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NEW DRUGS NEEDED FOR TUBERCULOSIS
92
Letters
to
the Editor
NEW DRUGS NEEDED FOR TUBERCULOSIS
SiR,—Your leader last week draws attention to an urgent problem. As tuberculosis is being brought under control in the more developed countries the situation in less economically favoured lands is not only not improving but tending to worsen because of the emergence and rapid increase of drug resistance. In both India and Africa this has already reached proportions such as to seriously threaten any proposed scheme for securing control of the disease. In some " up-country " towns in Southern India, where no organised scheme of control is in operation, up to 42% of treated " patients have been found with resistant organisms in their sputum- while 6% of untreated patients have had organisms resistant to isoniazid and another 6% organisms resistant to streptomycin.’ The situation in some parts of Africa, as you point out, is equally unsatisfactory. With pills containing small amounts of isoniazid being sold over the counter as a cure " for cough, and treatment outside the main centres being almost uniformly bad, the massive build-up of resistant organisms continues unchecked day by day, with the full weight of the blow still to come. "
death-rate at St. Thomas’s Hospital was 9-2 per 1000 live births in 1959 and 19-6 per 1000 live births in 1960. In addition to these inevitable fluctuations, improved methods of care must be taken into consideration. A significant advance in the correction of the biochemical complications of hyaline-membrane disease was introduced by Usher1 in 1959. Their reluctance to carry out a properly controlled trial because they " did not feel justified " in subjecting a series to early cord ligation is somewhat censorious of the many, if not the majority of, obstetricians in this country who do so to give the mother the relief of a shortened third stage of labour. A comparison of their data with those of units in which early cord ligation is practised might prove instructive (see table). MORTALITY OF PREMATURE BABIES OF
1000-2500 g. BIRTHWEIGHT
"
This is
a
sad and sorry business which we would do well
ponder. We have an armoury of drugs to combat tuberculosis, and the most effective are quite cheap. The re-
to
search centres in Madras and Nairobi have shown how these can be used to best advantage-but, unless the knowledge gained is put to use with energy and foresight, the opportunity will pass and the task of tuberculosis eradication prove unnecessarily difficult. New drugs would be a help, but surely we should not allow to be squandered without protest the magnificent resources we already possess. As President Prasad pointed out in his opening address to the International Union against Tuberculosis at Delhi, tuberculosis is a world problem and should be tackled as such. The W.H.O. and other international bodies have done much useful work; but more money, organisation, and training in basic " know-how " are urgently needed. Is it too "much to ask that the Governments of the advanced countries consider diverting more of the enormous resources they possess in skill, money, and man-power from futile destructive purposes to help alleviate suffering amongst our neighbours ? So far as disease is concerned it is one world we are dealing with, and it would seem to cost less to better it than to destroy it. "
Clare Hall Hospital, South Mimms, Barnet, Herts
NORMAN MACDONALD.
PLACENTAL TRANSFUSION AND HYALINE-MEMBRANE DISEASE SiR,—The proper time to clamp the umbilical cord has
been debated for over a century, and the origin of hyalinemembrane disease has tantalised innumerable investigators. Dr. Bound and his colleagues’ simple solution (June 9) to both problems at once can hardly be allowed to
pass
unchallenged.
Their claim is based on their reduction in deaths from hyaline-membrane disease from 7-3% to 2-5% of premature live births after introducing delayed ligation of the cord. Your editorial of June 9 did well to point out the notorious unreliability of comparing mortality-rates over consecutive periods. For instance, the neonatal 1.
Frimodt-Möller, J. Tubercle, Lond. 1962, 43, 88.
There is part sharing of obstetric and paEdiatric medical staff between St. Thomas’s Hospital and the Lambeth Hospital. The teaching unit books a high proportion of abnormal cases and has a high caesarean-section rate; the larger general unit has more normal deliveries but accepts many unbooked emergencies, often from low social groups. All the babies who died at these two hospitals were examined post mortem. Babies were considered to have died from hyaline-membrane disease if they had the clinical syndrome during life and resorption atelectasis post mortem; only a half had actual hyaline-membrane formation histologically, and our mortalityrate from this disease is therefore weighted by the inclusion of probable but unproven cases. When other lesions were present at post mortem, cases were included only if hyalinemembrane disease was the primary cause of death; intracranial hxmorrhage, when present, was considered primary over hyaline-membrane disease, but not necessarily congenital malformations or hasmolytic disease. Early cord ligation is practised at St. Thomas’s Hospital and the Lambeth Hospital. It will be noticed that the data are in agreement with the other hospitals except for the high mortalityrate in Blackpool in the first period. Although a comparison of the mortality from hyalinemembrane disease in different centres and countries is not permissible, the commonly reported average is between 3 and 4% of liveborn premature babies (e.g.,2). It would seem, therefore, that in the series from Blackpool the incidence is not so much low in the second period as excessively high in the first. In bringing the mortality in his unit into line with that of other centres, Dr. Bound is too modest about his own part in achieving a higher standard of care since he moved to Blackpool. The elaborate theory behind preventing hyaline1. 2.
Usher, R. Pediatrics, 1959, 24, 562; Pediat. Clin. N. Amer. 1961,8,525. Avery, M. E., Oppenheimer, E. H. J. Pediat. 1960, 57, 553.
