Abdool Karim remarked that, as Friedland’s presentation highlighted, when patients are placed on antibiotics, pressure to select resistance grows. The experience in Tugela Ferry (Chapter 2) illustrates the person-to-person spread of drug-resistant TB and the fact that fatalities can occur quickly following infection with XDR TB, particularly among patients with HIV coinfection. Abdool Karim added that a steady increase in resistance eventually will make TDR TB a serious and common problem. Cassell commented that another disturbing observation is the 60 percent rise in XDR TB incidence rates in the Eastern Cape.

As Chaisson noted, a good definition of TDR TB in terms of either the molecular detection of resistant genes or clinical failures does not yet exist. According to Abdool Karim, given the variability in drug susceptibility testing among patients in the region, susceptibility testing on second-line drugs is not necessarily a good way to define TDR TB. Instead, the definition of TDR TB could be based on a clinical diagnosis after failure of treatment for MDR/XDR TB. A workshop participant stressed the importance of accurately measuring the magnitude and distribution of the spread of TDR TB as part of efforts to confront and reverse the epidemic.

Improved infection control and contact tracing could lower morbidity and mortality from drug-resistant TB and lead to the treatment of many more cases. In addition, the creation of a culture of safety through infection control policies could provide greatly increased protection for patients and health care workers. Abdool Karim stated that infection control should be a part of every TB intervention and needs to begin when a patient is identified, diagnosed, and hospitalized. To support infection control, there is a need for further investigation of the mechanisms and sites of the spread of TB within communities, said Abdool Karim, and once infection control measures have been implemented, it will be important to evaluate their effectiveness and make them more broadly available. Improvement in the safety of existing health care facilities is warranted, as is incorporation of infection control in the design and construction of new health care facilities.

An important problem is the lack of district nurses to visit schools and homes. Part of the solution, Cassell suggested, could be to train community workers to become specialists in infection control, with a certificate program that could offer practical training and raise the profile of the role of the community worker. When community health workers are paid, trained, and qualified, they can help ensure that everyone becomes an active participant in health care. Abdool Karim highlighted Lawn’s remarks that contact tracing should be part of all TB programs and should include TB education as a component of the intervention.