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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa

Global and Local Challenges and Solutions

SUMMARY OF A JOINT WORKSHOP by the Institute of Medicine and the Academy of Science of South Africa

Steve Olson, Yeonwoo Lebovitz, and Anne Claiborne, Rapporteurs

Forum on Drug Discovery, Development, and Translation

Board on Health Sciences Policy

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
and
ACADEMY OF SCIENCE OF SOUTH AFRICA

THE NATIONAL ACADEMIES PRESS

Washington D.C.
www.nap.edu

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

THE NATIONAL ACADEMIES PRESS
500 Fifth Street, N.W.
Washington, DC 20001

NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine.

This study was supported by Department of Health and Human Services (Contract Nos. N01-OD-4-2139 and 223001003T), the U.S. State Department (S-LMAQM-08-GR-071), the American Diabetes Association, the American Society for Microbiology, Amgen Inc., the Association of American Medical Colleges, Bristol-Myers Squibb, the Burroughs Wellcome Fund, Celtic Therapeutics, LLLP, the Critical Path Institute, the Doris Duke Charitable Foundation, Eli Lilly & Co., GlaxoSmithKline, Howard Hughes Medical Institute, Johnson & Johnson, Novartis Pharmaceuticals Corporation, and Pfizer, Inc. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project.

International Standard Book Number-13: 978-0-309-16024-7

International Standard Book Number-10: 0-309-16024-3

Additional copies of this report are available from the

National Academies Press,

500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu.

For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.

Copyright 2011 by the National Academy of Sciences. All rights reserved.

Printed in the United States of America

The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

Suggested citation: IOM (Institute of Medicine). 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop. Washington, DC: The National Academies Press.

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

“Knowing is not enough; we must apply.

Willing is not enough; we must do.”

—Goethe

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

Advising the Nation. Improving Health.

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

THE NATIONAL ACADEMIES

Advisers to the Nation on Science, Engineering, and Medicine


The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.


The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.


The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.


The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.


www.national-academies.org

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

PLANNING COMMITTEE FOR THE WORKSHOP ON THE EMERGING THREAT OF DRUG-RESISTANT TUBERCULOSIS IN SOUTHERN AFRICA: GLOBAL AND LOCAL CHALLENGES AND SOLUTIONS1

GAIL H. CASSELL (Chair),

Eli Lilly and Company (retired)

DONALD M. BERWICK,2

Centers for Medicare and Medicaid Services

BARRY R. BLOOM,

Harvard School of Public Health

ENRIQUETA C. BOND, QE Philanthropic Advisors

RICHARD E. CHAISSON,

Johns Hopkins University

PAUL FARMER,

Partners In Health, Harvard Medical School

ANTHONY FAUCI,

National Institute of Allergy and Infectious Diseases

GARY FILERMAN,

Atlas Research

GERALD H. FRIEDLAND,

Yale University School of Medicine

ELAINE K. GALLIN,3 QE Philanthropic Advisors

STEPHEN C. GROFT,

Office of Rare Disease Research, National Institutes of Health

VICTORIA MCGOVERN,

Burroughs Wellcome Fund

NANCY SUNG,

Burroughs Wellcome Fund

ROY WIDDUS,

Global Forum for Health Research

IOM Staff

ANNE B. CLAIBORNE, Director

REBECCA A. ENGLISH, Research Associate

YEONWOO LEBOVITZ, Program Associate

GENEA S. VINCENT, Senior Program Assistant (until November 1, 2010)

RONA BRIERE, Consulting Editor

South Africa Liaison Planning Committee Members

GAVIN J. CHURCHYARD,

Aurum Institute for Health Research

HOOSEN COOVADIA,

Nelson Mandela School of Medicine, University of KwaZulu-Natal

SALIM S. ABDOOL KARIM,

University of KwaZulu-Natal, Centre for the AIDS Programme of Research in South Africa

1

Institute of Medicine planning committees are solely responsible for organizing the workshop, identifying topics, and choosing speakers. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.

