Divisive drug-resistance

Abstract

Even in places where tuberculosis control has seen the greatest progress, such as many of the countries in WHO's Western Pacific Region, the fight against drug-resistant tuberculosis faces huge challenges. most of the high-burden countries in the region, MDR-TB is either managed outside the public health sector or in the public sector, but outside the national tuberculosis programme says Dr Pieter van Maaren, regional adviser for Stop TB in WHO's Western Pacific Region, adding that treatment outside national programmes tends to be poor. many countries public health is under a different department to curative services, and it's difficult for national tuberculosis programmes to control what is happening in hospitals. As a result all kinds of poor management of MDR-TB are happening. Multidrug-resistant tuberculosis (MDR-TB) refers to strains of the tuberculosis bacillus that are resistant to at least the two most efficacious drugs (rifampicin and isoniazid), while a sub-set of MDR-TB, extensively drug-resistant tuberculosis (XDR-TB), refers to strains that are resistant to nearly all current tuberculosis drugs, and is considered to be virtually incurable. Growing drug resistance is largely the consequence of decades of mismanagement of antibiotics. Quality of antibiotics also contributes, although in the case of tuberculosis the true extent of this is unknown. [ILLUSTRATION OMITTED] Efforts to control drug-resistant forms are hampered by deep divisions in health-care systems. One division is between those with and without access to health care, others are the divides between public health and curative services, between private and public health-care providers and between health-care and other sectors. In countries where hospital treatment is offered on a fee-for-service basis, such in China, this can create a major barrier to referral for treatment tinder the national tuberculosis programmes. countries with a strong private sector, such as the Philippines, the cost of treatment is prohibitive for most patients with MDR-TB. Many patients start treatment then drop out, says van Maaren. [ILLUSTRATION OMITTED] China and India account for half of the world's estimated MDR-TB cases and are among the 27 countries where 85% of these cases have been found globally. causes of M/XDR-TB are a reflection of weak health-care systems, agrees Dr Ernesto Jaramillo, TB drug resistance team leader at WHO's Stop TB Department. For example, one of the major barriers to access to treatment is the limited health-care work force that is properly trained, Jaramillo says, adding that this a problem that is related to the dynamics of the labour market in general. Ministries of health have limited capacity to affect those market forces, he says. Efforts to control MDR-TB are particularly vulnerable to such pressures because of the high level of human resources needed to diagnose and treat patients effectively. To treat someone with MDR-TB takes two years of daily work, the drugs need to be directly observed and taken five or six days a week. The drugs are quite toxic and people develop intolerance quickly. If a patient starts to self-select the drugs they take, it amplifies the resistance within as little as one month, says Jaramillo. You can deal with drug-susceptible TB with fairly simple health-care infrastructure, when it comes to MDR-TB what you need is more sophisticated. Since the World Health Organization (WHO) began systematically surveying drug resistance to tuberculosis treatments in 1994, it has observed a continual increase in drug resistance. But the idea of tackling MDR-TB headon has been a more recent development. the 1980s the common wisdom was that MDR-TB was impossible to diagnose and treat, says Jaramillo. There were some centres in the United States [of America] and Europe, where a few experts were treating MDR-TB, but it was very complicated and no-one dared to think about treating it in very low-resource settings like, for example Lesotho or Timor-Leste. …