Estonia races to halt multidrug-resistant TB before HIV takes hold
"When they said I had TB I didn't even know what it was. All I knew was that if you get it, you die. It was just a disease of the lungs. I'm 21. This summer I'll be 22", said Pia, a patient at Tartu Lung clinic, Estonia, in a television interview in 1995. Pia died of multidrug-resistant (MDR) TB two days before her 22nd birthday.
Another patient in Estonia, Kairit, was interviewed in 1997, and said: "After four months of treatment they said I had a dangerous microbe which didn't react to the TB drugs. I felt really frightened. I'd heard of resistant bacteria. I knew they didn't give you much hope". She was being treated for MDR-TB, and her seven-year-old son lived with his grandmother. "Sometimes I go to see him. I creep away early in the morning because I don't want him to know I've got to go back to the hospital. I've been taking pills for two-and-a-half years but the disease just keeps growing." Not long after that, Kairit died too.
The stories of Pia and Kairit and their losing battle with MDR-TB were told in a short video to an audience of 150 national TB programme managers from 32 countries. They were attending a meeting of the DOTS-Plus working group in the fight against MDR-TB, held from 10 to 12 April 2002 in Tallinn, Estonia's capital city.
The global burden of MDR-TB is notoriously difficult to estimate. But the number of previously untreated cases of TB that were multidrug resistant in the year 2000 has been calculated recently to be between 185 000 and 414 000 (95% confidence intervals), about 3% of all new TB cases. Particularly hard hit are the Baltic states, Russian Federation, Eastern Europe and parts of China. According to these estimates Estonia is the MDR-TB capital of the world, with 14% of all new TB cases being multidrug resistant (Christopher Dye et al., Journal of Infectious Diseases, 2002,185: 1197-1202 (15 April)).
One of the prime causes of MDR- TB is patients defaulting on the basic treatment for TB - a daily dose of medication for six to nine months. Irregular dosage or stopping part of the way through the course lets drug- resistant organisms multiply. In order to avoid this, national TB programmes around the world are attempting to implement DOTS, the WHO-recommended strategy to control TB, which requires supervision by health or community workers during the first two months of daily TB medication.
For the TB patient, taking medication every day is time-consuming, costly and often unpleasant. After a couple of months of treatment, the patient begins to feel better and is tempted to stop taking the pills.
"They interrupt their treatment, and within one or two years develop multidrug-resistant disease" says Manfred Danilovits of the Estonia National Tuberculosis Programme. "After that, they spread the infection to others."
In Estonia MDR-TB has made its way into the general population. At least one fifth of the MDR-TB patients have full-time jobs - and a frequent reason for defaulting is that patients feel too busy to come to the clinic.
The homeless and the poor are at high risk, and half of Estonia's MDR-TB cases are alcoholics. In the cobbled streets of Tallinn's old town, a homeless alcoholic in his mid-30s, Sergei, says he is afraid that he will be infected as his living conditions are precarious, sleeping `underground' as he does, with other homeless alcoholics, often drinking from the same cup. On the other hand, Sergei says that if he were infected, he could look forward to a hospital stay "in a clean bed and being fed decent food."
In Kose, an hour away from the Estonian capital, there is a specialized MDR-TB hospital with 72 beds. They are all occupied. Once admitted, the patient passes through showers before taking the elevator up to his room in the infectious disease wards. As MDR-TB is contagious, control is particularly strict in the Kose hospital. Double-glazed sliding doors protect the health-care workers and ultraviolet air purifiers are on every wall. The patients receive intensive treatment with second-line drugs, the cost of which can amount to as much as US$ 19 000 for one person. But efforts of the Green Light Committee, led by WHO, Médecins Sans Frontières and Harvard Medical School, have enabled Estonia and other countries to save as much as 94% on these costs.
"Currently at least half our MDR cases are being treated, and transmission of the disease to the population has been reduced," claims Kai Vink, of Estonia's National TB Control Programme. "We think that we can have this infection under control before HIV/AIDS begins to make its own negative impact on TB rates". 
Marion Lindsay, WHO