Watch Out For The Russians

Watch Out For The Russians

Last night I watched a Scientific American TV program with

Alan Alda retracing Charles Darwin”s steps in the Galapagos

Islands. In Kansas, a creationist governmental body wants to

outlaw teaching evolution in the schools. In contrast, the

Governor of Minnesota calls organized religion a sham that

serves as a crutch for the weak-minded and wants to come back

as a bra! In a more recent TV interview, he says that being

weak-minded isn”t that bad! I won”t touch Jesse”s remarks; he”s

just too big for me! However, I will respond to the wishes of one

of my readers to talk about evolution; actually, about one of

today”s major evolutionary challenges which threatens mankind.

The challenge is the rapid evolution taking place in the world of

bacteria and viruses harmful to Homo sapiens. We”re all familiar

with AIDS and the ability of the HIV virus to evolve in response

to different drug treatments. In our area of New Jersey, we”ve

had family members with Lyme disease, which may not be an

evolving bug but one that”s been around for a long time. Now,

however, today”s frost is welcomed in many areas of New York,

New Jersey and Connecticut because it kills mosquitoes carrying

the new West Nile-like encephalitis. Just this morning I heard

that DNA studies have shown that this is a form of encephalitis

never been seen before. When my wife had surgery recently, I

was more confident in the outcome of the surgery in the hands of

a capable surgeon than I was that she would not pick up a drug-

resistant staph infection. These “superbugs” are demonstrating

evolution in a devastating fashion.

What really caught my attention was last week”s “60 Minutes”

segment on the evolution of drug-resistant forms of tuberculosis.

For those who missed the episode, it focused on the situation in

Russian prisons, notably in Siberia. Drug-resistant TB (DR-TB)

is running rampant in these prisons. One case cited was a prison

of 230 inmates, all of whom had DR-TB! Last year, some

20,000 prisoners contracted DR-TB and those who were released

after serving their terms infected some 15,000 Russian civilians.

To make matters worse, TB bacteria can be airborne and infect

you even after only casual contact with someone carrying the

disease. You may think, “Oh well, the problem is in Russia and

doesn”t concern me.” Hey, if you”ve followed these columns, you

know that I just came back from St. Petersburg in June. What”s

more, thousands of your fellow countrymen (or women) visit

Russia on cruise ships and other tours every week. Chances are

pretty good that you”ve been within a few yards of one of these

intrepid travelers yourself recently if you get out much.

Steve Croft interviewed Dr. Lee Reichman on the “60 Minutes”

show. Dr. Reichman is executive director of the New Jersey

Medical School National TB Center and lectures at the

University of Medicine and Dentistry of New Jersey (UMDNJ)

to visiting Russian physicians on the epidemiology and treatment

of TB. A big problem is that the proper treatment of DR-TB is

not simple and is not known to most physicians who encounter

TB patients. I”m an adjunct associate professor in the department

of surgery at UMDNJ-Robert Wood Johnson Medical School

and some of the information conveyed herein is from an article in

the Fall 1999 issue of the UMDNJ publication “Health State”.

Incidentally, just because I”m in the department of surgery, don”t

ask me to assist in your hernia operation. I”d faint dead away at

the first cut!

Back to DR-TB, why is it such a worrisome problem? In the

1950s, antibiotic therapy was shown to cure TB and it virtually

ceased to be a significant problem in the developed nations.

Then, the HIV virus made its appearance and, with lowered

immunities and increased immigration from the less-developed

countries, fueled a new wave of TB. Human nature began to

play an important role. How many times have you been

prescribed a certain medicine and told to take it until you”ve used

up all the pills in the bottle? Or, maybe the doctor failed to tell

you? Have you ever felt much better after a few days and

stopped taking the pills? If so, shame on you! You may have

unknowingly contributed to the development of a drug-resistant

strain of virus or bacterium. The reason is that, by stopping the

treatment early, the bacteria or viruses that remain behind are the

forms more resistant to the medication. They normally are

present in relatively small numbers, but thanks to your

negligence, are now the dominant species in your body. This

doesn”t even consider mutations of the normal viruses or bacteria

that might evolve to resist the drug. Sorry to beat up on you like

this, but I now take all the medication prescribed, regardless of

how I feel. However, I admit that in the past I may have done

my share to advance the cause of those superbugs.

