The New Profile of Drug-Resistant Tuberculosis in Russia A Global and Local Perspective: Summary of a Joint Workshop by the Institute of Medicine and the Russian Academy of Medical Science (2011) / Chapter Skim
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2 A Global Perspective on Drug-Resistant Tuberculosis
2 A Global Perspective on Drug-Resistant Tuberculosis
Pages 9-28
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From page 9... ...
• he battle against drug-resistant TB can be viewed from a social T medicine perspective, in which social and biomedical factors are intertwined. Salmaan Keshavjee, Harvard Medical School, Partners In Health, and chair of WHO's Green Light Committee (GLC)
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They include poor health care infrastructures, limited access to diagnostics, fragmented health care delivery systems, a lack of public support for TB care, varying levels of knowledge about TB among providers, inadequate infection control, and a shortage of appropriate drugs for circulating strains. However, the importance of these factors differs considerably between the two countries.
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An integral part of a social medicine perspective is the understanding that help-seeking behaviors also have a profound influence on a disease like TB. Regardless of whether formal programs or national policies to treat MDR TB are in place, the sick and their family members seek care.
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T Infection control is linked to ventilation, to administrative controls, and to the quality of diagnosis and care. Diagnostic methods are linked to both care and prevention.
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for TB has been validated and subsequently recommended by WHO for broad implementation as the initial diagnostic for individuals suspected of MDR TB or HIV−TB coinfection. The test simulta neously detects TB and rifampicin drug resistance (a reliable indicator for MDR TB)
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In the 16 provinces of China where the Global Fund to Fight AIDS, TB, and Malaria is supporting the treatment and management of drug-resistant TB patients, the total budget is about $78 million. 2 This section is based on the presentation of Gerrit Coetzee, National Health Laboratory Service of South Africa.
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It is increasing the number of pilot sites for implementing drug resistance surveillance and is improving laboratories from the national to the county level to meet the standards for MDR TB diagnostic tests (see Box 2-2 for a discussion of China's drug-resistant TB surveillance results)
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During the national drug resistance surveillance in 2007–2008, 70 counties in all 31 provinces of China were randomly selected for surveil lance by cluster sampling. Sputum smears and cultures were examined at the county level, while drug susceptibility tests were performed at the national level.
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a The information presented this box is based on the work of Renzhong Li, Lixia Wang, Mingting Chen, Yanlin Zhao, Caihong Xu, and Cheng Chen of the National Center for Tuber culosis Control and Prevention, Center for Disease Control and Prevention, China.
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Already a single stream of funding from the Global Fund has been received, and 87 prefecture levels in 29 provinces will be covered. Actions expected in the future include expert review and demonstration, issuance of an action plan by the State Council of China, and integration of the action plan for MDR TB control with the National TB Control Plan for the next 10 years (Chen, 2010)
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HISTORICAL PERSPECTIVE ON MDR TB CONTROL EFFORTS4 Keshavjee explained that when New York City experienced an outbreak of drug-resistant TB in the late 1980s and early 1990s (see Box 2-3) , it quickly became clear that these patients needed appropriate diagnostics, particular drug regimens, and a system of treatment follow-up in order to be cured.
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The implementation of DOTS increased the number of patients receiving directly observed therapy from 100 in 1988 to 1,300 in 1993. The city also increased screening, monitoring, and isolation capac ity in hospitals, shelters, and other congregate facilities.
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The challenge was substantial, Keshavjee noted, as their efforts were counter to the global discourse regarding the appropriate approach to treating drug-resistant TB in disadvantaged populations. Employing a treatment and transmission control strategy similar to that which had been used in New York City, the efforts in Peru were successful and achieved an 83 percent cure rate (PIH, 2010)
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grows, the organizational and technical challenges involved in implementing the necessarily complex health interventions also grow. Challenges remain in the areas of infection control, diagnostics and laboratory infrastructure, second-line drug supplies, treatment delivery and health care infrastructure, and drug development.
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Once they reach a clinic, solid culture tests can take 4 to 8 weeks, liquid culture tests 2 to 4 weeks, and rapid molecular tests 2 hours to 2 days; many of these tests require proper laboratory infrastructure (see Chapter 5 for more information on current diagnostic methods)
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Peter Cegielski of CDC agreed that a rapid molecular screen for resistance would permit individualized treatment. In the meantime, he suggested, suspected MDR TB cases should be treated aggressively with empiric regimens until their drug susceptibility test results become known, after which treatment can be individualized.
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Ambulatory care also can be much less expensive than hospitalization, although most physicians are trained to think in terms of the latter. In May 2009, the World Health Assembly adopted a resolution urging all member states to achieve universal access to diagnosis and treatment of MDR and XDR TB as part of the transition to universal health care coverage.
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From page 26... ...
"It's easy to say we need to control the second-line drugs, but we also have to look at the benefits that broad availability of antibiotics has had for populations." Drug Development The development of a new "cocktail" of three to four drugs to treat MDR TB is a scientific, organizational, and technical challenge that is key to advancing the treatment of drug-resistant TB, said Keshavjee. Antibiotics that are more effective, less expensive, and able to shorten the course of MDR TB treatment are greatly needed.
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From page 27... ...
Despite notable successes in recent decades, the global community has thus far been unable to significantly reduce the burden of MDR TB throughout the world. Keshavjee suggested that a major transformation is necessary to have a meaningful impact on this growing epidemic.
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