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Saturday, September 16, 2006

Ineffective strategies against Tuberculosis in underdeveloped countries.

Photo.BBC courtesy.
According to information coming from diverse scientific publications, in the last 10 years, has been identified in growing form in almost the whole world, a new strain of Mycobacterium tuberculosis, causing a human Tuberculosis (TBC), multiresistant of extended spectrum (XDR-TB), characterized by their resistance to at least 2 drugs: Isoniazide (INH), Rifampicin (RFP), employees in treatments of first line and at 3 or but drugs of the 6 classes of medications of second line. In other words: resistance to most of well-known antituberculostatics. Hence some specialists label to this illness like: incurable. The previous cases of multiresistance TBC: TB-MDR (4% of the 50 000 cases/year/TBC, in Peru), comprise resistances at 1 or, 2 medications (INH and/or RFP), of first line. Dr. Oswaldo Jave Castillo, Chief of the TB-MDR Unit, of the Ministry of Health (MINSA-PERU), declared yesterday to El Comercio of Lima that from 1997 to the date, 60 cases of XDR-TB had been detected in Peru. Numbers something doubtful (definitively here, a subreport exists) and ridiculous, if it is compared with those 1000/cases XDR-TB/year, in east Europe (250 000 cases/total year/TBC), subsaharian Africa : 8000/year (2 millions cases/total year/TBC) and 12 000 cases each year, in southeast Asia (3 millions cases/year total/TBC). The cases of XDR-TB, frequently happen in patients with incorrect prescripctions, medications of poor quality, irregular treatments, convicts, diabetics, malnourished people, alcoholic, > 65 years, coinfection affections with HIV or inmunosupressed persons, combinations these last ones with rates of high letality. From our point of view, the cases of XDR-TB, were conditioned in our country, for conceptual flaws. It is that up to 1997, the antiTBC fight prioritized standardized treatments (diagnosis -dx- treatments, administration of medications without antibiotic sensibility, treatment), mostly irregular and ineffective. For us, for poor that is a country, the strategies should involve, individualized treatments (dx, studies of sensibility using the economic method : MODS and treatment). Not to forget that an individualized successful treatment costs 2000 dollars on the average, as long as a successful treatment of 1 single case of XDR-TB: 250 000 dollars.

The increment of the morbimortality for TBC, in the entire world has alerted to world organizations of health and others. The problem is specially difficult in Africa where the coexistence of the pandemic of the AIDS, adds but difficulties. The thing is so serious that governments and altruistic people: Olusegun Obasanjo (Nigeria), Gordon Brown (United Kingdom) and Bill Gates (Microsoft), gathered in Davos/Switzerland, to support the Global Plan of fight against the TBC (2006-2015), with a tentative investment of 56 000 million dollars, with the aim of to stop the upward raising of TBC and to reduce the rates of TBC/year, at inferior levels to the current ones. For us the Global Plan (more healing than preventive), defers strategies of but value in underdeveloped countries, that is : massive setting-up of individualized treatments, in populational focuses of high population density - concentration of cases - of TBC (Lima, Callao, Loreto, Junin, Ica, Lambayeque, Iquitos), the subsaharian Africa, east Europe,etc., new generations of vaccines, establishing at the same time or next a series of social (glasses of milk popular programs, popular and of quality food programs (fish, cereals, milk and so on) for children, pregnancy woman and old people, buildings good popular housings, universal insurance health, extensive nets of water and drainage, etc), coordinated measures and of long reach.

M. tuberculosis, is a bacteria gram positive, aerobic, of slow growth which dies if it is exposed to the solar light, heat and radiation UV. On the other hand is extremely resistant to cold, freezing or, drying. Our emphasis in the generation of new vaccines rely on the total deciphering of the sequence's genome, of M. tuberculosis that has allowed to detect possible areas of antigenic variation. With these knowledge and so much money, a serious good option is to develop to the brevity vaccines starting from bacterial DNA, of certain proteins of the cellular (inmunogens) surface and/or attenuated M. tuberculosis. The absence of natural immunity to this germ, is because the human organism through the history didn't have time of establishing appropiate relationships host/germ, with M. tuberculosis. What induces us to differ with Veronique Vincent of the Institute Pasteur of Paris who affirms that the strains of XDR-TB, appeared 3 000 000 years ago to.C., being dispersed by the first hominids. If Vincent had studied the remains of the first ones hunter-gatherers (20-30 people's dispersed groups) that arrived to America and Peru (20 000 - 13 000 years to.C), she would verify that TBC was almost nonexistent among them. TBC is an illness that develops and generates new strains, where people live very near among them :high populational density (Lima-Callao) or, where the feeding is precarious (southeast Asia, Africa, east Europe). We agree that genomic studies will serve to carry out comparative studies between genomes of normal strains and those of XDR-TB, being possible to discover essential genes, able to confer resistance or aggressiveness to certain strains of M. Tuberculosis, essential knowledge to generate effective vaccines.

