Andrew Speaker caused an international incident in 2007 when he boarded an international flight while infected with XDR-TB, a form of tuberculosis resistant to most available drugs. It was terrifying to imagine what could have happened if the flight had taken off. Was there anything scarier than flying next to a person with extensively resistant TB?

Apparently, there is.

This week, doctors in India identified twelve cases of TB that are totally drug resistant (TDR-TB). Whereas XDR-TB is 60 percent fatal, this new form of TB is 100 percent fatal. Researchers, policymakers, and patients are scrambling to make sense of it all. Although India’s TB program has been successful, it fails to include patients with multi-drug resistant TB. Ninety-nine percent of Indians lack access to proper treatment for drug-resistance, which has fueled the rise in XDR and given root to this new form of totally resistant TB.

This new strain threatens to take us back 60 years ago when TB was incurable. But things have changed in the last 60 years. Now there’s HIV.

It’s terrifying to imagine the impact this new form of totally drug resistant TB could have if it combines with HIV. Sub-Saharan Africa has the highest rate of TB-HIV co-infection in the world. In some places like Swaziland, over 80 percent of people diagnosed with TB are also infected with HIV. Drug-resistant TB is particularly dangerous in this population because it preys on people with weakened immune systems.

“If we had a strain [of TB] for which there is no treatment… It would be mean mass devastation” says Carol Nyirenda, Zambian TB-HIV activist and patient advocate. Zambia is currently experiencing stock outs of anti-TB drugs –- shortages that develop of drug-resistance. Emergence of TDR-TB would place even more strain on the already fragile health system. Laboratory capacity is another problem. “We don’t have the capability to do that kind of testing,” Nyirenda explains.

The threat of drug-resistant TB and HIV has been around for the last decade, but little has been done to address the problem. Dr. Jim Kim, co-founder of Partners in Health, warned in PBS’s documentary Rise of the Superbugs, “When drug-resistant TB and HIV collide, as it is right now in places like South Africa…it is going to be a disaster, the likes of which I think will surprise many of us. … There is no reason we shouldn’t be able to get it under control now, with resources that are pitiful compared to what we spend on so many other silly things.”

It’s time global leaders take immediate action to control and prevent the spread of TB. “We need to ensure a constant supply of anti-TB drugs and more education around TB,” explains Nyirenda. This new form of totally drug-resistant TB must be taken very seriously. It won’t be long before the new strain surfaces elsewhere. After all, TDR-TB is only a plane ride away.

ACTION is an international partnership of civil society advocates working to mobilize resources for global health. To learn more about drug resistant TB, visit www.action.org.

On a plot of land about the size of a football field sit two yellow-and-white structures. The small building (pictured at top) is a tuberculosis “clinic” responsible for serving the 2 million people who live in Huaycán, a township of Lima that has the second-highest TB prevalence rate in Peru.

A new TB Excellence Center (pictured at bottom), financed in large part by the Global Fund to Fight AIDS, Tuberculosis and Malaria, sits just yards away. The center is already treating nearly 50 patients and is scheduled to open in full soon, providing treatment and care with modern equipment and proper ventilation.

Especially important are the center’s facilities for those infected with multidrug-resistant (MDR) and extremely drug-resistant (XDR) strains of TB. Without rooms available for quarantine, doctors and nurses in Huaycán have had no choice but to send the most highly contagious back into the community, where overcrowded housing increases the risk of patients’ passing TB along to their families and neighbors.

The recent 2011 report on TB control from the World Health Organization shows that, for the first time in two decades, the number of new cases of TB is dropping, with particular progress made in Latin America. These strides are thanks in large part to the many TB Excellence Centers supported by the Global Fund and others. But resistant strains in particular present a unique threat -– one that will only heighten if the world becomes complacent about anti-TB efforts.

The new building in Huaycán offers more than just increased capacity and adequate technology to guard against the transmission of MDR and XDR-TB -– it offers a dignified space where patients can be treated as individuals. “Norms say we should assign a number,” says nurse Victoria Zegarra. “We believe people aren’t numbers, so we keep their names on file. People don’t like to say that they are ‘Patient 18.’”

