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Drug-resistant TB

Sure. I mean, it might be tempting to try to separate perceived risk from actual risk, but it's not always possible to do that, because the way one looks at risk tends to influence behavior, and the actual degree of risk often depends a lot on how one behaves. For a person who smokes a lot and never exercises and has poor dietary habits and spends a lot of time driving (especially while drinking, texting, or talking on the phone), worrying about drug-resistant TB should probably rank somewhere alongside worrying about being hit by falling meteors.

Well, it's more than that. TB is associated with crowding, malnutrition, poor quality housing, high HIV rates -- in other words, with poverty in general.
Perceived risk was not what I meant.

What I was referring to was what you count as your outcome measure. If I only care if I am personally at risk, that is one outcome measure. If I care how my health care resource dollars are allocated, that is another measure. If I care about a significant health risk that devastates third world countries and therefore increases world political instability that is a different outcome measure.

As for controlling TB in third world countries there are some innovative measures such as using community workers for DOT rather than the traditional Western model of using nurses and other health care professionals that have been successful. Just because poverty is involved does not mean effective public health infrastructure cannot reduce the disease burden.
 
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I always thought that drug resistant bacteria were weaker than similar non drug resistant bacteria. So remove the drug and the non drug resistant bacteria would take over. Or am I wrong?
The hypothesis is reasonable however it fails in practice. Drug holidays were tried with HIV. Drug susceptible virus populations quickly replaced drug resistant strains. However, when the anti-retroviral drugs were reintroduced the genetic resistant populations were still there and they quickly replaced the drug susceptible strains.

Microorganisms tend to have a huge gene pool to draw on. Once a mutation is added the pool it remains regardless if that population is predominant or not. The resistant organisms don't go away, they merely fade ready to recur when conditions again favor them.
 
Pathogens wouldn't be able to mutate into drug resistant strains if patients took the entire course of their antibiotics.

Yes they would. In fact, the resistance already existed in nature before antibiotics were used as medicine. Where do you think antibiotics come from?
 
EXTREMELY scary, actually.
I would say that it is a cause for concern, but not a cause for alarm.

You know, there's a fairly good chance that you are already infected with TB, but will never develop symptoms.
 
....

You know, there's a fairly good chance that you are already infected with TB, but will never develop symptoms.
What country are you from? In the US there is not a "fairly good chance" one is infected already. If one is from Asia, Africa, E.Europe, and the Pacific Islands that may be true, and if one is from Latin America it might be true.

You never addressed my post, BTW, that risk depends on which outcome you are using to measure it:

"Perceived risk was not what I meant.

What I was referring to was what you count as your outcome measure. If I only care if I am personally at risk, that is one outcome measure. If I care how my health care resource dollars are allocated, that is another measure. If I care about a significant health risk that devastates third world countries and therefore increases world political instability that is a different outcome measure.

As for controlling TB in third world countries there are some innovative measures such as using community workers for DOT rather than the traditional Western model of using nurses and other health care professionals that have been successful. Just because poverty is involved does not mean effective public health infrastructure cannot reduce the disease burden."
 
The Lancet this month has a more revealing article on the occurrence of this new strain:

India reports cases of totally drug-resistant tuberculosis
“Basically, it is a failure of public health, and that has to be accepted in this country”, said Zarir F Udwadia, who has been treating the patients at the P D Hinduja National Hospital and Medical Research Centre, and who, along with colleagues, described four of the cases in a letter published online in Clinical Infectious Diseases. “The public doctors and private doctors are equally to blame”, he said. The city's health officials reject these charges. “State TB care and health care in Mumbai is excellent”, Anil Bandiwadekar, the Executive Health Officer of the Public Health Department of the Municipal Corporation of Greater Mumbai, the city's governing body told The Lancet.
It's worth noting that during the SARS epidemic the Indian government was reporting everything was under control including screening at airports while a reporter at one airport was exposing the fact the government's statements were outright lies. In addition, in one Indian town people chased a suspected SARS infected patient out of a hospital and threw stones at the person until he fled the town.

Not very reassuring when you also read these excerpts:
Mumbai would seem to be a prime breeding ground for drug-resistant infections. The city, home to more than 12 million people, is beset by poverty, overcrowding, and harsh living conditions.

Udwadia says that although the DOTS (Directly Observed Therapy, Short Course) programme has generally been successful for people with normal tuberculosis who do access it, for those with drug-resistant tuberculosis, it causes more than 8 months of delay as people are forced to go through standard treatments before they are diagnosed. All the time, they are generating further resistance.

...Tuberculosis was estimated to have accounted for at least 15% of the deaths in Mumbai in 2010.

India has one of the world's highest burdens of drug-resistant tuberculosis, (around 100 000 people), according to WHO. The failure of the government to provide treatment for all of these patients is due to the cost—about US$4000 per patient, a high cost for India, which spends only $45 per head on health care. Udwadia says that the government passes its actions off as “health policy real politik”, which in effect means it ignores most of the patients with drug-resistant tuberculosis. “They have become the untouchables of the Indian medical system”, he said.

