Multidrug-resistant (MDR) tuberculosis is defined as disease caused by strains of Mycobacterium tuberculosis that are at least resistant to treatment with isoniazid and rifampicin; extensively drug-resistant (XDR) tuberculosis refers to disease caused by multidrug-resistant strains that are also resistant to treatment with any fluoroquinolone and any of the injectable drugs used in treatment with second-line anti-tuberculosis drugs (amikacin, capreomycin, and kanamycin). MDR tuberculosis and XDR tuberculosis are serious threats to the progress that has been made in the control of tuberculosis worldwide over the past decade.1,2
In 2008, an estimated 440,000 cases of MDR tuberculosis emerged globally.1 India and China carry the greatest estimated burden of MDR tuberculosis, together accounting for almost 50% of the world’s total cases. More than three quarters of the estimated cases of MDR tuberculosis occur in previously untreated patients. The proportion of MDR cases among new cases and previously treated cases of tuberculosis reported globally from 1994 through 2009 ranged from 0 to 28.3% and from 0 to 61.6%, respectively (Figure 1FIGURE 1 Distribution of the Proportion of Cases of MDR Tuberculosis among New Cases of Tuberculosis, 1994–2009.
). The highest proportions of MDR cases, and the most severe drug-resistance patterns, appear in the countries of the former Soviet Union. By 2009, a total of 58 countries had reported at least one case of XDR tuberculosis. In eight countries, reported cases of XDR tuberculosis account for more than 10% of all cases of MDR tuberculosis, and six of these countries were part of the former Soviet Union. By far the largest number of cases of XDR tuberculosis has been reported from South Africa (10.5% of all cases of MDR tuberculosis in that country), owing to rapid spread among people infected with the human immunodeficiency virus (HIV).
National programs are failing to diagnose and treat MDR tuberculosis. Globally, just under 30,000 cases of MDR tuberculosis were reported to the World Health Organization (WHO) in 2008 (7% of the estimated total), of which less than one fifth were managed according to international guidelines. The vast majority of the remaining cases probably are not diagnosed or, if diagnosed, are mismanaged. This problem remains despite the evidence that management of MDR tuberculosis is cost-effective3 and that treatment of MDR tuberculosis, and even treatment of XDR tuberculosis, is feasible in persons who are not infected with HIV.4,5
In some countries, the incidence of tuberculosis is rising, and the incidence of MDR tuberculosis appears to be rising even faster (e.g., in Botswana and South Korea).6 However, in Estonia, Hong Kong, the United States, and Orel and Tomsk Oblasts (in the Russian Federation), the incidence of tuberculosis is falling, and the incidence of MDR tuberculosis appears to be falling even faster. 1,6 This trend is the result of high-quality care and control practices that result in high rates of case detection and cure, drug-susceptibility testing for all patients, and the provision of appropriate treatment for all patients carrying drug-resistant strains. In short, preventing initial infection with MDR tuberculosis and managing the treatment of existing cases appropriately are the keys to containing the spread of this disease.
The WHO-recommended Stop TB Strategy7 provides the framework for treating and caring for those who are sick and controlling the epidemic of drug-susceptible and drug-resistant disease. The DOTS approach, which underpins the Stop TB Strategy, calls for political commitment to national programs designed to control disease by means of early diagnosis with the use of bacteriologic testing, standardized treatment with supervision and patient support, and provision and management of the drugs used in treatment; the approach also includes the monitoring of treatment and evaluation of its effectiveness. Between 1995 and 2008, a total of 36 million people were treated successfully with the use of the DOTS approach, and 6 million lives were saved.8 Specific guidelines for controlling drug-susceptible and drug-resistant disease already exist,9,10 and the Global Plan to Stop TB, 2006 through 2015, developed by the Stop TB Partnership, specifies the scale at which these interventions need to be funded and implemented to achieve global targets.11 However, to date, planning, funding, and implementation are falling far behind the milestones that have been set.
Prompted by concern that political support for the management of MDR tuberculosis is insufficient, WHO, the Bill and Melinda Gates Foundation, and the Chinese Ministry of Health organized a ministerial conference in Beijing in April 2009.12 The report from the conference in Beijing and the subsequent resolution (number 62.15) approved by the World Health Assembly in May 2009 state that significant changes in several components of the health care system must be made if MDR tuberculosis is to be eliminated.13,14 This review assesses the critical factors impeding control and discusses the solutions required to address them.
The World Medical Association has realized that there is an urgent need to support physicians in their daily work with TB and MDR-TB patients by developing TB and MDR-TB training material. Since 2005, we have provided the MDR-TB online course and in 2011 we have completed the TB refresher course. Both courses are available free of charge from our webpage as online courses and as PDF for download. They are translated into several languages, and there will be more of them.
Teaching styles have changed and there is an increasing demand for interactive e-Learning methods.
Together with New Jersey Medical School and their Global Tuberculosis Institute, and INMEDEA, a company creating interactive software for medical professionals, WMA has developed as training material 2 interactive patient cases based on the existing TB and MDR-TB cases. Due to the use of new multimedia technology and the web, the user has the impression to solve a real patient case when doing anamnesis, physical examination, making the diagnosis and deciding on a treatment plan. This does not replace the online courses, which are more textbook based, but it is a complement to the existing courses and helps to check whether the learned content is really understood.
Brief introduction to how to solve the patient cases and how to navigate through the system is available through this link.
1st Patient Case:
Rafael Cordero is a 30 year old man who was born in Ecuador and immigrated to the US. He was admitted to a local hospital for night sweats, a 6 week history of productive cough, weight loss of 10 kg, fatigue, and hemoptysis. The patient had no other significant past medical history. The patient’s TST was negative and repeat testing also revealed negative results….
To enter the patient case please click: Rafael Cordero
2nd Patient Case:
Sandra Fisher, a German 34 year old female social worker presents to the clinic with cough of unknown origin with slightly bloody sputum (hemoptysis). She reports that, after a severe cold last winter, shortness of breath and dry cough have remained, now being accompanied by slightly bloody sputum. Also, she feels persistently tired what she always thought was due to spring time. She is lethargic, breaks often out in night sweats and has unintentionally lost 5 kg of weight during the last 2 months. Mrs. Fisher reports that she must often go to the homes of fellow citizens she must look after…
To enter the patient case please click: Sandra Fisher
Visit MDR-TB online course
Visit TB refresher course