Bucharest’s Marius Nasta Institute offers high-quality treatments for tuberculosis, but Dr Cristina Popa has a problem persuading her patients to remain there under her care, even when they are contagious – and highly mobile.
Last month, a man who had returned for treatment from Spain discharged himself against Dr Popa’s advice. Shortly afterwards, two women checked themselves out, one saying she planned to go back to her sister’s in Italy.
“What can I do?” Dr Popa says. “I tried to explain to her that she needed to stay, but she said she wanted to return to Italy and that her sisters would help her carry on treatment there.”
The result is part of a growing danger across the European Union of a life-threatening disease that is costly and difficult to treat.
The three patients, like the 40 currently occupying all of the institute’s beds, have multi-drug-resistant (MDR) TB strains which resist the basic six-month treatment and require far more expensive drugs over two years. When they left all were still infectious – they could spread the disease just by coughing.
The situation raises concerns across the continent. Figures released this month by the European Centre for Disease Prevention and Control showed that Romania had a quarter of the 80,000 TB cases identified in the EU, as well as the highest numbers of MDR and extensively drug-resistant (XDR) cases. Although Romania has fewer cases than Russia, Ukraine or the central Asian republics, its citizens move much more freely around the EU.
Recent improvements may also be about to reverse. Money from the Global Fund to Fight Aids, TB and Malaria, which channels international donor funding, is running out, and local officials have struggled to identify replacement sources.
“The EU and the Romanian government should make sure Europe’s money is spent on priority problems like TB,” says Dr Dana Farcasanu, head of the Centre for Health Policies and Services in Bucharest. “TB is a huge public health issue but I don’t see any concern.”
TB cases rose steadily in Romania from the late 1980s, surging after the 1989 revolution and peaking in 2002 at 31,000, driven by widespread unrest, migration, unemployment and poverty. Since then, basic TB infection has been steadily dropping.
But poor use of medicines and diagnostics is fuelling drug resistance. If those with MDR are given only basic TB drugs, or those with basic TB do not take their drugs properly, the bacteria mutate into MDR and XDR forms.
Elmira Ibraim, director of Romania’s national TB programme, says existing funding constraints mean fewer than half of those who do not respond to basic treatment are tested to see if they have MDR.
No detailed studies have tracked how many Romanians elsewhere in Europe have contracted TB, a situation made more complex because many have no legal papers and often avoid seeking medical treatment.
Dr Ibraim’s fear is that things will get worse. The Global Fund money – the only source for the purchase of MDR drugs and related support – runs out in September next year. But the last supplies have already been purchased, and by June no new patients will be able to gain access to MDR drugs unless fresh money is found. “We have tried without success to find ways to get EU money,” says Dr Farcasanu.
For those with access to treatment, the situation remains more positive. “We have great hope here,” says Dr Popa. “XDR does not have to mean death.”