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Published online 28 November 2007 | Nature | doi:10.1038/news.2007.306
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The evolution of a killer
Could better surveillance have staved off a deadly tuberculosis outbreak?
Failure to test patients with tuberculosis for drug-resistant strains may have spurred the development of a deadly antibiotic-resistant outbreak, researchers have found.
The work suggests that if better tuberculosis surveillance programmes had been in place during the past decade in developing countries, antibiotic treatments could have been better tailored to patients, and the emergence of extensively drug-resistant strains of tuberculosis (XDR-TB) could have been delayed.
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"Mere surveillance programs won't suffice to control drug-resistant tuberculosis (TB)" A study in KwaZulu-Natal reported emergence of extensively drug-resistant tuberculosis (XDR-TB)-a lethal descendent of multidrug-resistant TB (MDR-TB) among HIV positive patients(1). This study further suggests that if better TB surveillance programs had been in place in developing countries during the past decade, the emergence of XDR-TB could have been delayed. The author of this study argues that anywhere in the world, infectious disease can not be controlled without a surveillance program. There is no difference of opinion that the drug-resistance surveillance programs are required for controlling the spread of TB and its threatening drug-resistant forms. However, exorbitant costs required for diagnosis and treatment, longer duration of treatment (18-24 months) and severe side-effects of second-line drugs have remained major challenges for policy-makers in tackling this problem(2). In this context,it is also necessary to sufficiently attend health system and patient-related economic, behavioral and socio-cultural factors, which determine patient's compliance with treatment. This has repeatedly been pointed out through several studies(3,4). Additionally, measures are required from preventing the nosocomial transmission of drug-resistant TB strains as this mode is known to have resulted in the rapid propagation of drug-resistant cases(5). In high-burden countries like India, the private health sector, which cater more than 60% of TB cases, is known for expensive treatment and also for flouting standard treatment norms (4, 6). Inability to afford treatment in the private sector adds to the number of inadequately treated cases, which ultimately contributes to the pool of drug-resistant cases. In this context, regulation of the private sector is essential, nevertheless with a due consideration to their role in TB control. Thus, a more critical question for policy-makers and costing analysts would be- where and how do they invest rather than how much they invest for TB control to achieve goals of public health. Experiences with TB control so far essentially underscore a need for a holistic perspective, which is lacking in the currently implemented programs. References 1. Pillay M. and Sturm A. Evolution of the extensively drug-resistant F15/LAM4/KZN strain of Mycobacterium tuberculosis in KwaZulu-Natal, South Africa.Clin Infect Dis. 2007; 45(11): 1409-14. 2. Gupta R, Irwin A, Raviglione M, et al. Scaling-up treatment for HIV/AIDS: Lessons learned from multidrug-resistant tuberculosis. Lancet 2004; 363: 320-24. 3. Farmer P. Immodest claims of causality. Infections and Inequalities: The Modern Plagues, Berkeley CA: University of California Press, 1999. 4. Atre S. and Mistry N. Multidrug-resistant tuberculosis (MDR-TB) in India: An attempt to link biosocial determinants. J Pub Hlth Policy 2005; 26(1): 96-114. 5. Pearson M, Jereb J, Frieden T et al. Nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis. A risk to patients and health care workers. Ann Intern Med. 1992; 117: 191-96. 6. Uplekar M, Shepard D. Treatment of tuberculosis by private general practitioners in India. Tubercle 1991; 72: 284-90. Sachin R. Atre Dept. of Anthropology University of Pune Maharashtra, India atresachin2000@vsnl.net