Mr S looked calm and somewhat bemused by the commotion. He had twice unsuccessfully undergone standard treatment for tuberculosis (TB) and had been taking antiretrovirals for HIV for over a year—he was used to medications and health workers. But today was different. It was the first day of his multidrug-resistant tuberculosis treatment, and four staff from the international medical aid organisation Médecins Sans Frontières (MSF) were crowded into his house in varying states of excitement and nervousness. As Mr S swallowed the five different medications that he would have to take for the next two years, followed by the injection that he would undergo daily for at least six months, something vitally important had been achieved. Another programme had integrated treatment of multidrug-resistant TB into its routine HIV and TB care. But in truth the journey was only just beginning for the patient and the programme.
World TB Day (March 24) always carries slogans and messages, and 2010 is no exception with: “On the move against TB: innovate to accelerate action.” In December 2009, WHO recommended that drug-resistant TB should be detected and properly treated by all TB programmes. Sadly, for more than 90% of the approximately 500,000 people who become sick with drug-resistant TB every year, this remains an aspiration rather than reality. Worldwide, most TB programmes do not have access to the complex and expensive quality-assured diagnostics and drugs needed to treat patients with multidrug-resistant TB.
It took MSF nearly two years to start the drug-resistant TB treatment programme that has just enrolled Mr S, despite having money and health staff available. Problems introducing such treatments are frequent in resource-poor and especially rural settings. In the case of Mr S, import restrictions made sourcing WHO-approved quality medications difficult, and irregular supply from drug producers led to bottlenecks and delays. Diagnosing Mr S involved safely transporting (via special containers) his sputum sample to a quality-controlled laboratory, 1.5 hours drive and a plane flight away on the other side of the country. For his treatment, nurses had to be trained to provide safe delivery of treatment at home on a daily basis and to monitor for side-effects. Infection control measures were introduced to reduce the risk of TB transmission to other patients, relatives, and staff. Finally, Mr S and his family were educated about the treatment and how to manage the often unpleasant and debilitating side-effects—likely to be worsened by interactions with his HIV drugs.
It is clear from our experience that current tools and drugs for drug-resistant TB are not adequate. But barriers to treatment are by no means insurmountable, and we must use the tools that we have so as not to neglect the patients who might otherwise have gone undetected. Research is urgently needed to improve diagnosis, treatment, and programme management. This will involve addressing the yearly funding gap for TB research and development. (In 2008, funding fell $US1.5 billion short of the estimated $2 billion required yearly to eliminate TB worldwide by 2050).
The main diagnostic test for TB used across most of the world is sputum microscopy, which was first used over 100 years ago. Under field conditions in HIV-endemic areas, this test misses more patients with TB than it diagnoses. Access to better techniques such as TB culture and drug-sensitivity testing required to diagnose drug-resistant cases remain limited. Even when available, diagnosis often takes several weeks. A quick, cheap, reliable, point-of-care test is desperately needed.
Research into affordable and more effective treatments must also be a priority. We urgently need better treatments that work faster, with fewer side-effects, and are compatible with other medications—especially those for HIV. And the price of drugs must continue to come down—although most of the drugs used in multidrug-resistant TB treatment were developed before 1975, more than US$2000 is still needed to treat one patient.
Finally, many TB control efforts are overwhelmed by the complexity of treating multidrug-resistant patients. We need to document practical experience of innovative approaches to treatment in the resource-poor settings where most of these patients live. And we need to develop validated and cost-effective approaches to enable the scale-up of programmes. Treating drug-resistant TB must be done in a way that strengthens current TB programmes: by stopping transmission of drug-resistant cases with good infection control, and stopping increased drug resistance by effective diagnosis and treatment of all TB cases, as well as controlling the misuse of over the counter TB drugs.
Transforming the aspirations of World TB Day and WHO into reality for all patients needs to happen now. Currently, more than 4500 people die every day from TB. A patient with multidrug-resistant TB living in a country where treatment is not yet available recently asked me: “How long will I live?” Without urgent scale-up of available technologies, innovative approaches, and further research, that question will continue to be asked by thousands of patients every year. The answer I had to give my patient is unacceptable.
This blog also appears on the PLoS Speaking of Medicine site.
Originally from Perth, Australia, Philipp is an infectious diseases specialist. He has worked in Tajikistan, Uzbekistan, Malaysia, India, Myanmar, Nigeria, Uganda, Tanzania, and Swaziland. Currently he works as a TB programme implementer supporting MSF programmes in improving TB care specifically focusing on improved integration of TB-HIV services, infection control, and drug resistant TB care and diagnosis