2

Donald Berwick was with the Institute for Healthcare Improvement during planning for the workshop.

3

Elaine Gallin was with the Doris Duke Charitable Foundation until December 2010.

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

A. WILLEM STURM,

Nelson Mandela School of Medicine, University of KwaZulu-Natal

MARTIE VAN DER WALT,

Medical Research Council of South Africa

PAUL VAN HELDEN,

Stellenbosch University

ROBIN WOOD,

Desmond Tutu HIV Centre, University of Cape Town

Academy of Science of South Africa Staff

ROSEANNE D. DIAB, Executive Officer

PHAKAMILE TRUTH MNGADI, Project Officer

NTHABISENG TAOLE, Project Manager

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

FORUM ON DRUG DISCOVERY, DEVELOPMENT, AND TRANSLATION1

Gail H. Cassell (Co-Chair),

Eli Lilly and Company (retired), Indiana

Jeffrey M. Drazen (Co-Chair),

New England Journal of Medicine, Massachusetts

Barbara Alving,

National Center for Research Resources, Maryland

Leslie Z. Benet,

University of California-San Francisco

Ann Bonham,

Association of American Medical Colleges, Washington, DC

Linda Brady,

National Institute of Mental Health, Maryland

Robert M. Califf,

Duke University Medical Center, North Carolina

Scott Campbell,

Foundation for the National Institutes of Health, Maryland

C. Thomas Caskey,

University of Texas-Houston Health Science Center

Peter B. Corr,

Celtic Therapeutics, LLLP, New York

James H. Doroshow,

National Cancer Institute, Maryland

Gary L. Filerman,

Atlas Research, Washington, DC

Garret A. FitzGerald,

University of Pennsylvania School of Medicine

Elaine K. Gallin,2 QE Philanthropic Advisors,

Maryland

Steven K. Galson,

Amgen Inc., California

Harry B. Greenberg,

Stanford University School of Medicine, California

Stephen Groft,

National Institutes of Health, Maryland

Annalisa Jenkins,

Bristol-Myers Squibb, New Jersey

Michael Katz,

March of Dimes Foundation, New York

Jack D. Keene,

Duke University Medical Center, North Carolina

Ronald L. Krall,

University of Pennsylvania

Freda Lewis-Hall,

Pfizer, Inc., New York

William D. Matthew,

National Institute of Neurological Disorders and Stroke, Maryland

Mark B. McClellan,

Brookings Institution, Washington, DC

Carol Mimura,

University of California-Berkeley

John Orloff,

Novartis Pharmaceuticals Corporation, New Jersey

Amy P. Patterson,

National Institutes of Health, Maryland

Janet Shoemaker,

American Society for Microbiology, Washington, DC

Ellen V. Sigal,

Friends of Cancer Research, Virginia

Nancy S. Sung,

Burroughs Wellcome Fund, North Carolina

Jorge A. Tavel,

National Institute of Allergy and Infectious Diseases, Maryland

1

Institute of Medicine forums and roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteurs and the institution.

2

Elaine Gallin was with the Doris Duke Charitable Foundation until December 2010.

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

Janet Tobias,

Ikana Media, New York

Joanne Waldstreicher,

Johnson & Johnson, New Jersey

Janet Woodcock,

U.S. Food and Drug Administration, Maryland

Raymond L. Woosley,

The Critical Path Institute, Arizona

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the process. We wish to thank the following individuals for their review of this report:

Enriqueta C. Bond, QE Philanthropic Advisors

Jerrold J. Ellner, Boston University School of Medicine, Boston Medical Center

Gerald Friedland, Yale School of Medicine

Salim S. Abdool Karim, University of KwaZulu-Natal, Center for the AIDS Programme of Research in South Africa (CAPRISA)

Salmaan Keshavjee, Harvard Medical School, Partners In Health

Although the reviewers listed above have provided many constructive comments and suggestions, they did not endorse the final draft of the report before its release. The review of this report was overseen by Melvin Worth. Appointed by the Institute of Medicine, he was responsible for making

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authors and the institution.