In fact, health centres and hospitals could be a contributor to the growth in resistance, said Nerges Mistry, the director of the Foundation for Medical Research in Mumbai. There is “poor infection control at most of these settings”, ... The city could have as many as 3500 cases of multidrug-resistant tuberculosis (MDR-TB) each year, but lacks the laboratory infrastructure in the public system to identify and confirm the diagnosis, said Mistry.

Meanwhile, the patients with TDR-TB are walking the streets. Udwadia says that isolation is not practical due to cost and lack of hospital beds. He notes that four of the patients come from Dharavi, a notorious Mumbai slum with a population of 2·5 million people.
 
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I should also mention that as TB mutates, there is no guarantee it will continue to make only 10% of those infected ill. More contagious strains are seen occasionally as well as strains that cause more frequent disease.

But again, even if TB is not an immediate personal threat, it can eat up a huge percentage of health care resource dollars.

XRDTB was first seen in 2006 and by 2010 it had spread to 58 countries including the US. It costs >$100,000 dollars to treat.
A rare strain of extremely drug-resistant, XXDR-TB (only a handful of other people in the world are thought to have had it), is even more aggressive and difficult to treat than XDR-TB. Associated Press recently learned about the case of a young patient infected with an XXDR-TB strain who had to be treated during 19 months at a Florida hospital using experimental protocols at the cost of $500,000 (Time Magazine, Dec. 2009). In January 2012, reports of a deadly form of tuberculosis completely resistant to all drugs normally used to cure it, was reported in India and called totally drug-resistant tuberculosis (TDR-TB). Previous cases had been identified in Italy in 2007 and in Iran in 2009 (The Scientist, Jan. 16, 2012).
 
In the US there is not a "fairly good chance" one is infected already.
According to the CDC:11,182 cases per 100,000 in 2010, an incidence rate of 3.6 percent. Prevalence, is, of course, a different matter. These guys estimate LTBI prevalence at 4.2 percent.
http://www.ncbi.nlm.nih.gov/pubmed/17989346

So, close to one-in-twenty odds. Shall we quibble over whether that qualifies as "a fairly good chance"?

You never addressed my post, BTW, that risk depends on which outcome you are using to measure it:

"Perceived risk was not what I meant.
[snip reposted stuff]
I submit that perceived risk is the central context of this thread. If the OP's primary concern had been, say, cost, then instead of saying "This is kind of scary", he might have said something like "This sounds kind of expensive", and BenBurch might have responded with "EXTREMELY expensive, actually". Ditto "politically destabilizing", etc. Naturally, you can talk about whatever you want, and I may respond, perhaps right away. Then again, I may not.
 
According to the CDC:11,182 cases per 100,000 in 2010, an incidence rate of 3.6 percent. Prevalence, is, of course, a different matter. These guys estimate LTBI prevalence at 4.2 percent.
http://www.ncbi.nlm.nih.gov/pubmed/17989346

So, close to one-in-twenty odds. Shall we quibble over whether that qualifies as "a fairly good chance"?
Dymanic, I test a couple thousand people a year for latent TB and have done so for ~20 years. TB risk, both latent and active, is within the area of my specialty practice. Your claim, there is a "fairly good chance" one is infected already, only applies to very specific populations. You cannot justify your incorrect claim with NHANES stats you cited. If you look closer you'll find the one risk factor we can say Ben has is his age of 53. According to the cited data a person within that age group in the US had a LTBI prevalence of 6.5%. However, if you also look you'll see that unless Ben is not white (and we would need to know the country he was born in and his race to be more precise here) his ethnic demographic gives him a rate of 1.9%.

But regardless you are claiming something between 2% and 6.5% is equivalent to "a fairly good chance". That's really a stretch. Why not just admit you were mistaken? It's not a big deal.


I submit that perceived risk is the central context of this thread. If the OP's primary concern had been, say, cost, then instead of saying "This is kind of scary", he might have said something like "This sounds kind of expensive", and BenBurch might have responded with "EXTREMELY expensive, actually". Ditto "politically destabilizing", etc. Naturally, you can talk about whatever you want, and I may respond, perhaps right away. Then again, I may not.
Considering how significant the disease of TB is worldwide, all one need be is not USA-centric and the actual risk could be potentially "scary". In addition, in certain fields like the health care field, in the US, it is indeed a scary development. Perhaps to someone who doesn't deal with the problem it isn't an issue, but for me it is. The top 3 infectious disease killers in the world are HIV, TB and measles (which is finally decreasing significantly). On an annual basis influenza only kills more people intermittently. HIV and measles are coming under control. TB is becoming a more problematic hazard.

It's not something to dismiss.
 
But regardless you are claiming something between 2% and 6.5% is equivalent to "a fairly good chance". That's really a stretch. Why not just admit you were mistaken? It's not a big deal.
So you DO want to quibble over the definition of "fairly good chance". I knew you would.

Sometimes you really crack me up, SG.
 
So you DO want to quibble over the definition of "fairly good chance". I knew you would.
Sometimes you really crack me up, SG.
Should we take a poll on what "fairly good chance" means?