The dedicated nurses can enjoy their share of dignity, as well. “This is like a palace for us,” Victoria says of the new facility. “It makes us proud to come to work.”

Photo credit: Anne Marson/ Friends of the Global Fight

In the US, tuberculosis is not a part of our everyday life. We take for granted being able to live free of this deadly disease -– so much so that most of us probably don’t fully understand what having a case of tuberculosis (TB) would be like. For the record, this serious lung infection leads to chest pain, coughing up blood, fever and for some –- particularly young children -– eventual death.

Unfortunately, these grisly details are a part of everyday life for many in Peru, where despite tremendous strides in the fight against the disease over the past two decades, TB is still a major public health problem. I recently had a chance to visit Peru, where I saw clearly that the reality of TB and its effects on productivity and livelihood is knit tightly into the fabric of almost every community.

But this fabric is made stronger by the work of TB survivors, such as Silvia Condor. Silvia, once a tuberculosis patient, now leads an association of people affected by TB in Huaycán, Peru, a township outside of Lima. The epidemic is particularly concentrated in Huaycán, where overcrowding leads to the infection’s rampant spread.

The association, supported by Global Fund financing through CARE Peru, assists patients and their loved ones by distributing nutritious food, observing medical treatment and helping families to find “a dignified place to live” where, Silvia says, the disease can be contained. Treatment observation is also critical to avoid the development of drug-resistant strains of the disease.

Silvia has had six family members fall ill to TB; she is intimately familiar with the disease’s ability to devastate families, affecting a person’s ability to provide basic necessities such as food and shelter to his or her children.

“How can you support a household if you can’t work?” she asks. “Many of us get our food from social organizations, but we survive, we improve and we overcome our difficulties.”

Silvia lives these words to the fullest. Energetic and passionate, she has turned her experience into an opportunity “to be considered part of the solution,” enabling others to meet the challenges of TB head-on with dignity and faith.

“My motivation is loving God and loving our brethren,” she says. “I don’t feel this is an obligation, this is my will, and God will give us the strength to carry on.”

Silvia is committed to continuing the association’s work long after it has graduated from Global Fund financing. “I tell people, ‘we have a place for you … because of our allies: Global Fund and CARE Peru.’”

Did you know that 200 people die from tuberculosis around the world every hour? That’s nearly 2 million lives annually, and Kenya is leading the charge. It is the leading cause of death for people with HIV and one of the leading causes of death for women and children worldwide.

Yesterday, I felt overwhelmed after seeing a child who was suffering from malaria, meeting women and children with HIV, and learning of the conditions in which children give birth to children in Kenya.

Then today, the tide shifted from despair to hope as I went into villages and saw families and community members taking care of and supporting each other. Even though they deal with everyday struggles like making sure they have enough food to survive, they are determined to make it through painful and deadly diseases like HIV and tuberculosis.

The Centers for Disease Control set up a community volunteer program in villages near Kisumu in western Kenya. People who had recovered from tuberculosis stepped forward to be TB Ambassadors — a completely voluntary and time-consuming position to help fellow community members. They take their role seriously and are dedicated to helping reduce the suffering of the friends, family and neighbors.

We met one woman who talked about her own battle with TB and how she lost her mother to the infectious disease. She said that without volunteer workers, people would not take on the treatment. But through them, they are able to help the bedridden recover.

Sometimes, it is easy to focus on differences when traveling abroad…or even in our own communities. The food, the landscape and the language, among other things, can present a stark difference between two cultures. Yet, at our very core, we are so similar.

When asked about her greatest concern, one woman immediately replied: “raising good children.” Another said that her main motivation for volunteering is the love and compassion she feels for others.

The difference between despair and hope, I found, is people and the goodness in their hearts to make a difference.

Today’s Daily Action: Today we’re meeting with couples and mothers living with HIV, tuberculosis, and other infectious diseases. Want to take action? Using the hashtag #ONEMoms, tweet a message (or messages) you’d like us to deliver to mothers in Kenya.