Not only can a bacteria be resistant to one drug, but also the real

problem now is the multiple drug-resistant TB (MDR-TB)

bacteria. For the run-of-the-mill DR-TB victim, treatment is

initiated that involves a mix of the four drugs isoniazid, rifampin,

pyrazimide and ethambutol. After two months the latter two

drugs are dropped but the isoniazid and rifampin must be

continued for 4 more months. The exact treatment will depend

on tests that may reveal certain drugs are ineffective against the

specific bacteria.

Unfortunately, the patient may feel much better after a few

weeks and the side effects of taking the 10-12 pills daily may

seem worse than the TB. Result – they stop taking the drugs.

This results in even “smarter” TB bacteria resistant to the

standard drugs. Now more toxic and more expensive drugs are

needed and the time for a cure may run up to two years, not 6

months! Furthermore, surgery may be necessary and the cost of

treating one MDR-TB patient may be about $250,000, with a

fatality rate that may be as high as 45%! It doesn”t take a

mathematical genius to figure out that the cost to solve the

Russian MDR-TB problem will be huge! That laundered

Russian money we hear about needs to be re-laundered back to

Russia! Actually, the financial giant and philanthropist George

Soros has been donating millions to help address the Russian TB

dilemma.

How are we doing in the USA? House calls, that old-fashioned

concept, seem to be one answer. Designated by a fancier term,

Directly Observed Therapy (DOT), outreach workers are

assigned to visit each infected person every single day and watch

the patient take his or her medicine. DOT was instituted in the

1970s for uncooperative patients and today there are less than

500 cases of MDR-TB in the USA, or about 2% of the total

number of TB cases. All this is cause for a bit of celebration, but

the cost of such labor-intensive programs is not cheap. Also,

immigrants remain a continuing source of infection. Of the TB

cases in this country, 40% are brought in by immigrants, who

must have X-rays showing they are free of TB to enter the

country. However, many immigrants apparently buy “clean” X-

rays or bring X-rays of friends or relatives free of the disease.

The success of the TB bacterium is in large measure due to the

complexity of its cell wall and the fact that it divides very slowly,

once a day, compared to the familiar E. coli at 3 times an hour.

When the TB bacterium enters the lung, a dutiful macrophage

engulfs it, as it would other bad guys, but thanks to the

bacterium”s resistant cell wall, the macrophage can”t penetrate

and kill the invader. Instead the TB bacterium just sits there

inside the macrophage cocoon and in about 90% of the cases

nothing ever happens. In the other 10%, the susceptible

individuals may come down with the disease within weeks or

months; the rest may not show signs of TB until much later in

their lives. There is a lot of research going on to try to figure out

how to penetrate the cell wall and to develop tests that can

determine quickly which drugs will be effective for a given form

of the TB bacterium. A more detailed technical article on this

subject can be found in the May 17th issue of Chemical &

Engineering News.

As I was writing this piece, it occurred to me why I was drawn so

strongly to the “60 Minutes” story. I owe my very existence to

TB! When my father was young, living in the Pennsylvania

Dutch country around Allentown, Pennsylvania, he developed

what his parents thought was TB. In those early days of the 20th

century, you either went to a sanatorium or you moved out West

for the cleaner, drier air. My grandparents moved to Denver,

where my Dad eventually met and married my mother, who had

moved to Denver from Princess Anne, Maryland. So, without

the TB, you wouldn”t be reading this column today. OK, you

probably wish you hadn”t!

However, after this somewhat depressing piece, Brian Trumbore

has instructed me to write next week about a happier subject,

baseball!

Allen F. Bortrum