Ineficaces, estrategias, contra la Tuberculosis en paises subdesarrollados

De acuerdo a información procedente de diversas publicaciones cientificas mundiales, en los ultimos 10 años, se esta identificando en forma creciente en casi todo el orbe, una nueva variante (cepa), de Mycobacterium tuberculosis, causante de una Tuberculosis (TBC), humana multiresistente de espectro extendido (XDR-TB), caracterizada por su resistencia a al menos 2 drogas : Isoniazida (INH), Rifampicina (RFP), empleadas en tratamientos de primera linea y a 3 o mas medicamentos constituyentes de las 6 clases de medicamentos de segunda linea. En otras palabras : resistencia a la mayoria de antituberculostaticos conocidos. Por ello algunos especialistas etiquetan a esta enfermedad como :incurable. Los anteriores casos de TBC multiresistente : TB-MDR (4% de los 50 000 casos /año/TBC, en el Peru), comprendian resistencias a 1 o, 2 medicamentos (INH y/o RFP), de primera linea. El Dr. Oswaldo Jave Castillo, Jefe de la Unidad Tecnica de TB-MDR, del Ministerio de Salud (MINSA-PERU), declaró ayer al Comercio de Lima, que desde 1997 a la fecha, se habian detectado 60 casos de TB-XDR en el Peru. Cifra algo dudosa (definitivamente aquí, existe un subreporte) y ridicula, si se la compara con los los 1000/casos XDR-TB/año, en Europa oriental (250 000 casos/año/TBC total), 8000/año, en Africa (2 millones casos/año/TBC total) y 12 000 casos/año, en el sur de Asia (3 millones casos/año /TBC total). Los casos de XDR-TB, ocurren frecuentemente en pacientes con prescripcciones incorrectas, medicamentos de pobre calidad, tratamientos irregulares, presidiarios, diabeticos, malnutridos, alcoholicos, > 65 años, afectos de coinfeccion con HIV o inmunosuprimidos, combinaciones estas ultimas, con tasas de letalidad elevadas. Al parecer, los casos de XDR-TB, fueron condicionados en nuestro pais, por fallas conceptuales. Resulta que hasta 1997, la lucha antituberculosa priorizaba tratamientos estandarizados (diagnostico (dx), administración de medicamentos sin sensibilidad antibiotica, tratamiento), mayormente irregulares e ineficaces. A nuestro entender por pobre que sea un pais, las estrategias deben involucrar, tratamientos individualizados (dx, estudios de sensibilidad empleando el economico metodo Bactel y tratamiento). No olvidar que un tratamiento individualizado exitoso cuesta en promedio 2000 dolares, en tanto otro exitoso de 1 solo caso de XDR-TB : 250 000 dolares.

El incremento de la morbimortalidad por TBC, en todo el mundo ha alertado a las organizaciones mundiales de salud y otras. El problema es especialmente dificil en Africa donde la coexistencia de la pandemia del SIDA, añade mas dificultades. La cosa es tan seria, que gobiernos y personas altruistas :Olusegun Obasanjo (Nigeria), Gordon Brown (Reino Unido) y Bill Gates (Microsoft), reunidos en Davos/Suiza, decidieron apoyar el Plan Global de lucha contra la Tuberculosis (2006-2015), con una inversion tentativa de 56 000 millones de dolares, con el objetivo de detener la espiral ascendente y reducir las tasas de TBC/año, a niveles inferiores a los actuales. Para nosotros el Plan (mas mas curativo, que preventivo), posterga estrategias de mas valor en paises subdesarrollados, a saber instauración masiva de tratamientos individualizados, en focos poblacionales de alta tasa -concentración de casos- de TBC (Lima, Callao, Loreto, Tumbes, Ica, Lambayeque, Iquitos), Africa del subsahara, area suroriental de Asia, Europa oriental, nuevas generaciones de vacunas, instaurando concomitantemente o a continuacion una serie de medidas sociales (vasos de leche, comedores populares -a escala- de calidad para niños, gestantes y ancianos, destugurizacion de viviendas, seguro universal de salud, extensas redes de agua y desague,etc), coordinadas y de largo alcance.

M. tuberculosis, es una bacteria gram positiva, aeróbica, de crecimiento lento, que muere cuando es expuesta a la luz solar, calor y radiacion UV; en cambio extremadamente resistente al frio, congelamiento o, desecación. Nuestro enfasis en la generacion de nuevas vacunas se apoya en el desciframiento total de la secuencia genética (genoma), del M. tuberculosis, que ha permitido detectar las posibles areas de variacion antigenica. Con estos conocimientos y tanto dinero de por medio, una buena opcion seria desarrollar a la brevedad vacunas a partir del DNA bacteriano, de ciertas proteinas de la superficie celular (inmunógenos) y/o M. Tuberculosis atenuado. La ausencia de inmunidad natural a esta bacteria se presume sea debido a que el organismo humano a través de la historia no tuvo tiempo de establecer relaciones huésped/germen, adecuados con M. tuberculosis. Lo que nos induce a discrepar con Veronique Vincent del Instituto Pasteur de Paris, quien afirma que las cepas de XDR-TB, aparecieron hace 3 000 000 años a.C., siendo dispersadas por los primeros hominidos. Si Vincent estudiara los restos de los primeros cazadores-recolectores (grupos dispersos de 20-30 personas), que arribaron a America y al Peru (20 000- 13 000 años a.C), constataria que la TBC era casi inexistente entre ellos. La TBC es una enfermedad que desarrolla y genera cepas nuevas alli, donde las personas viven unas, muy cerca de las otras : alta densidad poblacional (Lima-Callao) o, donde la alimentación es precaria (sur del Asia, Africa, Europa oriental). Concordamos que los estudios genómicos serviran eso si, para realizar estudios comparativos entre genomas de cepas normales y los de XDR-TB, siendo posible descubrir genes esenciales, capaces de conferir resistencia o agresividad a ciertas cepas de M. Tuberculosis, conocimiento esencial para generar vacunas eficaces.

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