons in the United States was 11 times greater than among U.S.-born persons.

 

TB rates among Hispanics, non-Hispanic blacks, and Asians were seven, eight, and 25 times greater, respectively, than among non-Hispanic whites. Among U.S.-born racial and ethnic groups, the greatest racial disparity in TB rates was for non-Hispanic blacks, whose rate was seven times greater than the rate for non-Hispanic whites.

 

Progress toward TB elimination in the United States will require ongoing surveillance and improved TB control and prevention activities to address persistent disparities between U.S.-born and foreign-born persons and between whites and minorities.

FIGURE 1. Rate* of tuberculosis (TB) cases, by state/area --- United States, 2010†

Source: National TB Surveillance System.

* Per 100,000 population.

† Provisional data as of February 26, 2011.

§ 20 states had TB case rates <2.0 (range: 0.61--1.88) per 100,000

What is already known on the topic?

In 1989, the Strategic Plan for Elimination of Tuberculosis in the United States set a target date of 2010 to achieve its goal, defined as an annual tuberculosis (TB) case rate of <0.1 per 100,000 population.

 

What is added by this report?

For 2010, preliminary data show a national TB case rate of 3.6 per 100,000 population, a decrease of 3.9% from 2009, but the goal of eliminating TB in the United States by 2010 was not achieved, and foreign-born persons and racial/ethnic minorities continued to be affected disproportionately.

 

What are the implications for public health practice?

Ongoing surveillance and improved TB control and prevention activities, especially among disproportionately affected populations, are needed to eliminate TB in the United States.

WHO Releases New Global Action Plan On Tuberculosis

 

 

# 4980

 

The World Health Organization released a new action plan, which they hope will cut global TB deaths by half over the next few years.

 

Tuberculosis – although generally curable - kills millions of people each year around the world.   Twenty-two countries account for 80% of the world’s TB burden, with South Africa one of the worst affected.

 

While ambitious, WHO officials believe the targets outlined today are achievable . . . assuming the 4.2 billion dollar yearly shortfall in necessary funding can be addressed.

 

A difficult task given today’s economy.

Here then are excerpts from today’s press release, along with links to the plan.

 

New action plan lays the foundation for tuberculosis elimination

Targets are realistic, but a projected shortfall of US$ 4.2 billion per year for TB care and crucial research must be filled

13 OCTOBER 2010 | JOHANNESBURG | BERLIN | GENEVA -- The world could be on its way towards eliminating tuberculosis (TB) if governments and donors fully invest in a plan released today by the Stop TB Partnership. The global plan to stop TB 2011-2015: transforming the fight towards elimination of tuberculosis for the first time identifies all the research gaps that need to be filled to bring rapid TB tests, faster treatment regimens and a fully effective vaccine to market. It also shows public health programmes how to drive universal access to TB care, including how to modernize diagnostic laboratories and adopt revolutionary TB tests that have recently become available.

Related links
The Stop TB Partnership
The global plan to stop TB 2011-2015: transforming the fight towards elimination of tuberculosis

Action needed against TB

"There is an urgent need to scale up action against TB - 10 million people, including 4 million women and children, will lose their lives unnecessarily between now and 2015 if we fail," says Dr Margaret Chan, Director-General of WHO, which hosts the Stop TB Partnership. "TB control works, with global incidence of the disease declining since 2004, although much too slowly."

 

Twenty-two countries, including South Africa, bear 80% of the burden of TB worldwide. Some 9 million people become ill with active TB and nearly 2 million die each year. The new Global Plan sets out to provide diagnosis and treatment approaches recommended by the World Health Organization (WHO) for 32 million people over the next five years.

 

Blueprint to cut global TB deaths by half

"The Global Plan to Stop TB provides an urgently needed blueprint to cut global TB deaths by half," says Dr Aaron Motsoaledi, Minister of Health of South Africa. "In South Africa we have embarked on an ambitious agenda for reducing the toll of TB on our people, and we are committed to meeting the Global Plan's targets. We call on world leaders to invest in the plan, which can help move us towards ridding the world of TB."

 

Although TB is curable, the treatment requires taking a combination of drugs for at least six months. Laboratories in most countries are still using a century-old diagnostic method that involves searching for TB bacteria derived from a person's sputum under a microscope. And there is still no vaccine able to prevent pulmonary TB, the most common form of the disease.

(Continue . . .)

 

 

In a related story today, South Africa has announced that they plan to eventually test all HIV positive patients for Tuberculosis.

 

South Africa to test all HIV patients for TB

By JENNY GROSS, Associated Press Writer Jenny Gross,

 

South Africa has for many years endured an epidemic of HIV, and those whose immune systems have been weakened by that virus are more prone to contract TB. 

 

While the need is great today, routine testing isn’t expected to become a standardized procedure for several more years.

Badgers? We Don’t Need No Stinkin’ Badgers!

 

 

 

# 4873

 

 

 

Cinema lovers will no doubt recognize the above title as an homage to perhaps the 2nd most misquoted line from the movies (the first being Casablanca’s  `Play it Again, Sam’). 

