Multidrug-resistant tuberculosis (MDR-TB) is a global problem, but one that is particularly worrisome in Asia. An estimated 60% of the 500,00 MDR-TB cases in 2011 occurred in Brazil, China, India, Russia and South Africa. The problem is made worse by the low number of people with MDR-TB enrolled in treatment in countries like China, Myanmar and India.
Information on MDR-TB in the reclusive North Korea has been hard to come by, until now. Dr. KJ Seung has been working in North Korea on TB for years and heard from his colleagues that first-line TB drugs were not working for patients.
“I’ve treated MDR-TB in a lot of different countries, but the situation in North Korea is the worst I’ve ever seen,” he said in a recent interview with PIH. “There are simply too many patients. At every sanatorium we visit, there are lines of patients who have failed multiple courses of treatment with regular TB drugs and are hoping to get into our treatment program.”
Dr Seung decided to analyzed sputum samples from 245 of TB patients to get to the bottom of it. His results were stunning. Eighty-seven percent of the patients analyzed have MDR-TB. The results of the study were published this week in the open-access medical journal PLOS Medicine.
He collected information as a part of his work with EugeneBell, an NGO formed by US-based Eugene Bell Foundation and South Korea’s EugeneBell Korea. For more than a decade, the NGOs have supported a half dozen TB sanatoria throughout North Korea. Some of the tested strains of TB were resistant to second-line drugs and there was evidence of extensively drug-resistant (XDR) TB.
“A lot of the credit has to go to Dr. Linton (director of the Eugene Bell Foundation). He’s not a medical doctor, but just by listening to the North Korean doctors, he discovered a major epidemic. Sometimes the evidence is staring you in the face. You just have to listen to what people are telling you,” said Dr Seung.
A Model Response?
North Korea has done a reasonably good job in treating the spread of TB. Dr Seung says that the North Korean Ministry of Public Health followed the basic recommendations from the World Health Organization (WHO), going as far as to asking for support in 1998. It was followed by North Korea’s securing of drugs from the Global Drug Facility, a WHO initiative, beginning in 2003. The efforts were recognized and led to a 2010 pledge by the Global Fund to Fight AIDS, TB and Malaria for $41 million over five years.
There was little reason to believe MDR-TB was a problem based on the actions by North Korea. The active program that engaged with international bodies seemed to be one of the few bright spots within the troubled country. However, North Korea has never conducted surveys to determine the extent of MDR-TB, nor does it have the surveillance capabilities to track cases as they happen. This prevented knowledge about MDR-TB cases, but it is the way that North Korea treated TB which propelled resistance in the country.
New patients with TB were given a kit of medicines, without testing if their form of TB was resistant to the drugs. The first-line drugs used by every patient helped to create resistance in the TB and make it more widespread.
“Drug-resistant tuberculosis is a man-made disease, created when TB is treated incorrectly. Treating drug-resistant TB with ineffective regimens provokes the TB to become even more resistant. From a public health point of view, bad treatment is worse than no treatment at all, because it can quickly make the problem of drug-resistant TB worse,” wrote Dr Seung in the Atlantic.
The donors and development community also have a stake in the blame for the spread of MDR-TB. Despite warnings of MDR-TB in North Korea by Dr Seung and others, the WHO and Global Fund kept the course as if there was no problem. Part of the issue is the way that data is reported back to the WHO, says Dr Seung. The analysis used on TB patients after they complete treatment will show that they are TB-free even if it is not the case. A more precise measure will tell if the first-line treatment worked or if it failed.
Cases of MDR-TB slip under the radar and health officials cite the high rate of curing TB in North Korea as evidence of a successful program. Dr Seung tells PIH of one official with the WHO who provide an incredulous response upon hearing of diagnosed cases of MDR-TB in North Korea. The comments from the WHO were not lining up with what was observed on-the-ground.
Vital Access to Second-Line Drugs
Neighboring Russia, Azerbaijan and Uzbekistan all experienced an increase in TB cases in the wake of the economic troubles that followed the collapse of the Soviet Union. MDR-TB soon followed in the countries and Dr Seung says that there is reason to believe that North Korea has quietly traveled along the same path.
Dr Seung is concerned that people with TB who are not cured by first-line drugs will turn to second-line drugs on their own. This could create more problem for the patient and other North Koreans. Inferior or the use of the wrong medicines could create strains that are resistant to even more drugs.
The first step for fixing the problem is for a study to be conducted to determine the number of MDR-TB cases in North Korea. It matters because an appropriate response can be employed and it also can give a better sense of the scale of the problem. If the rate of MDR-TB is closer to that of neighboring China there may be 8,000 cases of MDR-TB, twice as many as current estimates.
North Korea must also increase access to second-line TB drugs to treat patients with MDR-TB and stop the progress of resistance. Many doctors are treating patients multiple times with first-line drugs, a policy that is ineffective for the patient with resistance and one that increases resistance.
Most concerning is what is not known about the state of MDR-TB in North Korea. The country may be facing a crisis and its current approach is making things worse.
“I am quite sure the Eugene Bell program is only seeing a sliver of the total MDR-TB population in the country. Wherever we’ve been asked to expand our program, we’ve seen the same problem. There are many patients who don’t respond to regular TB drugs, and when we test them, they have MDR-TB,” said Dr Seung.