Michael Kimerling, M.D., comes racing down the hall to his office, cup of coffee in one hand, briefcase in the other and a piece of paper in his mouth. He’s barely a minute late for an appointment, but it’s easy to see he’s a man on a mission.
“Sorry,” he says after returning from a whirlwind trip to Geneva, Switzerland, where he was attending an emergency meeting of the World Health Organization (WHO). “It’s been a busy week.”
And Kimerling’s work is about to get much busier. He attended the WHO Task Force meeting Oct. 8-10 to examine what he calls a potential pandemic emerging in South Africa and elsewhere.
A strain of Extremely Drug Resistant Tuberculosis, or XDR-TB, has broken out in rural South Africa, with mortality reaching near 100 percent in patients with HIV. Early in September in a rural district in South Africa, 221 of 536 patients with TB were diagnosed with Multi-Drug Resistant TB (MDR-TB) and 53 of those were defined as XDR-TB, most of whom were co-infected with HIV. Fifty-two of those 53 patients died shortly after diagnosis. That number jumped to 62 dead, followed by another jump to 73 by the end of the month.
“There are three urgent barriers of the emerging epidemic,” Kimerling says. “First, we don’t know where all of the XDR-TB is. Second, we don’t have any effective drugs to treat it and any new drugs are at least five years down the road. Third, we don’t have rapid diagnostics available, so, by the time we diagnose XDR, people are dead.”
That has WHO, and Kimerling, extremely concerned. The WHO global task force meeting was called to draft a plan to combat XDR-TB, which is resistant to all the key first- and second-line drugs. Health officials are concerned about the strain in South Africa becoming more widespread – and about the speed at which the strain causes death, which is usually between 16 to 25 days after diagnosis.
“Think about Ebola and SARS (severe acute respiratory syndrome) and how those have been looked at globally as a threat along with the avian flu,” Kimerling says. “This should certainly be looked at the same way. There are more people dying of TB every day than those diseases combined have killed, and that’s just regular TB.”
One of the decisions to come out the meeting was for the health professionals treating and researching TB to become more vocal about the danger it possesses and the need for further support in the areas of research.
“There are just not enough people trained — not enough experts, and now we don’t have the right drugs or the right diagnostics,” Kimerling says. “The TB community has been quiet, conservative and used to working with limited resources. Now we have to change that.
“We can’t be quiet anymore.”
What’s the U.S. threat?
Kimerling, who works in UAB’s newly merged Division of Geographic Medicine and Division of Infectious Diseases, has been at the university since 1994.
Before coming to UAB, Kimerling spent time in refugee camps in Asia in global health and TB outreach. Kimerling continues that work for WHO, helping mobilize governments and the health systems within those countries to deal with the TB problems, particularly in their prisons.
Kimerling directs the Gorgas TB Initiative, coordinated at UAB, which helps countries with a high disease burden develop general strategies and specific interventions for improved TB control. He also oversees field operations and the analysis and dissemination of results.
Even though WHO declared TB a global emergency in 1993, efforts to expand research on new drugs and diagnostics still are in the early phases. Kimerling says one of the reasons for this – especially in the United States – may be because many have assumed it’s an easily treatable disease since antibiotics were first used to combat the problem after World War II. While TB rates were at an all-time low in the United States in 2005, drug resistance to the disease is increasing, according to the Centers for Disease Control and Prevention (CDC).
“There are 9 million new TB cases globally diagnosed every year, and that number is growing by 1 percent a year,” Kimerling says. “There are 450,000 to 600,000 new MDR-TB cases diagnosed around the world every year. That’s huge, and only about 5 percent of them are being treated appropriately.”
And when someone has MDR-TB they are only one step away from XDR-TB.
What’s the threat here at home? One Kimerling say has to be taken seriously.
More than 50 percent of all newly diagnosed cases in the United States are from persons born outside the country, so the potential for direct spread to America is real, Kimerling says.
Kimerling is on the road again now. He’s in Burma and Yangon-Myanmar through most of November, helping to devise a national plan for dealing with drug-resistant TB before heading to Africa in December. He anticipates another WHO meeting will be held in early 2007 to consider global priorities for TB research needs in face of the MDR/XDR and HIV threats.
“This is a top priority for WHO,” he says. “If XDR-TB expands in Africa, it’s going to be a real problem because there’s just not an infrastructure in place to deal with it.”