 

In this case, it comes from another Bogart movie – The Treasure of the Sierra Madre – and the actual quote delivered by Alfonso Bedoya was:

 

Dobbs: "If you're the police where are your badges?"

Gold Hat: "Badges? We ain't got no badges. We don't need no badges! I don't have to show you any stinkin' badges!"

 

Over the years Gold Hat’s lines have morphed in popular culture and memory – aided and abetted by Mel Brook’s Blazing Saddles – into `Badges?  We don’t need no Stinkin’ Badges!’.

 

And of course, a thousand (now a thousand and one) parodies thereof.

 

Which brings us (at long last) to an infectious disease story out of the UK, where the power to cull badgers – which are viewed by many farmers as a serious threat to their cattle – is about to be granted.

Badgers can carry Mycobacterium bovis which is the cause of tuberculosis in cattle (known as bovine TB).

 

M. bovis is also capable of infecting humans (mainly through unpasteurized milk), although famers in contact with infected cattle are at risk as well.

 

In fact, of the three type of Tuberculosis bacteria (Mycobacterium bovis, M. avium, and M. tuberculosis), M. Bovis has the largest host range – being capable of infecting just about all warm-blooded vertebrates.

 

In countries where pasteurization of dairy products is common, human infection by M. bovis is relatively rare, but not unheard of.  

 

The UK’s HPA describes the risks thusly:

 

Humans and M bovis

TB caused by M. bovis is diagnosed in a small number of people  in the UK every year. The majority of cases are in people over 65 years old (and who drank infected unpasteurised milk in the past) or in those of any age who picked up the infection abroad. 

The number of human TB cases due to M. bovis infection is closely monitored by the Health Protection Agency in England and Wales, and Health Protection Scotland in Scotland.

Overall, human TB caused by M. bovis accounts for less than 1% of the total TB cases in the UK. However, those working closely with livestock and/or regularly drinking unpasteurised (raw) milk have a higher risk of exposure.

 

Over the last decade, it has been estimated that 150,000 head of cattle in the UK have been slaughtered because of M. Bovis infection – with compensation payments to farmers in 2009 running nearly £90mn.

 

Many farmers see badgers as the primary source of bovine TB, and blame them for reintroducing the disease into their herds each year.

 

Conservation and animal rights groups strongly disagree, and argue that the badger is the victim here.

 

They maintain that cow-to-cow transmission is the primary route of infection, and that badgers usually get the disease from cattle – not the other way around.

 

Both sides have their own experts, supportive studies, and a constituency behind them.  The debate has been vigorous, lengthy, and often heated as the following media reports illustrate:

13 July 2010

Welsh badger cull decision does not refute science

 

May 20, 2010

Minister blocks cull of badgers in bovine TB hotspots

 

14 Nov 2008

Cattle, not badgers, are reservoir of bovine TB

Bovine TB is not a threat to the health of Britain's badgers but farming unions are, says Trevor Lawson from the Badger Trust.

 

Animal rights groups hang their hat on a decade-long study by the Independent Scientific Group on Cattle TB, which concluded that culling could not “meaningfully contribute” to control of the disease.

 

Other researchers disagree.

 

The British Veterinary Association (BVA) has come down in favor of targeted, humane culling of badgers as part of an overall bTB (Bovine TB) eradication plan.

 

Some excerpts from their policy statement.

 

BVA Tuberculosis policy

 

The British Veterinary Association (BVA) believes that the eradication of bTB from cattle and wildlife populations must be the ultimate aim, with initial steps being taken immediately to control the spread of infection.

• The current Government Strategy for bTB control is inadequate.
• Control measures in cattle must be accompanied by simultaneous and coordinated measures in badgers and other wildlife and susceptible farmed species including deer and camelids for the success of any eradication programme.
• Failure to tackle wildlife sources of infection has prolonged the presence of the disease in all affected species populations.
• Targeted and managed badger culling is necessary in carefully selected areas where badgers are regarded as a significant contributor to the persistent presence of bTB.

 

Which brings us to the decision announced in today’s story, which will no doubt provoke the ire of a number of environmentalist and animal rights groups.

A hat tip to Dutchy on FluTrackers for this link.

 

 

Farmers to be handed powers to cull badgers

Farmers will be handed powers to slaughter badgers as part of a widespread cull in England aimed at halting the spread of tuberculosis in cattle herds.

(Continue. . . )

 

 

While the decision to proceed with limited culls appears to have been reached, legal challenges and the weight of public opinion may still prove to be impediments to the plan.

 

Not being an expert in the ecology of M. bovis, or the efficacy of badger culling, I’m hard pressed to take sides here. With conflicting studies and scientific assessments, any definitive answers as to what control methods actually work are unlikely in the near-term.

 

 

But for opposing viewpoints you may wish to visit:

 

 

The British Veterinary Association has scores of documents on the problems of bovine TB in the UK, which may be accessed at this link.

 

Badger Trust, which has opposed culling, presents its case on their website.