The Lancet : TB 2013

(From the 2011 TB Progress Report)

 

# 7025

 

 

To coincide with World TB Day, The Lancet Infectious Diseases  today has published a series of six papers (and comments) on the ongoing battle against tuberculosis, and the rising tide of of multidrug resistant (MDR) and extensively drug-resistant (XDR) TB infections around the globe.

 

Roughly 1/3rd of all new TB cases fall into the MDR-TB or XDR-TB category. Just over a year ago new alarm bells began ringing when an ahead-of-print letter to the journal Clinical Infectious Diseases announced that four cases of TDR (totally drug resistant) tuberculosis had been identified in India.

 

The term TDR-TB was quickly labeled as controversial, and poorly-defined. From the January 2012 ECDC report New drug resistant form of tuberculosis reported in India.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

During this time, Maryn McKenna – Flublogia’s favorite scary disease girl – wrote extensively about these developments on her Superbug Blog:

 

Totally Resistant TB: Earliest Cases in Italy

• By Maryn McKenna January 12, 2012

India Reports Completely Drug-Resistant TB

• By Maryn McKenna January 9, 2012 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna January 14, 2012 

 

A couple of my efforts included Resistant TB: The Limits Of Surveillance & Reporting & EID Journal: Challenges To Defining TDR-TB.

 

Recently the World Health Organization released their 2012 Global Tuberculosis Report, with the following statement regarding reports of TDR-TB.

 

“Totally drug-resistant TB” and developments in India in 2012

In December 2011, clinicians in Mumbai, India reported TB patients with what was termed “total drug resistance”.1 As a result of the intense public interest generated by this episode, in March 2012 WHO convened 40 experts to discuss its implications, whether current evidence makes it possible to define patterns of drug resistance beyond extensively drug resistance TB (XDR-TB) and if better guidance on appropriate treatment options for these patients was possible. While the group acknowledged that patients such as those described in Mumbai pose a formidable challenge to clinicians and public health authorities, no reliable definition beyond XDR-TB could be proposed.

 

Without having a better evidence base, no changes to the current guidelines on how to design treatment regimens for patients with broad patterns of resistance could be recommended. Improvements in the accuracy of drug susceptibility testing to certain drugs and the release of innovative new drugs will, however, change this position in future.

Since December 2011, several important measures have been taken by the Indian government. In Mumbai, laboratory and hospital facilities were improved, contact-tracing stepped up and efforts made to train staff on drug-resistant TB and infection control. Medical staff and funding were increased substantially. Access to second-line drugs was provided to eligible patients. National regulations governing private sales of anti-TB medication were strengthened. By the end of 2012, all 35 states in the country are expected to provide
programmatic management of drug-resistant TB. In May 2012, India made TB a notifiable disease and data collection on TB using a webbased system was initiated.2

 

 

Despite the academic debate over the definition (and existence) of TDR-TB, in January of this year - in  EID Journal: The Emergence Of `Totally Resistant TB’ - more evidence was presented suggesting that TDR-TB is either already here, or on its way.

 

In a similar vein, one of the articles appearing in the Lancet today called Drug-resistant tuberculosis: time for visionary political leadership, warns that:

 

WHO estimates roughly 630 000 cases of MDR tuberculosis worldwide, with great variation in the frequency of MDR tuberculosis between countries. In the past 8 years, extensively drug-resistant (XDR) tuberculosis has emerged, and has been reported in 84 countries, heralding the possibility of virtually untreatable tuberculosis.

 

While a free registration is required, these articles are available online in their entirety. Follow the links to read:

 

Tuberculosis 2013

Published March 24, 2013

Executive summary

To commemorate World TB Day 2013, The Lancet Infectious Diseases publishes a Series of papers on tuberculosis, a disease that has long plagued human beings and was declared a global emergency in 1993 by WHO. Without concerted action from political leaders, health policy makers, funders, and others, health systems worldwide are at risk of being overwhelmed by increasing numbers of patients with treatment-resistant tuberculosis.