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×
Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

Table, Figure, and Boxes

TABLE

4-1

 

Percentage of Health Care Workers Reporting Various Infection Control Measures,

 

35

FIGURE

2-1

 

More than 75,000 new cases of MDR TB are estimated to have occurred in Africa in 2010,

 

11

BOXES

1-1

 

The Nature of the Threat,

 

2

2-1

 

Problems of Dealing with Drug-Resistant TB in Mozambique,

 

13

2-2

 

Estimating the Contribution of TB to Mortality in South Africa,

 

15

5-1

 

Some Diagnostic Methods Currently in Use for TB,

 

46

6-1

 

CD4 Count as a Predictor of Mortality Among MDR and XDR TB Patients,

 

66

7-1

 

A Family Case Study Illustrating Issues in Pediatric MDR TB,

 

74

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

Acronyms

ACME Automated Classification of Medical Entities

ACR adult clinical record

AIDS acquired immune deficiency syndrome

AIR Airborne Infection Research

ANRS Agency for AIDS Research (France)

ARASA AIDS and Rights Alliance for Southern Africa

ART antiretroviral treatment

ARV antiretroviral

ASADI African Science Academy Development Initiative

ASSAf Academy of Science of South Africa

BCG Bacillus Calmette-Guérin vaccine

C-DOTS Community-based Directly Observed Treatment Short Course

CAPRISA Center for the AIDS Programme of Research in South Africa

CD4 Cluster of Differentiation 4

CDC Centers for Disease Control and Prevention

CoSH Church of Scotland Hospital

CSIR Council for Scientific and Industrial Research

DNA deoxyribonucleic acid

DOTS Directly Observed Treatment Short Course

FIND Foundation for Innovative New Diagnostics

Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

GFP green fluorescent proteins

GLC Green Light Committee

GLI Global Laboratory Initiative

GPS global positioning system

HIV human immunodeficiency virus

ICD-10 International Classification of Diseases, 10th revision

IFNg interferon-gamma

IOM Institute of Medicine

IRIS immune reconstitution inflammatory syndrome

ISTC International Standards for Tuberculosis Care

LAM lipoarabinomannan

LIPHE Laboratory Information for Public Health Excellence

LPA line probe assay

LRP luciferase reporter phage

M.tb. Mycobacterium tuberculosis

MDR TB multidrug-resistant tuberculosis

MGIT mycobacteria growth indicator tube

MRC Medical Research Council

NIAID National Institute of Allergy and Infectious Diseases

NIH National Institutes of Health

PCR polymerase chain reaction

PETTS Preserving Effective Tuberculosis Treatment with Second-line drugs study

QFT-GIT QuantiFERON-TB Gold In-Tube test

RNA ribonucleic acid

SAPiT Starting Antiretroviral therapy at three Points in Tuberculosis therapy study

TB tuberculosis

TCR T cell receptor

TDR TB totally drug-resistant tuberculosis

TF CARES Tugela Ferry Care and Research Collaboration

Page xvii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

UN United Nations

UV ultraviolet

WHO World Health Organization

WP work package

XDR TB extensively drug-resistant tuberculosis

Page xviii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×

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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×
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×
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Page xiii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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×
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
×
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Suggested Citation:"Front Matter." Institute of Medicine. 2011. The Emerging Threat of Drug-Resistant Tuberculosis in Southern Africa: Global and Local Challenges and Solutions: Summary of a Joint Workshop by the Institute of Medicine and the Academy of Science of South Africa. Washington, DC: The National Academies Press. doi: 10.17226/12993.
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Tuberculosis (TB) kills approximately 4,500 people worldwide every day. While most cases of TB can be treated with antibiotics, some strains have developed drug resistance that makes their treatment more expensive, more toxic and less effective for the patient. The IOM Forum on Drug Discovery, Development, and Translation and the Academy of Science of South Africa held a workshop to discuss ways to fight the growing threat of drug-resistant TB.

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