2% prevalence? Seriously?

And let's look at your math exaggeration while we are at it. You rounded off 4.2% prevalence to claim 1 in 20 odds? Four out of every 100 people would be one in 25 odds, not one in 20.

Nope, no matter how you look at this no one would say these numbers made your claim correct. I suspect you don't want to admit you made a bad assumption about the prevalence of LTBI, probably because you recalled something like 90% of those infected don't get active disease. Admit it. It's obvious anyway.
 
I suspect you don't want to admit you made a bad assumption about the prevalence of LTBI, probably because you recalled something like 90% of those infected don't get active disease. Admit it. It's obvious anyway.
Tell you what: Why don't you just continue holding up both sides of the conversation, just like you're doing already, and I'll find something actually worthwhile to occupy my time.
 
That's disappointing Dymanic. It was such a minor misconception on your part. Taking your ball and going home is hardly necessary.
 
Dynamic - It is sad that you are willing to trivialize a read danger simply to argue.
I find that I must "trivialize" a number of real dangers just so as to be able to get through a day. I can only assume that most others do this as well. There just aren't enough hours in the day to worry about everything worth worrying about.

In this thread, the drug-resistant TB situation has been described as "scary" and "EXTREMELY scary". I will stand by my response to that: it's a cause for concern, but not for alarm. There may not be a perfect balance point between those two, but my approach is to do what I can about those things I may be able to actually do something about, and try not to dwell too much on the others. But maybe that's just me.

In developed countries, more than six times as many people die from heart disease than from TB, and about the same from cerebrovascular disease. These are largely preventable diseases, but only to the extent that one recognizes the dangers and takes steps to avoid the risk factors. The same can be said of Chronic Obstructive Pulmonary Disease, which kills nearly twice as many people as does TB. There's a very good chance (not merely a "fairly good chance") that I will join that statistical group soon, as I have not always taken the same approach to avoiding risk factors that I do now, and as a result, my lung function test scores now place me in the "very severe" category there. Influenza and pneumonia both pose a much greater risk for me than they do for the average person, but even for the average person in the US, they pose a much greater statistical risk than does TB.

As a tool for maintaining some modicum of mental and emotional stability in the face of these very real dangers, I sometimes remind myself that if I make it through the day, I will have outlived a large number of people who, despite having started the day with perfectly healthy lungs, will have died from firearms, traffic accidents, and other causes. Having seen first-hand what death by COPD looks like makes it a little easier to accept the fact that I am eligible for those as well.

So let's keep this in perspective: Of the ten leading causes of death in the US, tuberculosis doesn't even make the list (and incidence continues its steady decline). Even in those undeveloped countries where it does, it is well behind heart disease and stroke. I'll repeat: For a person who smokes a lot and never exercises and has poor dietary habits and spends a lot of time driving (especially while drinking, texting, or talking on the phone), TB does not deserve first priority for the worry units.

I still maintain that the real danger is not TB itself, but the poverty which creates conditions that allow it to thrive -- and that the real threat from drug-resistant TB is not the drug-resistant TB itself, but the phenomenon of drug resistance in general. One might even go a step further and argue (which I fully admit that I do enjoy) that it is not the drug resistance itself, but our heavy reliance on antibiotics which creates the problem

This concept may be extended just as far as one pleases. Consider the dikes that provide flood protection for low-lying areas in, say, the Netherlands. Build them, and people come to rely on them. The longer those dikes are able to provide effective protection, the greater the number of people whose lives depend on them not to fail. Yet are they not ultimately doomed to fail at some point?

"Trivialize a real danger"? We build our homes on the floodplains of major rivers and at the feet of active volcanoes. We climb inside steel boxes weighing several tons and go hurtling down highways at sixty plus miles an hour and inside aluminum tubes that scream through the air at hundreds of miles an hour at tens of thousands of feet above the ground -- and sometimes, just for fun, we strap big nylon sheets to our backs and jump out. We jump off tall bridges after tying big rubber bands to our ankles. We climb on the backs of bulls and see how long we can stay on, or stand in front of them and see how many times we can jump out of the way without getting gored. We drink and drive, we smoke in bed, we elect delusional religious fanatics to important government positions and consider the idea of placing them in control of the world's largest nuclear arsenal.

We're humans. We laugh in the face of danger.
 
"Trivialize a real danger"? We build our homes on the floodplains of major rivers and at the feet of active volcanoes. We climb inside steel boxes weighing several tons and go hurtling down highways at sixty plus miles an hour and inside aluminum tubes that scream through the air at hundreds of miles an hour at tens of thousands of feet above the ground -- and sometimes, just for fun, we strap big nylon sheets to our backs and jump out. We jump off tall bridges after tying big rubber bands to our ankles. We climb on the backs of bulls and see how long we can stay on, or stand in front of them and see how many times we can jump out of the way without getting gored. We drink and drive, we smoke in bed, we elect delusional religious fanatics to important government positions and consider the idea of placing them in control of the world's largest nuclear arsenal.

We're humans. We laugh in the face of danger.

I like this point.
 

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