Apocalypse or Redemption: Responding to Extensively Drug-Resistant Tuberculosis
Upshur, Ross, Singh, Jerome, Ford, Nathan, Bulletin of the World Health Organization
Responding to drug-resistant tuberculosis is possibly one of the most profound challenges facing global health. Leading experts have used apocalyptic language in describing the scope of the challenges posed by extensively drug-resistant TB (XDR-TB), even suggesting that we resort to prayer as a solution. (1,2) Recent reports indicating that aggressive treatment confers benefit raise hope that the situation may not be so dire. (3) However, the structural and political changes and resources needed to prevent and treat XDR-TB on a large scale are not sufficient to assure that the tide of XDR-TB will be stemmed any time soon.
Drug-resistant TB is not the result of catastrophic natural forces such as earthquakes, tsunamis and hurricanes. It is not caused by malign human intent, as are terrorism and war, nor is it fostered by our dysfunctional relationship with the animal kingdom as are severe acute respiratory syndrome (SARS) and avian influenza. The locus of risk and control is entirely within the human domain. Our response to the emergence of drug-resistant TB is profoundly ethical as it raises issues of how justice and human rights are realized in our collective response to a disease. It also underscores how the global community responds to its most disadvantaged members.
The progressive worsening of resistance of TB to pharmacotherapy has raised the spectre of a response to TB without medication--what some have labelled the dawn of the post-antibiotic age. The combination of high rates of TB infection with high seropositivity rates for HIV in sub-Saharan Africa adds new levels of complexity to diagnosis and treatment and has raised the ante of global TB control. (4)
WHO has launched an eight-point plan to respond to XDR-TB. (5) This paper provides an elaboration of these recommendations and adds some additional considerations as moral correlates to the current WHO plan (Box 1).
Adherence research and drug development
The main financial response to drug-resistant TB favours the development of new drugs and vaccines, both long-term strategies offering little succour to those currently or soon to be afflicted. Developing less-toxic drugs with greater potency that could shorten treatment is an important goal, but this must go hand in hand with investment in adherence research. We know some, but not enough, about how to enhance medication adherence.
Health care institutions in under-resourced areas are often poorly equipped to implement adequate infection control measures, leaving healthcare providers (and other health service users) at particular risk for TB infection. Ensuring adequate numbers of health-care providers willing to care for patients with drug-resistant TB will be difficult if they are not protected from infection themselves.
Box 1. The WHO eight-point plan and additional considerations WHO recommendations 1. Strengthen quality of basic TB and HIV/AIDS control 2. Scale up programmatic management of MDR-TB and XDR-TB 3. Strengthen laboratory services 4. Expand MDR-TB and XDR-TB surveillance 5. Develop and implement infection control measures 6. Strengthen advocacy, communication and social mobilization 7. Pursue resource mobilization at all levels 8. Promote research and development of new tools Additional considerations 1. Adherence research 2. Building the evidence-base for infection control practices 3. Supporting communities 4. Enhancing public health response while addressing the social determinants of health 5. Embracing palliative care 6. Advocacy for research MDR-TB, multi drug resistant tuberculosis XDR-TB, extensively drug-resistant tuberculosis; TB, tuberculosis.
While the WHO plan calls for the development of infection control measures, existing approaches have ah underappreciated potential. The use of UV light, air exchange, cohort nursing and personal protective equipment used by health-care providers are effective ways to reduce the spread of disease and are remarkably cost effective. …