 

As new diagnostic tests, drugs, and drug regimens become available that have the potential to radically improve the detection and management of tuberculosis, the papers in the Series explore the challenges for successful implementation of these interventions.

Comments

Tuberculosis 2013 Series

John McConnell, Sally Hargreaves

Full Text | PDF

Zero deaths from tuberculosis: progress, reality, and hope

Alimuddin Zumla, Peter Kim, Markus Maeurer,Marco Schito

Full Text | PDF

Progress and challenges in childhood tuberculosis

Ben J Marais, Stephen M Graham, Markus Maeurer,Alimuddin Zumla

Full Text | PDF

Series Papers

Advances in tuberculosis diagnostics: the Xpert MTB/RIF assay and future prospects for a point-of-care test

Stephen D Lawn, Peter Mwaba, Matthew Bates, Amy Piatek, Heather Alexander, Ben J Marais, Luis E Cuevas, Timothy D Mchugh, Lynn Zijenah,Nathan Kapata, Ibrahim Abubakar, Ruth McNerney, Michael Hoelscher, Ziad A Memish, Giovanni Battista Migliori, Peter Kim, Markus Maeurer,Marco Schito, Alimuddin Zumla

Full Text | PDF

Tuberculosis biomarkers discovery: developments, needs,and challenges

Robert S Wallis, Peter S Kim, Stewart Cole, Debra Hanna, Bruno B Andrade, Markus Maeurer, Marco Schito, Alimuddin Zumla

Full Text | PDF

Tuberculosis comorbidity with communicable and non-communicable diseases: integrating health services and control efforts

Ben Marais, Knut Lönnroth, Stephen D Lawn, Giovanni B Migliori, Peter Mwaba, Philippe Glaziou, Matthew Bates, Ruth Colagiuri, Lynn Zijenah,Soumya Swaminathan, Ziad Memish, Michel Pletschette, Michael Hoelscher, Ibrahim Abubakar, Rumina Hasan, Afia Zafar, Guiseppe Pantaleo,Gill Craig, Peter Kim, Markus Maeurer, Marco Schito, Alimuddin Zumla

Full Text | PDF

Alignment of new tuberculosis drug regimens and drug susceptibility testing: a framework for action

William A Wells, Catharina C Boehme, Frank G J Cobelens, Colleen Daniels, David Dowdy, Elizabeth Gardiner, Jan Gheuens, Peter Kim, Michael E Kimerling, Barry Kreiswirth, Christian Lienhardt, Khisi Mdluli, Madhukar Pai, Mark D Perkins, Trevor Peter, Matteo Zignol,Alimuddin Zumla, Marco Schito

Full Text | PDF

Drug-resistant tuberculosis: time for visionary political leadership

Ibrahim Abubakar, Matteo Zignol, Dennis Falzon, Mario Raviglione, Lucica Ditiu, Baroness Susan Masham, Ifedayo Adetifa, Nathan Ford,Helen Cox, Stephen D Lawn, Ben Marais, Timothy D McHugh, Peter Mwaba, Matthew Bates, Marc Lipman, Lynn Zijenah, Simon Logan,Ruth McNerney, Adam Zumla, Krishna Sarda, Payam Nahid, Michael Hoelscher, Michel Pletschette, Ziad Memish, Peter Kim, Richard Hafner,Stewart Cole, Giovanni-Battista Migliori, Markus Maeurer, Marco Schito, Alimuddin Zumla

Full Text | PDF

Engaging communities in tuberculosis research

Renaud F Boulanger, Stephanie Seidel, Erica Lessem, Lee Pyne-Mercier, Sharon D Williams, Laia Ruiz Mingote, Cherise Scott, Alicia Y Chou, James V Lavery, on behalf of the Critical Path to TB Drug Regimens' Stakeholder and Community Engagement Workgroup

Full Text | PDF

EID Journal: The Emergence Of `Totally Resistant TB’

 

(From the WHO 2011 TB Progress Report)

 

# 6896

 

 

The existence of TDR-TB (Totally Drug Resistant Tuberculosis) has been fraught with controversy since the term first sprang into the headlines a little more than a year ago (see Crofsblog India: New TB strain is "totally drug-resistant" (updated)).