-Jyl Pattee, Mom It Forward

A year has passed since the catastrophic earthquake of January 2010 tore through the streets of Haiti, yet a difficult truth remains; despite the millions of aid dollars pledged and the countless relief teams dispatched, Haiti is still devastated on many levels. One of the most serious aftershocks of the earthquake has been the surge in disease spread, making epidemics of diseases that were previously en route to being controlled.

One disease which has become a heightened concern since the earthquake is tuberculosis (TB). More than one third of the world’s population is infected with the bacteria that cause TB, making the disease a major global health concern. According to the World Health Organization, there are approximately 9 million new cases of TB each year, and close to half a million are resistant to multiple drugs that once effectively treated the disease. Two million people die of TB each year. Haiti is estimated to have the highest per capita TB burden in the Latin American and Caribbean region (USAID).

The Infectious Disease Research Institute (IDRI), a Seattle based nonprofit organization, has developed a new TB vaccine that protects against multiple strains of the disease in preclinical studies. Though a vaccine for TB known as BCG has been used widely for decades, it only immunizes against childhood forms of the disease, its protection waning over time. IDRI’s TB vaccine enhances and extends BCG and protects against drug-resistant strains through its unique combination of a molecule containing four tuberculosis proteins. Dr. Rhea Coler, Vice President of Preclinical Biology at IDRI, explains, “Combining proteins in a vaccine is important because tuberculosis bacteria are variable, and no single protein will be effective against all strains.” In addition, because of human genetic diversity, individuals will respond differently to different proteins. A combination of proteins increases the vaccine’s effectiveness across the board.

IDRI’s vaccine is now being developed for clinical testing in humans, with plans for future studies in an area where the vaccine is so desperately needed—Port-au-Prince, Haiti. IDRI’s vaccine and partnership with Haitian clinic GHESKIO will be the featured cause of the Party with a Purpose (PWAP) in Seattle, June 17th. PWAP is an event for 20 and 30-somethings to plug into the growing global health movement. A sold-out crowd of 1,000 will learn why a TB vaccine is needed, how an IDRI test is cutting down the time for TB diagnosis and why investing in research, especially vaccine research, is one of the best investments in global health. Learn more and join the party.

-Kendra Curtin, Project Coordinator, Infectious Disease Research Institute; PWAP Board Member

John Keats, DH Lawrence, Dylan Thomas, Henry David Thoreau. Famous poets that turned words to art. Sadly, they also had another thing in common: tuberculosis. In the late 1800s, TB was tearing through the US and Europe, causing many deaths.

Today is World TB Day, an opportunity to take stock of progress made in ridding the world of this horrible disease and also identifying opportunities to make more progress. For most of us, TB is not a big concern. Once in a while we get a scare –- remember that guy a few years back who flew back to the US even though he’d been diagnosed with infectious TB? -– but for the most part it’s a disease of the past.

Not so for many people living in Asia, Eastern Europe and Africa. About 2 million people die every year from TB, making it one of the world’s top killers. It’s become even more deadly with people with HIV, and is what causes most AIDS-related deaths in Africa.

“Without additional funding in the battle against tuberculosis for research, improved prevention, early diagnosis and treatment, some 8 million people will die from what is largely a curable disease between now and 2015,” according to a statement from UN Secretary General Ban Ki Moon.

Thanks to a lot of work by partners across the world, there’s been great progress. More and more people are diagnosed and treated, and that’s thanks in large part to increased funding through the Global Fund -– a key focus of our ONE advocacy work. About two-thirds of all donor support for TB flows through the Global Fund, and this has helped many poor people get the treatment they need. There’s also a good strategy in place, thanks to the Stop TB Partnership, an active coalition of more than 1 thousand organizations working together to eliminate TB.

Still, there’s a lot more to do. On the prevention front, there’s still a shocking disconnect between HIV and TB services –- even though we know that the rate of TB is much higher, and more deadly, among people living with HIV. Those managing programs and funding need to do much more to ensure that HIV and TB are treated as one in the many countries where they’re raging together.