Letters
to
the Editor
NEW DRUGS NEEDED FOR TUBERCULOSIS
SiR,—Your leader last week draws attention to an urgent problem. As tuberculosis is being brought under control in the more developed countries the situation in less economically favoured lands is not only not improving but tending to worsen because of the emergence and rapid increase of drug resistance. In both India and Africa this has already reached proportions such as to seriously threaten any proposed scheme for securing control of the disease. In some " up-country " towns in Southern India, where no organised scheme of control is in operation, up to 42% of treated " patients have been found with resistant organisms in their sputum- while 6% of untreated patients have had organisms resistant to isoniazid and another 6% organisms resistant to streptomycin.’ The situation in some parts of Africa, as you point out, is equally unsatisfactory. With pills containing small amounts of isoniazid being sold over the counter as a cure " for cough, and treatment outside the main centres being almost uniformly bad, the massive build-up of resistant organisms continues unchecked day by day, with the full weight of the blow still to come. "
death-rate at St. Thomas’s Hospital was 9-2 per 1000 live births in 1959 and 19-6 per 1000 live births in 1960. In addition to these inevitable fluctuations, improved methods of care must be taken into consideration. A significant advance in the correction of the biochemical complications of hyaline-membrane disease was introduced by Usher1 in 1959. Their reluctance to carry out a properly controlled trial because they " did not feel justified " in subjecting a series to early cord ligation is somewhat censorious of the many, if not the majority of, obstetricians in this country who do so to give the mother the relief of a shortened third stage of labour. A comparison of their data with those of units in which early cord ligation is practised might prove instructive (see table). MORTALITY OF PREMATURE BABIES OF
1000-2500 g. BIRTHWEIGHT
"
This is
a
sad and sorry business which we would do well
ponder. We have an armoury of drugs to combat tuberculosis, and the most effective are quite cheap. The re-
to
search centres in Madras and Nairobi have shown how these can be used to best advantage-but, unless the knowledge gained is put to use with energy and foresight, the opportunity will pass and the task of tuberculosis eradication prove unnecessarily difficult. New drugs would be a help, but surely we should not allow to be squandered without protest the magnificent resources we already possess. As President Prasad pointed out in his opening address to the International Union against Tuberculosis at Delhi, tuberculosis is a world problem and should be tackled as such. The W.H.O. and other international bodies have done much useful work; but more money, organisation, and training in basic " know-how " are urgently needed. Is it too "much to ask that the Governments of the advanced countries consider diverting more of the enormous resources they possess in skill, money, and man-power from futile destructive purposes to help alleviate suffering amongst our neighbours ? So far as disease is concerned it is one world we are dealing with, and it would seem to cost less to better it than to destroy it. "
Clare Hall Hospital, South Mimms, Barnet, Herts
NORMAN MACDONALD.
PLACENTAL TRANSFUSION AND HYALINE-MEMBRANE DISEASE SiR,—The proper time to clamp the umbilical cord has
been debated for over a century, and the origin of hyalinemembrane disease has tantalised innumerable investigators. Dr. Bound and his colleagues’ simple solution (June 9) to both problems at once can hardly be allowed to
pass
unchallenged.
Their claim is based on their reduction in deaths from hyaline-membrane disease from 7-3% to 2-5% of premature live births after introducing delayed ligation of the cord. Your editorial of June 9 did well to point out the notorious unreliability of comparing mortality-rates over consecutive periods. For instance, the neonatal 1.
Frimodt-Möller, J. Tubercle, Lond. 1962, 43, 88.
There is part sharing of obstetric and paEdiatric medical staff between St. Thomas’s Hospital and the Lambeth Hospital. The teaching unit books a high proportion of abnormal cases and has a high caesarean-section rate; the larger general unit has more normal deliveries but accepts many unbooked emergencies, often from low social groups. All the babies who died at these two hospitals were examined post mortem. Babies were considered to have died from hyaline-membrane disease if they had the clinical syndrome during life and resorption atelectasis post mortem; only a half had actual hyaline-membrane formation histologically, and our mortalityrate from this disease is therefore weighted by the inclusion of probable but unproven cases. When other lesions were present at post mortem, cases were included only if hyalinemembrane disease was the primary cause of death; intracranial hxmorrhage, when present, was considered primary over hyaline-membrane disease, but not necessarily congenital malformations or hasmolytic disease. Early cord ligation is practised at St. Thomas’s Hospital and the Lambeth Hospital. It will be noticed that the data are in agreement with the other hospitals except for the high mortalityrate in Blackpool in the first period. Although a comparison of the mortality from hyalinemembrane disease in different centres and countries is not permissible, the commonly reported average is between 3 and 4% of liveborn premature babies (e.g.,2). It would seem, therefore, that in the series from Blackpool the incidence is not so much low in the second period as excessively high in the first. In bringing the mortality in his unit into line with that of other centres, Dr. Bound is too modest about his own part in achieving a higher standard of care since he moved to Blackpool. The elaborate theory behind preventing hyaline1. 2.
Usher, R. Pediatrics, 1959, 24, 562; Pediat. Clin. N. Amer. 1961,8,525. Avery, M. E., Oppenheimer, E. H. J. Pediat. 1960, 57, 553.