News & Analysis
Global Health
Health Care Attacks Continue
in 23 Countries Around the World
The extensive violence perpetrated against
health workers, health facilities, and pa-
tients in conflict-ridden countries around the
globe last year is documented in the report
Impunity Must End: Attacks on Health in 23
Countries in Conflict in 2016.
The fourth annual report, produced by
the Safeguarding Health in Conflict Coali-
tion, details the killing of health workers,
emergency medical personnel, and pa-
tients; the bombing, shelling, and looting of
hospitals and clinics; the intimidation, as-
sault, arrest, and abduction of health work-
ers and patients; the obstruction of access
to care; and the takeover and occupation of
health facilities by police, military, or other
armed factions.
Syria was most affected in 2016, with
108 attacks on health facilities and
91 deaths of health professionals veri-
fied by Physicians for Human Rights. The
level of violence in other countries, includ-
ing Yemen, Afghanistan, Iraq, and South
Sudan, was also high. The report notes that
the extent and severity of attacks may be
underreported because documentation of
the violence is not comprehensive.
These attacks profoundly undermine
the availability of health care by degrading
the health care infrastructure and limit-
ing the number and effectiveness of
health workers, which has resulted in out-
breaks of disease, among other issues.
Combatants continue to target hospitals
despite the resolution adopted last May by
the United Nations Security Council to
protect medical personnel and facilities
under conflict.
The report calls on the Security Council
to establish national data collection and
analysis systems to better document at-
tacks on health care and strengthen na-
tional mechanisms for investigating viola-
tions of laws aimed at protecting health care
personnel and facilities.
Drug-Resistant Tuberculosis Predicted
to Increase in High-Burden Countries
AP Images
According to a report published in The Lan-
cet Infectious Diseases, multidrug-resistant
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(MDR) and extensively drug-resistant
(XDR) tuberculosis (TB) are expected to
increase by 2040 in India, the Philippines,
Russia, and South Africa, countries that
already have a high burden of MDR TB.
Despite gains against TB in recent years,
the disease remains 1 of the top 10 causes
of death worldwide. MDR TB is resistant to
at least 2 of the most potent drugs used to
treat TB, isoniazid and rifampin. XDR TB is
defined as MDR TB with additional resis-
tance to fluoroquinolones and second-line
injectable drugs for TB.
The investigators used data from
World Health Organization reports and
drug resistance surveys estimating the
number of drug-resistant TB cases to
develop a mathematical model to forecast
the future burden of MDR and XDR TB.
According to the model, between 2000
and 2040, MDR TB cases as a proportion
of incident TB cases will increase from
24.8% to 32.5% in Russia, from 7.9% to
12.4% in India, from 6% to 8.9% in the
Philippines, and from 2.5% to 5.7% in
South Africa. The percentage of XDR TB
among incident MDR TB cases will
increase from 1.3% to 9.0% in Russia, from
0.9% to 8.9% in India, from 1.6% to 9.0%
in the Philippines, and from 0.4% to 8.5%
in South Africa.
The study predicts that fewer cases of
drug-resistant TB will be caused by strains
that acquire resistance but will instead
increasingly result from person-to-person
transmission of existing resistant strains.
The authors note that these results support
the need for additional efforts to halt the
spread of MDR and XDR TB.
Vaginal Microbiome Affects Efficacy
of HIV Microbicide
Certain species of vaginal bacteria can
inhibit the efficacy of the topical microbi-
cide tenofovir, which is used to prevent
HIV, by breaking it down before it is
absorbed, reports an international team of
investigators in Science.
Women using the vaginal antiretroviral
gel tenofovir to prevent acquisition of HIV
have experienced inconsistent results. Vari-
ability in adherence has been shown to be a
(Reprinted) JAMA July 18, 2017 Volume 318, Number 3
Attacks on health care continue around the globe.
factor in the diverse trial outcomes, but
little is known about the biological factors
that may contribute to variable results.
In this study, the researchers compared
the vaginal bacterial communities of 688
South African women who were HIV-
negative when enrolled into the random-
ized controlled trial (CAPRISA 004)
evaluating the efficacy of 1% tenofovir
intravaginal gel in preventing HIV. The
researchers identified 2 major types of vagi-
nal bacterial communities—one populated
mainly by the genus Lactobacillus and the
other dominated by a diverse bacterial mix
of non-Lactobacillus microbiota, namely
Gardnerella vaginalis. Gel adherence was
similar in both groups.
The researchers found that tenofovir
significantly reduced HIV incidence only in
women with Lactobacillus-dominant vagi-
nal microbiota (61% vs 18% in women
with non-Lactobacillus dominance). In
vitro studies showed that G vaginalis and
other anaerobes metabolized tenofovir
before the body could absorb it, while 2
Lactobacillus species did not.
The findings indicate that differences in
bacterial metabolism contribute to tenofo-
vir’s variable effectiveness in HIV preven-
tion and suggest that screening vaginal
microbiota could be useful in identifying
women most likely to benefit from such
topical HIV microbicides. − M.J. Friedrich
Note: The print version excludes source references.
Please go online to jama.com.
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