MULTI-DRUG RESISTANT TUBERCULOSIS IN THAILAND: GLOBAL RISKS

UNCLAS SECTION 01 OF 03 BANGKOK 003439 SIPDIS SENSITIVE SIPDIS STATE FOR EAP/MLS AND EB COMMERCE FOR EAP/MAC/OKSA TREASURY FOR OASIA STATE PASS TO USTR FOR WEISEL STATE PASS TO FEDERAL RESERVE SAN FRANCISCO FOR DAN FINEMAN STATE PASS FEDERAL RESERVE NEW YORK FOR MATT HILDEBRANDT E.O. 12958: N/A TAGS: ECON EAID PGOV PHUM PREL TH SUBJECT: MULTI-DRUG RESISTANT TUBERCULOSIS IN THAILAND: GLOBAL RISKS REFS: A) Rangoon 588 B) Rangoon 134 This is a joint-cable between the U.S. Embassy in Bangkok and the U.S. Embassy in Rangoon. Summary -------------- ¶1. Collaborative efforts between the CDC and the Thai Ministry of Public Health (MOPH) have improved the accuracy of testing and reporting of tuberculosis (TB) cases in Thailand. As a result, health authorities here better understand the prevalence of multi-drug resistant (MDR) and extensively drug-resistant (XDR) TB. There are several hotspots for MDR TB in Thailand. Tak Province, located along the Burma/Thai border is one such hotspot, where 10% of culture-confirmed TB cases are MDR. Recently, two migrants from Burma were diagnosed with XDR TB in Tak. The emergence of XDR TB and the high rate of MDR TB in Tak Province are due to poor compliance of patients with TB treatment and lack of appropriate diagnostic and treatment services for populations originating in Burma. The political situation in Burma shows no signs of abating and the displaced will continue to travel into Thailand, some of them settling in refugee camps in Tak Province. Migrants will also continue to travel to Thailand as long as it offers better economic opportunity and access to higher quality health services. Without improvements in the diagnosis and treatment of TB patients in Burma, the numbers of MDR and XDR TB cases are expected to increase in Burma and subsequently Thailand. This potentially has global health implications due to the ongoing resettlement of refugees from Burma to the United States, as well as Thais traveling internationally. We recommend seeking HHS agreement to permit CDC personnel to travel to Burma to assist with reducing the spread of this threat. End Summary. ¶2. Thailand's ability to accurately diagnose and effectively treat TB is improving. However, many Thai health professionals still do not use sputum cultures to test for TB, which is the most accurate way to diagnose TB and MDR TB. Sputum culture tests are time consuming, more expensive and require laboratory capabilities that are not available in many Thai hospitals. The Thai MOPH - U.S. CDC Collaboration is currently trying to improve this situation by building laboratory capacity in five provinces in Thailand, including Tak. In regards to treatment, most patients in Thailand do not receive directly observed therapy by a health care worker (DOT). DOT involves medical staff or trained personnel directly observing the ingestion the TB medications. DOT is recommended by WHO and CDC as the most effective way to treat TB. It protects the patient's health and prevents drug resistance by ensuring compliance with the drug regimen. Many Thai hospitals give patients the option of using DOT, but do not require it. Thailand's failure to use DOT may contribute to MDR. In 2001, 1% of all TB patients in Thailand had MDR TB. Preliminary data from a Thai MOPH survey currently underway indicate that the number of MDR TB cases in Thailand may have doubled since then. CDC is currently working with the Thai MOPH to measure the number of XDR TB cases nationally in Thailand. ¶3. In Burma, a 2002/03 survey demonstrated 4% MDR TB among new patients and 15.5% among previously treated patients. Diagnosing and treating these patients is complicated by the overall poor state of the public health system, restrictions on the delivery of assistance in many areas, and conflict in border areas. Reftels describe in more detail the challenges facing TB programs operating in Burma. Among the most important are: late case diagnosis, lack of a standardized treatment regimen, and inadequate funding for basic diagnostic tests and medications. ¶4. Tak Province is a convenient crossing point for Burmese migrants and displaced persons. On June 7, 2007, a Doctors Without Borders TB clinic for Burmese migrants in Tak Province reported that 2 cases of XDR TB had been diagnosed in migrants from Burma; the diagnoses was confirmed by laboratory testing done at the Thai MOPH reference laboratory. Approximately 10% of all culture-confirmed cases in Tak Province are MDR TB, most of which are diagnosed in migrants from Burma. The emergence of XDR TB and the large number of MDR TB cases in Tak is directly caused by the weak infrastructure of the TB program in Burma and amplified by weaknesses in the Thai TB program. Migrants