The story concerned at least 12 patients treated at an Indian hospital that had been diagnosed with `TDR-TB’. 

 

Not - as has been seen in the past - MDR-TB (multi-drug resistant tuberculosis), and XDR-TB (extensively drug resistant Tuberculosis), but tuberculosis that was supposedly resistant to all known drugs.

 

Varyingly resistant forms of TB have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients. Patient compliance for long-term treatment has consistently been a major obstacle.

 

Until now – as difficult as treatment might have been - there has always been some combination of antibiotics that could be used to treat even the most resistant of TB cases.

 

The emergence of a totally resistant form of the disease would be a game-changer, and so these reports began to set off alarm bells around the world.

 

A few days later, in ECDC Comment On Drug Resistant TB In India, we saw calls to avoid using the term TDR-TB until it could be better defined. 

 

From the ECDC report New drug resistant form of tuberculosis reported in India.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

During this time, Maryn McKenna – Flublogia’s favorite scary disease girl – wrote extensively about these developments on her Superbug Blog:

 

Totally Resistant TB: Earliest Cases in Italy

• By Maryn McKenna January 12, 2012

India Reports Completely Drug-Resistant TB

• By Maryn McKenna January 9, 2012 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna January 14, 2012 

 

That same week, in Resistant TB: The Limits Of Surveillance & Reporting, I wrote about the World Health Organization’s initial response to these reports (they did not currently recognize TDR-TB due to reasons stated in their TDR-TB FAQ), along with an article in the Indian Express suggesting that TDR-TB cases may be more widespread than reported. 

 

By the end of January, India’s government was denying the existence of untreatable TB in their country (see Referral: McKenna On India’s Denial Of TDR-TB), a response not dissimilar to their denials of NDM-1.

 

In March of 2012, the World Health Organization  released a statement on the supposed TDR-TB, titled  More evidence and better diagnostics needed before redefining severe forms of drug-resistant TB says WHO.

 

The `TDR-TB’  story simmered quietly for the next few months, that is, until October of 2012, when in EID Journal: Challenges To Defining TDR-TB we looked at an EID Journal article called:

NOTE: Corrected Link

 

Challenges and Controversies in Defining Totally Drug-Resistant Tuberculosis

Peter Cegielski , Paul Nunn, Ekaterina V. Kurbatova, Karin Weyer, Tracy L. Dalton, Douglas F. Wares, Michael F. Iademarco, Kenneth G. Castro, and Mario Raviglione

(Excerpt)

Susceptibility tests for several drugs are poorly reproducible. Few laboratories can test all drugs, and there is no consensus list of all anti-TB drugs. Many drugs are used off-label for highly drug resistant TB, and new drugs formulated to combat resistant strains would render the proposed category obsolete. Labeling TB strains as totally drug resistant might lead providers to think infected patients are untreatable. These challenges must be addressed before defining a new category for highly drug-resistant TB

 

All of which brings us to a new EID Journal article (abstract reparagraphed for readability), published yesterday, called:

 

Emergence and Spread of Extensively and Totally Drug-Resistant Tuberculosis, South Africa

Marisa Klopper, Robin Mark Warren, Cindy Hayes, Nicolaas Claudius Gey van Pittius, Elizabeth Maria Streicher, Borna Müller, Frederick Adriaan Sirgel, Mamisa Chabula-Nxiweni, Ebrahim Hoosain, Gerrit Coetzee, Paul David van Helden, Thomas Calldo Victor, and André Phillip Trollip

Abstract

Factors driving the increase in drug-resistant tuberculosis (TB) in the Eastern Cape Province, South Africa, are not understood. Using a convenience sample of 309 drug-susceptible and 342 multidrug-resistant (MDR) TB isolates, collected July 2008–July 2009, we characterized them by spoligotyping, DNA fingerprinting, insertion site mapping, and targeted DNA sequencing.

