Drug-resistant tuberculosis

EXECUTIVE SUMMARY
Key Issues in the Management of Drug-Resistant Tuberculosis

1. Multidrug-resistant tuberculosis (MDR-TB) is defined as tuberculosis (TB) disease where there is in vitro resistance to both isoniazid and rifampicin, with or without resistance to other anti-TB drugs. As isoniazid and rifampicin are the two most important first-line TB drugs, their removal through resistance from the anti-TB drug armamentarium has serious implications.

The spread of drug-resistant disease is one of the biggest challenges in international health. It can cost up to one million dollars to treat a patient with drug-resistant tuberculosis (TB) in the United States. But what is the cheapest and most effective way to treat the disease? Can treatment strategies used in industrialised nations be applied in developing countries? Researchers from the UK Universities of East Anglia and Bristol looked at different methods of treating tuberculosis in the USA and South Africa. In both countries, they found that directly observed treatment (DOT) is cheaper and more effective treatment than conventional methods which allow patients to administer the drugs themselves. New York and Florida have reported epidemics of TB that does not respond to treatment with several different drugs. Drug-resistant TB is also spreading in Africa - rates have increased six-fold in some places. Drug-resistance can emerge when patients take drugs incorrectly or fail to complete the course of treatment. So observation of treatment may be more effective than self-administration by patients. The study’s findings include: * Mortality levels from TB are worse in South Africa than in the USA because more of the patients are co-infected with HIV. * DOT results in fewer deaths and more complete cures because patients are more likely to complete the course of treatment. * In South Africa, conventional therapy costs twice as much as DOT. In the USA, the cost saving over conventional treatment is eight percent. * DOT saves $2215 per patient in South Africa and $1788 in the USA. It allowed 6798 patients more to be treated in South Africa than if conventional therapy had been used. * Savings with DOT are even higher for more expensive second-line drugs. Policy implications of the research include: * Directly observed TB treatment saves money and reduces mortality in both developing and industrialised nations and should be used whenever possible. * Given limited healthcare resources, it will be particularly important to use DOT in developing countries.