from Burma who are treated for TB in Thailand report that BANGKOK 00003439 002 OF 003 TB clinics in Burma, particularly along the border, have limited or no staff and do not have a consistent supply of quality medicines. These migrants with TB report purchasing anti-TB medicines from pharmacies or private doctors in Burma and taking these medicines haphazardly. Normally, TB can be cured by taking medication for six months to one year. Failure to take medications consistently and correctly, poor quality of medications, and poor record keeping can disrupt the treatment process and cause the TB bacteria to become resistant to first-line and second-line (reserve) drugs. ¶5. A mobile population makes it particularly difficult to diagnose and treat TB. In order to determine if TB is either MDR or XDR, a sputum sample must be sent to an appropriate lab, where a culture test is performed. After TB bacilli is grown in culture, the laboratory can test whether the bacteria is resistant to first and second line drugs. This entire process takes approximately four to six weeks using the best techniques, and if the patient is mobile, it may be difficult to locate them once the results are known. In this case, the patient will not be able to receive treatment and could infect others. ¶6. CDC and the Thai MOPH suspect that there are high rates of MDR TB in migrants and displaced people along the border between Thailand and Burma. Their suspicions are based on the fact that there is a high prevalence of MDR TB in the same populations in Tak Province and that XDR TB has now been identified in migrants from Burma. Furthermore, Burma does not have the medical infrastructure to accurately test and effectively treat TB. The political situation in Burma shows no signs of abating and it is reasonable to conclude that the flow of migrants and displaced people will not stop in the near future. Therefore, CDC expects that highly resistant strains of TB will continue to emerge in Burma, particularly along the border with Thailand. ¶7. The increase in the number of cases of MDR and the emergence of XDR TB in Tak Province could have global health implications if allowed to continue unchecked. This is best illustrated by the Hmong refugee resettlement in 2004 - 2005. Despite the CDC's best efforts to screen those bound for the US, 37 refugees were diagnosed with TB upon arrival in the U.S. and four of those cases were MDR. The increased mobility of Thais also poses a threat to the health of countries in Southeast Asia. Porous borders with Laos and Cambodia and an increased standard of living in Thailand make it possible for Thais to travel frequently throughout the region. Frequent travel, especially by airplane, could facilitate the spread of MDR TB. ¶8. Recently, USAID in Bangkok, the World Health Organization's office in Burma, and Embassy/Rangoon have requested assistance from CDC Bangkok staff in improving TB programs in Burma. However, we understand that CDC has been unable to respond to requests, because HHS policy does not permit travel to Burma. U.S. foreign policy permits humanitarian assistance to the people of Burma through non-governmental and multi-lateral organizations. USAID and the State Department currently have health programs operating in this manner in Burma. These programs include global health threats, such as Avian Influenza. If permitted to travel to Burma, CDC personnel could assist State Department, USAID, and their partners (including multi-lateral organizations and non-governmental organizations) in assessing and addressing the threat of drug resistant TB, consistent with U.S. government foreign policy. Comment -------------- ¶9. In light of the current situation involving the transnational spread of XDR TB from Burma into Thailand, we request that the Department meet with HHS to change its policy on restricting CDC personnel from traveling to Burma. This is a regional health issue with potential global health and economic implications. Health organizations in Burma are unable to quell the spread of MDR TB in Burma by themselves and require technical assistance. Due to political repression and limited economic opportunity in Burma, migration is spreading MDR and XDR TB to Thailand. The Thai health authorities are better poised to diagnose and treat MDR TB than the Burmese, but their surveillance and treatment programs are still under development and we believe that most infected patients are not identified before leaving the border area. As a result, there is the BANGKOK 00003439 003 OF 003 potential for the number of MDR cases to increase in Thailand and there is also the potential for it to spread to the U.S. (especially through U.S. policies for resettling certain refugee populations) and neighboring countries. End comment. Boyce