 

Analysis of molecular-based data showed diverse genetic backgrounds among drug-sensitive and MDR TB sensu stricto isolates in contrast to restricted genetic backgrounds among pre–extensively drug-resistant (pre-XDR) TB and XDR TB isolates.

 

Second-line drug resistance was significantly associated with the atypical Beijing genotype. DNA fingerprinting and sequencing demonstrated that the pre-XDR and XDR atypical Beijing isolates evolved from a common progenitor; 85% and 92%, respectively, were clustered, indicating transmission.

 

Ninety-three percent of atypical XDR Beijing isolates had mutations that confer resistance to 10 anti-TB drugs, and some isolates also were resistant to para-aminosalicylic acid.

 

These findings suggest the emergence of totally drug-resistant TB.

 

 

For those unfamiliar with para-aminosalicylic acid (PAS), it’s an older drug discovered in 1944, and one of the first drugs to effectively treat TB.  Its use as a first-line drug treatment was discontinued when newer antibiotics – like Rifampin - became available.

 

PAS is still used in treating XDR-TB although its value is limited and there are problems with toxicity.

 

Whether we should label them XDR-TB or TDR-TB may be debatable, but what is not is that we continue to see an erosion in our arsenal of effective drugs as new, resistant forms of TB emerge and spread.

 

As reported in last week’s MMWR, getting the best drugs to treat resistant TB can be difficult, even here in the United States (Interruptions in Supplies of Second-Line Antituberculosis Drugs — United States, 2005–2012).

 

Semantics aside, if you are unlucky enough to be infected by one of these resistant TB strains - and no effective drug is available to you  – then the fine distinction over whether it is XDR or TDR TB is of little practical consequence to you.

EID Journal: Challenges To Defining TDR-TB

 

(From the 2011 TB Progress Report)

 

# 6600

 

In January of this year reports began to emerge out of India regarding what was being called Totally Drug Resistant (TDR) tuberculosis (see Crof’s report India: New TB strain is "totally drug-resistant" (updated)).

 

While not an officially recognized term, TDR-TB was portrayed by the media as a frightening escalation of the existing classifications of Multi-drug resistant (MDR-TB) and Extensively-drug resistant (XDR-TB).

 

Resistant forms of Tuberculosis have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients.

 

A few days later (January 14th), the World Health Organization updated their Drug-resistant tuberculosis FAQ where they take exception to the term TDR-TB.

 

Why are these terms not yet recognised by WHO?

Terms such as “totally drug resistant” have not been clearly defined for tuberculosis. While the concept of “total drug resistance” is easily understood in general terms, in practice, in vitro drug susceptibility testing (DST) is technically challenging and limitations on the use of results remain: conventional DST for the drugs that define MDR and XDR-TB has been thoroughly studied and consensus reached on appropriate methods, critical drug concentrations that define resistance, and reliability and reproducibility of testing

Around the same time we saw an ECDC Comment On Drug Resistant TB In India. One of the points being made in the comments section (excerpted below) is that the term TDR-TB is as yet not well defined, and may be misleading.

 

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

In March, as part of my World TB Day Roundup, the World Health Organization released this statement on the supposed TDR-TB, cautioning:

 

More evidence and better diagnostics needed before redefining severe forms of drug-resistant TB says WHO

Note for the media

23 March 2012 | Geneva - Reports of tuberculosis (TB) cases with severe patterns of drug resistance are increasing, said experts who attended a WHO meeting in Geneva on 21-22 March. Participants stressed that the emergence of drug resistance should be a wake-up call for Ministries of Health. The group urged the global TB community to make greater efforts to prevent drug resistance and scale up provision of appropriate care and management to avoid a scenario where TB becomes incurable.

