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23/05/2017
M/XDR-TB:
WHAT ARE THE UNRESOLVED PROBLEMS?
Jean-Pierre Zellweger, MD
Swiss Lung Association
Faculty disclosure
• I am a clinician caring for patients and fed up by errors and
mismanagement of TB and MDR-TB
• I have no interest in any organization or industry making profit from
MDR-TB (who will anyway?)
• Most of the data I will present are from WHO or ECDC reports. I
have no personal or secret data to present
M/XDR-TB UNRESOLVED PROBLEMS:
1. EPIDEMIOLOGY
• The number of M/XDR-TB cases is increasing
worldwide
• The increase concerns in particular Eastern
Europe and Central Asia
• In some countries, the proportion of MDR-TB
increases in spite of a decrease in the rate of TB
• The surveillance and the available data are far
from comprehensive.
TREND IN TOTAL TB, MDR-TB AND
PROPORTION OF MDR-TB IN NEW CASES
MDR-TB: GLOBAL BURDEN OF DISEASE
M/XDR-TB UNRESOLVED PROBLEMS:
2. DIAGNOSIS
• Insufficient diagnostic capacities in many
countries
• Insufficient use of cultures and DST
• Insufficient support of lab networks by local
authorities
M/XDR-TB UNRESOLVED PROBLEMS:
3. CHOICE OF TREATMENT
• Niveau 1
– Niveau 2
• Niveau 3
– Niveau 4
» Niveau 5
M/XDR-TB UNRESOLVED PROBLEMS:
3. CHOICE OF TREATMENT
• There are Guidelines but few recommendations
are based on a strong evidence
• The best Guidelines are useless if the drugs
are not available
• The best drugs are useless if the patients do
not tolerate them
• Sotgiu G et al, Eur Respir J 2012:40(2) 500
/ 400’000
M/XDR-TB UNRESOLVED PROBLEMS:
3. OUTCOME OF TREATMENT
• The outcome of treatment – if known – is still
below the expected standards
• Patients treated in a GLC-supported
programme have a better outcome (because the
best drugs are available)
TREATMENT OUTCOME BY WHO REGION,
2010 REPORTING YEAR
WHO European Region
Other WHO Regions
100%
7
90%
80%
6
1
6
1
5
2
4
3
10
5
1
3
3
1
1
2
4.3
6.1
7.3
6.7
11.3
14.1
8
11.3
1
5
9.0
13.0
70%
93
88
88
60%
80
9.3
76
68.7
11.3
50%
56.3
40%
AFR
AMR
Not evaluated
EMR
SEAR
Defaulted
New pulmonary
lab.confirmed
WPR
Failed
Died
Re-treated
lab confirmed
Successfully treated
MDR-TB cohort
M/XDR-TB UNRESOLVED PROBLEMS:
4. MANAGEMENT OF ADVERSE EVENTS
• Adverse events are frequent and may be severe
• Treatment of adverse events means – in the best
of cases – the use of further drugs (if available)
or interruption of treatment
ADVERSE EVENTS DURING TREATMENT OF
MDR-TB
• 1027 patients with MDR-TB treated in Latvia
– Adverse events in 79%
• Nausea (58%)
• Vomiting (39%)
• Abdominal pain (24%)
• Serious psychiatric episodes (13%)
• Hepatitis (9%)
• Real failure (4%)
– Change in drug dosage in 20%
– Discontinuation of one or more drug in 64%
Bloss E, IJTLD 2010;14(3):275
M/XDR-TB UNRESOLVED PROBLEMS:
5. CASE HOLDING
• Cas holding is – still –not a tradition in many
countries
• Even if needed, DOT is frequently not possible
because there are no outreach workers to do
the job and there are many administrative
obstacles
MANAGEMENT OF AN OUTBREAK OF MDR-TB:
IMPACT OF DOT ON DEATH RATE
• The Chuuk experience
Brostrom R, AJPH 2011;101(1):14-18
M/XDR-TB UNRESOLVED PROBLEMS:
6. COSTS OF TREATMENT
• The treatment of MDR-TB is 10-20 times more
expensive than the treatment of drug-sensitive
TB
• MDR-TB can ruin the budget of TB in countries
with weak economy
• In many developed countries, the treatment of
MDR-TB is more expensive than cardiac
transplantation
• Who can afford it?
M/XDR-TB UNRESOLVED PROBLEMS:
7. INFECTION CONTROL
• Hospitals are a perfect place for the
transmission of MDR-TB
• Implementing all infection control measures can
only prevent a part of all cases transmitted in
hospital settings
• How to prevent the transmission of MDR-TB to
other patients, HCW and visitors?
• How to manage contacts of MDR-TB cases who
have been infected?
OUTBREAK MANAGEMENT OF MDR-TB
• 2 independent but simultaneous outbreaks of MDR-TB
observed in July 2008 in the State of Micronesia
• 232 contacts identified, 139 examined:
– 15 MDR-TB
– 5 drug-sensitive TB
– 119 infected
• 105 offered preventive therapy with quinolone+E or
quinolone +ethio
• 93 completed the preventive treatment  0 TB
– 28 contacts without preventive treatment (2/14 refusal)
developed TB between 2008 and 2012
M/XDR-TB UNRESOLVED PROBLEMS:
8. PALLIATIVE CARE
• Back to sanatoria, fresh air, rich meals and
morphine (and large graveyards)?
M/XDR-TB UNRESOLVED PROBLEMS:
9. PREVENTION
• MDR-TB is a problem because errors have
been committed and are perpetuated
• As long as these errors will not be
acknowledged and corrected, there will be no
prospect for a decrease
M/XDR-TB UNRESOLVED PROBLEMS:
10. LEGAL ISSUES
• In many settings, legal issues (laws,
regulations and Guidelines) are an obstacle to
the adeqate management of TB and MDR-TB
• The committment of the governments should
start with the updating of the laws and
regulations
MDR-TB: TURN OFF THE TAP!
IF NOT…
TRENDS IN M/XDR-TB BY REGION (WHO
REPORT 2012)