Currently Skimming:
1 Introduction
1 Introduction
Pages 1-16
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provided background for and informed the development of four subsequent workshops in countries with a high burden of drug-resistant TB. The first international workshop in the series was held in Pretoria, South Africa, on March 3–4, 2010 (IOM, 2011a)
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Data from many countries are based on statistical modeling results rather than laboratory based surveillance, often because the laboratories in countries with a high burden of MDR TB lack the capacity to test for susceptibility to second-line drugs.b Pediatric Drug-Resistant TB Existing MDR TB surveys rarely include children. Cassell noted that even when children are included, they generally are lumped together into broad age groups, a practice that obscures the profile of pediatric MDR TB.
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In the 2008 South African study noted above, only 4 of the 13 children diagnosed with MDR TB had known exposure to an adult with TB, and none of these adult contacts had MDR TB (Fairlie et al., 2011)
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. Of 27 countries with a high burden of MDR TB, however, just 13 meet both of these standards (Armenia, Azerbaijan, Bulgaria, Estonia, Georgia, Kazakhstan, Kyrgyzstan, Latvia, Lithuania, Republic of Moldova, Russian Federation, South Africa, and Ukraine)
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Despite overall global increases in the coverage of data on drug resistance, however, considerable uncertainty remains as to the actual levels of MDR TB among TB patients. c Data provided via personal communication, June 22, 2011, with Kristina Wallengren, Acting Clinical Core Manager, KwaZulu-Natal Research Institute for Tuberculosis and HIV (K-RITH)
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Meeting objectives included sharing the latest scientific information on drug discovery research focused on combating MDR and XDR TB, discussing TB drug development needs and the ways in which biomedical research can contribute, and identifying partnership opportunities to advance and accelerate new drug discovery efforts in order to simplify and improve therapeutic options for drug-resistant TB. Topics and meeting participants overlapped between the NIAID and IOM meetings in India, creating synergies and connections for future collaborations in the areas of TB research and policy.
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The provision of optimal patient care for MDR and XDR TB patients is based on DST, and many countries are ill equipped to conduct such tests. It is through such testing that physicians determine which drugs are likely to be effective against a particular drug resistance profile.
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or acquired infection with such a strain that occurs in the course of a patient's treatment, resulting, for example, from failure to ensure regular treatment with high-quality existing drugs. Amplified resistance, or the enhancement of existing drug resistance as a result of initiating an inap propriate drug regimen at the beginning of care, is a significant challenge TREATING TB IN CONTEXT The diagnosis of TB is no longer a death warrant, said Krishan Lal, President, INSA, but the existence of treatments raises sociological and psychological issues.
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Even when an empirically appropriate drug regimen is selected at the beginning of treat ment, by the time drug susceptibility information is available, resistance may be amplified. WHO and the International Union Against Tuberculosis and Lung Disease (IUATLD)
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TB also disproportionately affects the poorest and most marginalized populations in India, as well as people in their most productive ages -- 70 percent of TB patients are aged 15–54. People with TB incur an average potential loss of 20–30 percent of their annual household income as a result of 3–4 months of lost work time.
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However, its magnitude remains undetermined because of a lack of laboratories capable of conducting quality-assured second-line DST.7 The Revised National TB Control Program The United Nations' Millennium Development Goals call for halting and beginning to reverse the incidence of TB by 2015. The STOP TB Partnership has established the target of reducing the global burden of TB (defined by per capita prevalence and death rates)
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A high-level expert group recently recommended that a larger portion of the country's health budget be allocated to providing drugs free of cost and that the national capacity to produce and supply low-cost drugs, including public procurement, be enhanced (Planning Commission of India, 2011)
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India needs a strong vertical program that integrates all aspects of MDR TB control and care, including infection control, diagnosis, treatment, and follow-up. However, Reddy added, it is difficult to impose a strong vertical program on a weak national health system.
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Infection control policies are needed, and investments should be made to promote research, surveillance, molecular diagnostics, and drug development. Reddy concluded by lauding the collective commitment to combating drug-resistant TB, "which now transcends geographical barriers and also brings scientific coalescence from multiple disciplines." In this context, he suggested, "this workshop should be a landmark for initiating action against MDR TB and XDR TB." SETTING THE STAGE8 To set the stage for the remainder of the workshop, Salmaan Keshavjee, Assistant Professor, Harvard Medical School, provided a global overview of the challenges and potential solutions in confronting drug-resistant TB (discussed in detail in Chapter 3)
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. About 3.5 million of the 5 million patients received no reported treatment, although an unknown fraction undoubtedly received some treatment of unknown quality from private physicians, pharmacies, or other sources.
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Observations and recommendations made by individual speakers and participants do not represent the formal positions of the planning committee, the Forum, the IOM, INSA, or ICMR; however, they have provided valuable input to the Forum and to the IOM and the workshop contributors as they deliberate on future initiatives. Presentations at the workshop addressed the following topics: • TB and MDR TB in India, including local and national responses to the epidemic (Chapter 2)
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