Insufficient evidence

The meeting concluded that there is currently insufficient evidence to adopt new case definitions for drug-resistant TB. Drug susceptibility testing (DST), which is key to defining new levels of drug resistance, lacks accuracy for several of the drugs that are used to treat multi drug-resistant (MDR) and extensively drug resistant (XDR)-TB. Secondly, there is insufficient correlation of DST results with clinical response to treatment for several drugs currently used to treat XDR-TB. Thirdly, new drugs are currently undergoing clinical trials, and could prove effective against drug resistant strains. The meeting urged diagnostics companies and TB laboratories to develop better diagnostic tests and also agreed that WHO and technical partners should develop more detailed guidance on XDR-TB treatment.

(Continue . . . )

 

 

All of which brings us to a new article appearing ahead of print in the CDC’s EID Journal that looks at the:

 

Challenges and Controversies in Defining Totally Drug-Resistant Tuberculosis

Peter Cegielski , Paul Nunn, Ekaterina V. Kurbatova, Karin Weyer, Tracy L. Dalton, Douglas F. Wares, Michael F. Iademarco, Kenneth G. Castro, and Mario Raviglione

Abstract

In March 2012, in response to reports of tuberculosis (TB) resistant to all anti-TB drugs, the World Health Organization convened an expert consultation that identified issues to be resolved before defining a new category of highly drug-resistant TB.

 

Proposed definitions are ambiguous, and extensive drug resistance is encompassed by the already defined extensively drug-resistant (XDR) TB. There is no evidence that proposed totally resistant TB differs from strains encompassed by XDR TB.

 

Susceptibility tests for several drugs are poorly reproducible. Few laboratories can test all drugs, and there is no consensus list of all anti-TB drugs. Many drugs are used off-label for highly drug resistant TB, and new drugs formulated to combat resistant strains would render the proposed category obsolete. Labeling TB strains as totally drug resistant might lead providers to think infected patients are untreatable. These challenges must be addressed before defining a new category for highly drug-resistant TB.

(Continue . . . )

 

Given the complexities of evaluating for total drug resistance, attaching the label TDR-TB to these strains may well be both premature and inaccurate.

  

But the sobering fact remains, if you are infected with one of these XDR-TB strains - and no drug is available to you that can treat it – for you, it may as well be totally resistant.

 

Of course, this disparity of available medical treatment exists for a great many diseases around the world, and is not just limited to TB.

 

 

The authors of the EID study conclude with this warning:

 

As countries increase treatment of MDR and XDR TB, it is inevitable that resistance to second-line drugs will increase. New drugs and better diagnostic tools are needed urgently for patients with highly drug-resistant TB.

 

For more on the global spread of TB, you may wish to revisit:

 

WHO-ECDC: Joint Report On Tuberculosis In Europe

Resistant TB: The Limits Of Surveillance & Reporting

WHO: Blood Tests To Detect Active TB Unreliable

Referral: McKenna On India’s Denial Of TDR-TB

 

 

# 6108

 

When I saw the reports on Friday about India’s Health Ministry’s attempts to downplay reports of totally drug resistant tuberculosis, I was immediately reminded of the old joke about the doctor who couldn’t cure you, but for a small fee he’d touch up your X-rays.

 

Today, Maryn McKenna takes a closer look at India’s denials (which are similar to the official reaction we saw last year over NDM-1)  in her Superbug Blog.

 

Follow the link to read:

 

 

TDR-TB: The Indian Government Denies It

• By Maryn McKenna
• January 29, 2012 

An update to the news two weeks ago of totally drug-resistant tuberculosis, TDR-TB, being identified in India (and earlier in Italy and Iran): The Indian government has announced that it doesn’t exist, and is putting pressure on the physicians who identified it to say they made a mistake.