On the research front, there are some new diagnostic tools to help quickly identify people with active TB, including those that have developed drug-resistant TB (you get drug-resistant TB when the systems for providing regular TB fail, leaving patients vulnerable to mutating viruses that are harder and more expensive to treat). The Foundation for Innovative Diagnostics (FIND) has an active effort on TB that’s really focused on addressing real problems in developing countries that don’t have lots of expensive laboratories, microscopes, and trained personnel).

The world needs a vaccine for TB! There is one now, called BCG and developed about 90 years ago, and it’s used to protect infants but it doesn’t protect them from adult forms of TB and is only partially effective. The Aeras Global TB Vaccine Foundation is leading in this area; they’re hopeful that a vaccine will be ready by the end of the decade. Let’s hope they’re right!

So what can you do to save the poets of today and tomorrow? Help us keep up the pressure to fully fund the Global Fund. The fights still on, sadly, and it’s caught up in the big budget debates going on in many donor capitols. Join ONE, and respond when we ask –- we really do need your voice to help support political leaders to do the right thing.

Photo of Henry David Thoreau courtesy of Wikimedia commons

Several weeks ago, I visited the Central Tuberculosis Research Institute (CTRI) of the Russian Academy of Medical Sciences in Moscow. It plays a central role in Russia’s battle with tuberculosis (TB) as the country’s top TB treatment hospital, research center, and medical training facility. Russians with the most difficult multi-drug resistant (MDR) – TB and extensively drug-resistant (XDR) -TB are treated there. I was struck by the determination of the Russian doctors in the face of the continued threat of MDR-TB and XDR-TB and I am glad that USAID counts them as partners in our common fight.

As we commemorate World Tuberculosis Day on March 24, it is important for all of us to recognize that Eastern Europe and Eurasia continue to have the highest rates of MDR-TB and XDR-TB infections in the world. According to the World Health Organization (WHO), 12 countries have reported proportions of MDR-TB of 6% or more among new TB cases: all of these countries are in Eastern Europe and Eurasia. Five countries report MDR-TB proportions of 50% or more among previously treated cases: all of these countries are also in Eastern Europe and Central Asia. The WHO estimates that in Russia, 42.4% of previously treated TB cases are MDR-TB; in Azerbaijan, 55.8%; in Georgia, 27.4%; and in Ukraine, 44.3%.

In our interconnected planet where people constantly cross borders and millions of people fly every day, not only are U.S. citizens travelling abroad vulnerable to MDR and XDR-TB, but Americans from Georgia to Maine could face this threat at home. Therefore, we have a national security interest in stopping TB around the world and we need the grit of those dogged Russian doctors I met in Moscow.

Tuberculosis is curable but potentially deadly. It is spread through the air and is second only to HIV among infectious killers worldwide. Tuberculosis exacts an enormous personal and economic toll, often striking people in their most economically productive years. MDR-TB and XDR-TB are major risks to effective TB control. MDR-TB is resistant to the two most important first-line drugs used in the treatment of TB. XDR-TB is resistant to additional drugs. The usual six-month treatment with first-line TB drugs is not effective for MDR-TB and XDR-TB. The treatment for MDR-TB and XDR-TB is more expensive, less effective, with greater side effects, and it requires two years to complete—if that form of TB is treatable at all.

MDR-TB and XDR-TB arise due to a number of controllable factors, such as high patient treatment default rates, late diagnosis, irregular treatment, easy access to first and second line drugs in private sector pharmacies without prescription, and, in some cases, population displacement due to unrest. Therefore, it is possible to prevent and control MDR-TB and XDR-TB.

USAID missions through the Eastern Europe and Central Asian regions are working with host countries to combat MDR-TB and XDR-TB. There is hope. For example, USAID in Georgia supported the National TB Program and provided technical assistance to create DOTS spots—special TB outpatient centers located inside of the general urban outpatient clinics. As a result, in the capital city of Tbilisi, the clinics reduced treatment defaults from 23% in 2003 to 9% in 2008. With lowered treatment default rates, the risk of MDR and XDR-TB are lessened. With USAID-supported technical and financial assistance, MDR-TB reported cases decreased in the Balkans from 14.4% in 1996 to less than 9% in 2003. In Ukraine, USAID assisted implementation of laboratory quality control procedures in 8 regions, resulting in 92% of USAID-supported laboratories demonstrating high proficiency in laboratory-based TB diagnosis. These successes show that USAID support is yielding results and helping to control MDR and XDR-TB.

