Despite the global increase in tuberculosis and the worrying rise in the number of cases resistant to the two principal antituberculosis drugs, isoniazid and rifampicin, the authors of a personal view in the current issue of the Lancet Infectious Diseases think that if action is taken now this tide can be turned (1).
Multidrug resistant tuberculosis (MDR-TB) is widespread, with alarmingly high prevalence in several countries of the former Soviet Union and some provinces in China and India. Some experts believe that the high incidence of MDR-TB in former Soviet Union countries could lead to a worldwide health disaster costing billions of pounds. The high prevalence of MDR-TB in the more populous countries of China and India means they will have an estimated 158 813 and 238 906 new cases of MDR-TB each year, respectively. The control of MDR-TB in these countries must be given high priority by the World Health Organization (WHO) and international funding agencies. With fewer medications that work against MDR-TB, however, and the reluctance of pharmaceutical companies to develop new drugs for a disease that affects the poor, the solution is far from evident.
Although MDR-TB can be treated, the cost is very high (over £60 000 or 96 000 per case in London, United Kingdom). The current approach to control advocated by WHO is directly observed treatment - short course (DOTS) (http://www.who.int/gtb/dots/), based on government commitment, a regular supply of drugs, passive case finding based on sputum microscopy, audit of efficacy of the control programme, and direct supervision of medication. It is, however, uncertain whether DOTS can contain the problem of MDR-TB. It prevents the emergence of multi-resistant forms of the disease, but cannot deal with established MDR-TB. DOTS-plus has emerged as a potentially effective solution, but a costly one as it relies on laboratory facilities for the identification of MDR-TB and provision of empirical or, preferably, individualised treatment regimes. Many countries would require financial and manpower assistance from international agencies to implement this treatment.
Immediate action is required from the global community to prevent the emerging epidemic of MDR-TB. It is hoped that the Global Alliance for TB Drug Development (http://www.tballiance.org/), launched in 2000 and incorporating governments, non-government organisations, pharmaceutical companies, and funding agencies, will start this action. Using recent breakthroughs in science, they aim to develop new cost-effective antituberculosis drugs that will quicken and simplify treatment, improve the treatment of latent infection by the tubercle bacillus, and be effective against MDR-TB.
The authors conclude that the tide of MDR-TB can be turned if the international community acknowledges that the prevalence of tuberculosis is a reflection of the inequities and injustices that exist today in the world. This community finally has the financial means and medical and technical expertise to tackle tuberculosis, and it is now time for it to take action.