(Continue . . . )

Resistant TB: The Limits Of Surveillance & Reporting

 

 

 

# 6071

 

 

With practically any disease you’d care to mention the number of cases that we see, and are counted, generally represent only a small subset of the total.

 

As the chart from the CDC below indicates, public health officials are usually only aware of the `tip of the disease pyramid’.

 

 

Many people suffering an illness do not become sick enough to seek medical care (or may live in an area where such care, or testing is unavailable). Those that see a doctor may not be properly diagnosed.  And those that are diagnosed may not be reported to the health department.

 

When the World Health Organization announced the detection of the 571st human H5N1 infection, or the ECDC reports that 4,200 people were infected by the E. coli O104:H4 outbreaks in Germany and France, everyone in the public health arena understood that those numbers are unlikely to include all of the cases out there.

 

Reporting and surveillance – even in technologically advanced regions like the United States and Europe – are simply not that good. 

 

So when we learn – as we have this week – of a dozen cases of `totally resistant tuberculosis’ in India, it’s a pretty fair assumption that there are more cases out there, as yet undetected.

 

The question is:  How many?

 

While the answer to that question remains elusive, we’ve some troubling hints today from an article that appears in the Indian Express.  

 

The story revolves around an interview with Dr John Kenneth, Professor and Head, Infectious Diseases, St John’s Research Institute. The article can be accessed at the following link:

 

The new, deadly TB strain may be more widespread

Johnson T A : Bangalore, Sat Jan 14 2012, 03:47 hrs

 

 

While the headline, that this new form of resistant TB `may be more widespread’ is practically a given - what is worrisome are the percentages being reported.

 

Dr. Kenneth states that his group has unpublished data showing that out of one hundred TB patients they had randomly selected for drug susceptibility studies, six were found to be `totally drug resistant’.

 

Additionally out of these 100 cases, 30 were found to be multi-drug resistant (MDR), and 13 were defined as being extensively drug resistant (XDR).

 

Dr. Kenneth admits that there may be some selection bias in the 100 patients selected for this study, and that all cases tested were randomly selected from among TB patients at only one treatment facility.

 

Until this study is published, we are lacking details on how the screening for drug resistance was done, and exactly how `totally drug resistant’ was defined. This is an issue that the ECDC brought up earlier this week, when they cautioned against the use of the term TDR-TB (see ECDC Comment On Drug Resistant TB In India).

Whether these results reflect the prevalence of resistant TB across a wider region is – for now, at least – unknowable.

 

For more on all of this, you can’t do better than Maryn McKenna’s coverage on her Superbug Blog.   Her latest entry (which includes links to her radio interview yesterday) can be read at:

 

Totally Drug-Resistant TB: A Patient Is Missing

• By Maryn McKenna
• January 14, 2012  |   

 

 

For some more background on Tuberculosis, which kills 1.7 million people each year,  last March I wrote a blog titled World TB Day: March 24th.

 

Some of the resources I cited that day may be of interest.

 

(From the 2011 TB Progress Report)

 

The World Health Organization  released a new report and a factsheet on MDR-TB & XDR-TB in advance of this yearly event on the the status of Tuberculosis around the world and the progress being made in its control.

 

WHO progress report 2011

Towards universal access to diagnosis and treatment of MDR and XDR-TB by 2015

 

 

While progress has been cited in the global fight against tuberculosis, the addition of a new supposedly `totally resistant’ form of TB to the mix complicates matters enormously. 

 

Yesterday the WHO published the following notice:

 

Tuberculosis that is “resistant to all drugs”

13 January 2012 | Geneva | WHO's Stop TB Department has just published a briefing note with "Frequently Asked Questions" to provide information on tuberculosis that is resistant to all drugs.