USAID is helping to save thousands of lives and showing the goodwill of the American people. Together with the people of Europe and Eurasia, we must continue to fight MDR and XDR-TB for their sake and our own national interest. Let us not lose focus, take decisive action and curb the spread of MDR-TB and XDR-TB. It is the right thing to do morally, economically, and for our national security.

-Jonathan Hale, Deputy Assistant Administrator, Bureau for Europe and Eurasia, USAID

Today marks yet another moment in the “holidays without greeting cards” series: World Tuberculosis Day. Each year, there are 9 million new cases of TB and close to 2 million people die from the disease. An estimated 10 percent of people with TB also are co-infected with HIV, further compounding the diseases’ burden. Dr. Paul Nunn, a self-described “physician-turned-bureaucrat,” is responsible for coordinating TB control efforts throughout the WHO system — took some time to talk with me about his work on TB. I’ve taken the liberty of paraphrasing some of his answers below:

Today is World TB Day. What does that mean to you?
Travel! [Ed note: Dr. Nunn was off to mark World TB day with a speech at the Swiss Anti-Tuberculosis Association]. Besides that, I see it as a key advocacy moment to drive awareness of TB, highlight the progress we’ve made, and motivate the global community to do more on TB.

What sort of progress have we made on TB in the last decade?
There are still more than 9 million cases per year, but we have made significant progress. The incidence rate of TB flattened in 2004, and it has fallen (albeit fractionally) in the years since, in part thanks to the DOTS strategy. We’ve also significantly decreased the prevalence (total number of cases at any given time) and mortality from TB overall.

Millennium Development Goal 6 set the target of reversing and reducing the incidence of TB along with AIDS, malaria, and other diseases — and for TB that has been achieved. The Stop TB Partnership also set additional goals by 2015: that we would halve the prevalence rate and mortality relative to 1990. It looks like we’re almost there on prevalence rate and may just barely achieve the mortality reduction treatment — although not for Africa specifically.

What work still needs to be done on TB? Where are we having the most difficulty, and what steps are in place to achieve progress?

The achievement of MDG 6 for TB is tempered by the fact that the absolute number of people getting TB continues to rise due to the rising overall world population. Africa also lags far behind many other regions when it comes to TB. The big challenge there is that HIV drives the TB epidemic, and the quality of health services overall is poor. We need to ensure that efforts to fight HIV in both prevention and treatment also take on TB. TB patients tend to be ignored — in part because TB is highly infectious in social settings, and thus stigmatizing — but it’s important that services for HIV and TB are integrated to reach those who are vulnerable and missed in the health system.

MDR-TB and XDR-TB are serious and growing threats to TB control. It’s estimated that there were 440,000 cases of MDR-TB last year, of which 67 percent were identified by the health care system; of those identified, we only managed to treat 30,475 cases (the WHO launched a new report on the topic this week). 69 countries have reported at least 1 case of XDR-TB through 2010, as well. Still, 95 percent of TB remains treatable with existing drugs—and that needs to be the primary focus.

Current tools to diagnose and prevent TB are outdated, but hope is on the horizon. A new diagnostic test Xpert (see our blog about it here) can tell within a few hours if someone has TB and whether the TB is multi-drug resistant. It’s already being used extensively in parts of the world, and we’re hoping to roll it out even further in the coming years, including through the Global Fund’s next round of grants. The currently existing TB vaccine, BCG, works to prevent the worst forms of childhood TB, but is too risky for many with compromised immune systems, including many who are HIV positive. New vaccines are still in the research phase; it’s likely we will go another 10 years before we see a new TB vaccine delivered to patients, yet it’s still an important future tool. Lastly, a few new drugs are nearly certified which, in 3-5 years, could be used to cure TB patients in high burden countries, especially those with MDR-TB.

