Annals of Tropical Medicine and Public Health

EDITORIAL COMMENTARY
Year
: 2017  |  Volume : 10  |  Issue : 3  |  Page : 497--498

Addressing the challenges of diagnostic delay and longer treatment duration for multidrug resistant tuberculosis: World Health Organization


Saurabh R Shrivastava, Prateek S Shrivastava, Jegadeesh Ramasamy 
 Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai, Chennai, Tamil Nadu, India

Correspondence Address:
Saurabh R Shrivastava
3rd Floor, Department of Community Medicine, Shri Sathya Sai Medical College and Research Institute, Ammapettai village, Thiruporur: Guduvancherry Main Road, Sembakkam Post, Kancheepuram, Tamil Nadu
India




How to cite this article:
Shrivastava SR, Shrivastava PS, Ramasamy J. Addressing the challenges of diagnostic delay and longer treatment duration for multidrug resistant tuberculosis: World Health Organization.Ann Trop Med Public Health 2017;10:497-498


How to cite this URL:
Shrivastava SR, Shrivastava PS, Ramasamy J. Addressing the challenges of diagnostic delay and longer treatment duration for multidrug resistant tuberculosis: World Health Organization. Ann Trop Med Public Health [serial online] 2017 [cited 2019 Sep 22 ];10:497-498
Available from: http://www.atmph.org/text.asp?2017/10/3/497/188509


Full Text

Dear Editor,

The global target of stopping and reversing the tuberculosis (TB) epidemic by the year 2015 was achieved and even the disease associated incidence and mortality has been reduced by 18% (since 2000 estimates) and 47% (since 1990 estimates).[1] Nevertheless, the global efforts have been seriously questioned by the emergence of resistance to both first-line and second-line antituberculosis drugs in most of the nations worldwide.[1],[2] In-fact, it was observed that almost 0.48 million cases of multidrug-resistant TB (MDR-TB) and 0.19 million deaths attributed to MDR-TB has been reported worldwide in the year 2014.[1] Further, the current global figures reflect that almost 5% of TB cases will be suffering from MDR-TB, whereas 9% of MDR-TB patients will develop extremely drug-resistant TB (XDR-TB).[1],[2],[3]

MDR-TB has been acknowledged as a major global public health crisis and tends to have serious consequences on the medical, social, and financial aspects on the life of the affected persons.[2],[4] It has become a major concern, predominantly because of the failure of the health system to promptly diagnose cases of MDR-TB, and due to the longer duration of the conventionally available regimen (which seriously questions the issues of compliance to the treatment regimen.[1],[2] The World Health Organization (WHO) has come out with an effective solution for both of these challenges and to ensure that the outcome of the disease can be improved worldwide.[1]

From the diagnostic perspective, it was really alarming that only 25.6% of the diagnosed MDR-TB cases were detected and notified. In order to bridge this diagnostic gap, the WHO has recommended for the adoption of a rapid diagnostic test MTBDRsl a line probe assay to detect resistance to second-line anti-TB drugs (SL-LPA).[5] Its advantage is its rapid turnaround time (1–2 days, in contrast to the 3-month period associated with conventional tests), can simultaneously detect both MDR and XDR forms of TB, and even aid the programme managers to take a decision to either initiate or not initiate (due to the heightened risk of development of XDR-TB) patients on the shorter MDR-TB regimen (newly approved).[1],[5] In other words, the rapid detection of the disease will lead to prompt initiation of the appropriate treatment and, thus, reduce the potential risk of transmission of the disease.[1]

Thus, the current recommendation is to subject diagnosed rifampicin-resistant TB or MDR-TB patients to SL-LPA, as a preliminary test to detect the presence of resistance to fluoroquinolones/second-line injectable drugs, instead of the earlier approach of culture-based drug-susceptibility testing.[1],[5]

From the treatment aspect, it has been observed that less than 20% of the estimated MDR-TB patients were in reality treated properly worldwide, which again raises many questions about the reach of the existing services to those who need it the most.[1],[3] It is very well known that patients with MDR-TB can't be managed with the six-month standard first-line therapy, and the treatment easily extends for 18 months or even more.[2] After a series of studies, a shorter MDR-TB regimen lasting for a period of 9-12 months has been recommended for MDR-TB patients, irrespective of their HIV status, provided conditions such as no evidence of resistance or suspected effectiveness of medicines (except isoniazid), history of exposure to more than one second-line medicines in the shorter MDR-TB regimen for more than one month, pregnancy, extrapulmonary disease, and the absence of any medicine prescribed under the shorter MDR-TB regimen, are met.[3] Overall, the shorter regimen not only cheaper, but is also expected to improve clinical outcome and reduce mortality rates due to better treatment adherence or minimal loss to follow-up.[1],[3]

Moreover, both of these recommendations will be of extreme utility for millions of patients.[2] Nevertheless, the success of these strategies depends on immediately adopting SL-LPA in those settings in which LPA has been already functional, provision of appropriate infrastructure and equipments, training of health personnel, systematic monitoring for effectiveness-harms-relapse, offering patient-friendly care and supportive services, and sustained financial support from both national and international welfare agencies.[1],[3],[5]

To conclude, in the global mission to end TB by the year 2030, in particular MDR-TB, the global adoption of the novel diagnostic test and shorter-TB treatment regimen will play a crucial role in bringing down the TB deaths, and catastrophic expenditures.

Acknowledgement

S.R.S. contributed in the conception or design of the work, drafting of the work, approval of the final version of the manuscript, and agreed for all aspects of the work.

P.S.S. contributed in the literature review, revision of the manuscript for important intellectual content, approval of the final version of the manuscript, and agreed for all aspects of the work.

J.R. contributed in revising the draft, approval of the final version of the manuscript, and agreed for all aspects of the work.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest to declare.

References

1World Health OrganizationRapid diagnostic test and shorter, cheaper treatment signal new hope for multidrug-resistant tuberculosis patients; 2016. Available from: http://who.int/mediacentre/news/releases/2016/multidrug-resistant-tuberculosis/en/. [Accessed 2016 May 14].
2Wares F, Falzon D. Progress in achieving universal access to care for multidrug- resistant tuberculosis (MDR-TB). Indian J Tuberc 2014;61:298-96.
3World Health OrganizationThe shorter MDR-TB regimen; 2016. Available from: http://who.int/tb/Short_MDR_regimen_factsheet.pdf. [Accessed 2016 May 14].
4Zhang T, Lv CF, Wang J, Zheng WB, Lu LZ, Liu SJ. Direct tuberculosis drug susceptibility testing: time-saving and cost-effective in detecting MDR-TB. Int J Tuberc Lung Dis 2016;20:323-28.
5World Health OrganizationMolecular Line-Probe Assay for the detection of resistance to second-line anti-TB drugs (SL-LPA); 2016. Available from: http://who.int/tb/Factsheet_SLLPAfinal.pdf. [Accessed 2016 May 13].