 

In 2006, the first reports of extensively drug-resistant tuberculosis (XDR-TB), an even more severe form of drug resistant TB than multidrug-resistant TB (MDR-TB), began to appear. Within a year of the first reports of XDR-TB, isolated cases were reported in Europe that had resistance to all first-line anti-TB drugs (FLD) and second-line anti-TB drugs (SLD) that were tested. In 2009, a cohort of 15 patients in Iran was reported which were resistant to all anti-TB drugs tested. The terms “extremely drug resistant” (“XXDR-TB”) and “totally drug-resistant TB” (“TDR-TB”) were given by the respective authors reporting this group of patients. Recently, another study has been published that describes 4 patients from India with resistance to all tested drugs.

• To access the Frequently Asked Questions please click here.

 

ECDC Comment On Drug Resistant TB In India

 

 

 

# 6067

 

 

While more than a little discomfiting, in recent years we’ve grown accustomed to hearing about MDR-TB (multi-drug resistant tuberculosis), and XDR-TB (extensively drug resistant Tuberculosis). 

 

These varyingly resistant forms of Tuberculosis have come about primarily as the result of incomplete, irregular, or inappropriate treatment and management of infected patients. Patient compliance for long-term treatment has long been a major obstacle.

 

Until now – as difficult as treatment might have been - there has always been some combination of antibiotics that could be used to treat even the most resistant of TB cases.

 

All that appeared to change a few weeks ago when it was announced in an ahead-of-print letter to the journal Clinical Infectious Diseases that a four cases of TDR (totally drug resistant) tuberculosis had been identified in India. A follow up news report indicated that there are now at least 12 known cases in one hospital alone.

 

For more background on this announcement, I would invite you to read Maryn McKenna’s recent blog entry called India Reports Completely Drug-Resistant TB.

 

Today the ECDC has published their own comments on this development, along with links to other TB-related documents, on their website.

One of the points being made in the comments section (excerpted below) is that the term TDR-TB is as yet not well defined, and may be misleading.

 

Total drug resistant TB is a relative notion and depends on the local drugs available and tested on. This term/expression should either be avoided or should be defined worldwide. The World Health Organization (WHO) has internationally-endorsed treatment recommendations for the treatment of drug-susceptible, MDR-TB and XDR-TB.

 

Successful treatment of TB is possible but requires full support from the health care system by offering optimal diagnostic services, high-quality drugs for the full time of treatment and support to the patient in fulfilling the treatment. To make this happen, strong TB diagnostic services and processes that ensure the rational use of TB drugs (1,2,3) are essential in order to be able to test all suspected TB cases for drug-resistance and to identify resistance as soon as possible to enable appropriate therapy. Furthermore, ensuring treatment outcome monitoring of all cases is vital.

 

Follow the link below to read the entire comment.

 

 

New drug resistant form of tuberculosis reported in India

12 Jan 2012

In a recent scientific article (Udwadia, F et al. Clin. Infect. Dis. 2011, Dec 21, Eprint) four cases of so-called total drug resistant tuberculosis (TB) were reported from India. According to the article, these patients have shown resistance to all the first line TB drugs and to seven second line anti-TB drugs.

With the existing forms of multi-drug and extensively drug resistant TB (M/XDR-TB) this so-called total drug resistant TB would indicate that none of the known TB combination regimens would be effective for such patients.

Read more:

Read the ECDC comment on this in our full

Public Health Development “New drug resistant form of tuberculosis reported in India”

 

ECDC Tuberculosis Programme

Tuberculosis, a global challenge: discover the ECDC Spotlight

Get the facts: read the ECDC special report “Progressing towards TB elimination”

Download the report “Tuberculosis surveillance in Europe 2009”

Discover the Spotlight “Tackling tuberculosis in children: towards a TB-free generation

Keep in touch with ECDC on facebook

Read the ECDC/WHO co-authored article “Tackling the spread of drug-resistant tuberculosis in Europe”

 

 

 

This story is just beginning to unfold, and I’m sure we’ll hear a lot more about it – and whether or not this new form of tuberculosis is indeed, as the study authors dubbed it - `totally resistant’ – in the coming months.