Controlling multidrug-resistant tuberculosis and access to expensive drugs: a rational framework.
The emergence and spread of multidrug-resistant tuberculosis (MDR-TB), i.e. involving resistance to at least isoniazid and rifampicin, could threaten the control of TB globally. Controversy has emerged about the best way of confronting MDR-TB in settings with very limited resources. In 1999, the World Health Organization (WHO) created a working group on DOTS-Plus, an initiative exploring the programmatic feasibility and cost-effectiveness of treating MDR-TB in low-income and middle-income countries, in order to consider the management of MDR-TB under programme conditions. The challenges of implementation have proved more daunting than those of access to second-line drugs, the prices of which are dropping. Using data from the WHO/International Union Against Tuberculosis and Lung Disease surveillance project, we have grouped countries according to the proportion of TB patients completing treatment successfully and the level of MDR-TB among previously untreated patients. The resulting matrix provides a reasonable framework for deciding whether to use second-line drugs in a national programme. Countries in which the treatment success rate, i.e. the proportion of new patients who complete the scheduled treatment, irrespective of whether bacteriological cure is documented, is below 70% should give the highest priority to introducing or improving DOTS, the five-point TB control strategy recommended by WHO and the International Union Against Tuberculosis and Lung Disease. A poorly functioning programme can create MDR-TB much faster than it can be treated, even if unlimited resources are available. There is no single prescription for controlling MDR-TB but the various tools available should be applied wisely. Firstly, good DOTS and infection control; then appropriate use of second-line drug treatment. The interval between the two depends on the local context and resources. As funds are allocated to treat MDR-TB, human and financial resources should be increased to expand DOTS worldwide.
College of Physicians and Surgeons, Columbia University, New York, USA. ap39@columbia.edu
Ariel
A
Pablos-Mendez
Deepthiman K
DK
Gowda
Thomas R
TR
Frieden
D000995:Antitubercular Agents / Q000191:economics / Q000600:supply & distribution* / Q000627:therapeutic use*; D003140:Communicable Disease Control / Q000191:economics*; D003362:Cost-Benefit Analysis; D003906:Developing Countries / Q000191:economics; D016527:Drug Costs; D018954:Drugs, Essential / Q000191:economics / Q000600:supply & distribution; D015276:Health Care Rationing; D006292:Health Priorities; D006297:Health Services Accessibility / Q000191:economics*; D006801:Humans; D009313:National Health Programs / Q000191:economics*; D016896:Treatment Outcome; D018088:Tuberculosis, Multidrug-Resistant / Q000188:drug therapy* / Q000453:epidemiology / Q000517:prevention & control*; D014944:World Health Organization
D000995:Antitubercular Agents; D018954:Drugs, Essential