Who are key partners working on TB around the world?
The Global Fund is key—it’s probably our most important partner—providing countries with financial support to do the work they need to do on TB. We also work closely with countries themselves, particularly those with high disease burdens. Technical agencies from many European capitals are strong partners, as well as the Gates Foundation and USAID, among others.

What messages about TB can advocates use that are the most compelling?

We’re big supporters of the Global Fund to Fight AIDS, TB, and Malaria here at ONE, with so many of our members helping raise awareness about the great work it’s doing to save lives. Despite fantastic results — providing AIDS treatment for 3 million people, anti-TB treatment for 7.7 million people, and 160 million insecticide-treated bed nets for prevention of malaria – the Global Fund is under attack.

Columnist Mike Gerson has just written an excellent column on this issue that’s published in today’s Washington Post. We encourage you to read it, and share it widely!

We at ONE have been working hard to respond to this wave of negative coverage of the Fund, which is based almost entirely on one initial press report that took incidents in a few countries where funding was misappropriated – incidents caught and identified by the Fund itself! – and twisted them to imply that fraud was widespread. We blogged here on this, joining other allies in trying to get out the facts. It’s been tough, with so many being all too willing to believe the worst.

We’re also pleased to hear that the Global Fund announced today that it is taking some extra measures to increase its vigilance, including an external review of all of its financial safety systems. Those already in place are robust, but this might help assuage the donors. The Global Fund needs to deal with this problem to be sure, but its most important work is to speed resources to countries fighting three raging epidemics and the sooner it can get back to that the better.

Over the weekend, the Associated Press filed a story about corruption involving a small number of grants made by the Global Fund, an international partnership that channels funds to fight AIDS, TB and malaria from donors, like the United States, to some of the poorest countries in the world. It’s always interesting to me when stories create news with misused facts and salacious headlines. So I thought it might be useful to have a little background and perspective from someone who’s spent a lot of time with the Global Fund.

The AP report was correct in saying that the Global Fund’s Inspector General has taken an aggressive approach to rooting out and publicizing incidents of fraud and abuse, but the story erred by extrapolating the findings in a few countries to tarnish the entire grant portfolio. Let’s put this to rest: there is absolutely no evidence that there is widespread fraud or corruption of Fund grants. On the contrary, of the $13 billion disbursed by the Global Fund to date, only a portion has been audited by the Global Fund’s inspector general, and of that only a relatively small amount — US $43 million — has been rescinded.

Now just because the percentage of grants found to be misused is relatively small doesn’t mean it’s okay — just the opposite. That’s still a lot of money, and it should piss off anyone who cares about the world’s poorest. We should not rest until all taxpayer supported programs can report no misuse of funds — including those administered right here at home.

While I was thinking about this over my morning coffee, I spied a New York Times front-page article that started, “Since the government took over Fannie Mae and Freddie Mac, taxpayers have spent more than $160 million defending the mortgage finance companies and their former top executives in civil lawsuits accusing them of fraud.” Now I’m willing to bet that all those gloating over the Global Fund stories won’t get nearly so exercised about this kind of pervasive corruption.

I also don’t want to fall into the trap of denying there are problems. We will undoubtedly hear about other instances of abuse. So I’m thankful that the Global Fund and its partners, especially the countries that desperately need the money, take this all very seriously.

There’s already lots of work underway to continue to make improvements. The Fund is pursuing suspected corruption aggressively, usually in close cooperation with local authorities: corrupt officials are going to jail, funds are being returned, new safeguards are being put in place. At the same time, the Global Fund is working hard to strike a balance, continuing its policy of zero tolerance for corruption while not becoming so risk adverse that it can’t get its job done.

So in the end what’s the conclusion? We should celebrate the openness of the Global Fund, even if the information it provides can be abused. We should fight hard to support programs that improve global health AND governance and transparency — fighting for funds needed to save lives and at the same time to build robust systems and checks and balances needed to guaranty their effective use. And we should feel proud that we’ve helped the Global Fund weather this storm and continue its amazing work to save lives.