What happens when the most commonly used drugs are no longer effective against tuberculosis?

For decades, people with tuberculosis (TB) relied on a combination of four readily available, inexpensive antibiotics to cure this debilitating and potentially deadly disease. The bacteria that cause TB, however, are becoming increasingly resistant to the two most effective drugs—isoniazid and rifampicin. When this happens, people develop multidrug-resistant TB (MDR-TB).

To be cured, a person with MDR-TB must take a combination of drugs that are less effective, more expensive, and more toxic than the commonly used antibiotics, and they must take these drugs for two years. If an MDR-TB strain develops resistance to one of the drugs used to treat it, the condition is called extensively drug-resistant TB (XDR-TB). XDR-TB is even more difficult and expensive to treat than MDR-TB, and it carries a higher risk of death.

Complicated circumstances, curtailed hopes

MDR-TB is preventable. It can develop when people receive drugs that are poor-quality, counterfeit, or prescribed in the wrong dosages. It may occur when people don’t complete a full, six-month course of treatment. People may stop treatment early for many reasons. For example, they may feel better and stop taking the drugs, there may be shortages of the drugs they need, or civil unrest may disrupt the health care system. People with little access to health care—the poor, minority groups, or those with low-standing in society—often suffer the most.

It can take two years or more to treat multidrug-resistant TB.

Everyone, however, is at risk. With more MDR-TB cases in every region of the world and exposure to people with MDR-TB increasing, more people are becoming infected with this form of TB from the start of their illness. Faced with the complicated circumstances of everyday life in many low-resource countries, how can the people charged with managing health care know where to start the fight against MDR-TB?

Strengthening health systems to beat MDR-TB

With funding from the United States Agency for International Development (USAID), PATH is working to find solutions that can help prevent, diagnose, and treat MDR-TB.

In India, PATH provides upgrades to the laboratories that are critical for diagnosing MDR-TB and monitoring treatment. With the Government of India, we work to improve the infrastructure, equipment, and design of laboratories to meet national and international standards for TB culture and drug susceptibility testing. Improved laboratory facilities help health care providers more quickly determine if their patients have MDR-TB so they can prescribe effective treatment, prevent deaths, and stop further transmission of MDR-TB.

In Tanzania and the Democratic Republic of Congo, PATH and our partners from the University of California, San Francisco and Partners in Health provide intensive clinical training to health staff in specialized facilities. Our training helps staff treat MDR-TB patients effectively and gain confidence in managing these complex cases.

In Mexico, PATH is helping the national TB program better understand the MDR-TB situation and improve planning and management of MDR-TB control. We work with the national TB program and the states to refine data collection and strengthen analysis to identify opportunities for improvement.

In Asia, where the MDR-TB problem is the largest, PATH is working with USAID’s Regional Development Mission Asia and others to plan a network that will build MDR-TB expertise in the region and help countries address this daunting challenge.

Creating tools to tackle MDR-TB

PATH is working with the World Health Organization and the Stop TB Partnership to create a set of MDR/XDR-TB assessment and planning tools. The tools help a country’s health care managers plan their national response to MDR-TB by identifying which aspects of the TB program are working well, where there are gaps or challenges, and how the health care system and its providers can best prevent, diagnose, and treat MDR-TB.

PATH has already used these tools with national TB control programs in Mexico and Zimbabwe, as well as with a state-level program in India and in regional trainings for health care managers and consultants in South America and Asia. We plan to expand our support to countries in the coming years.

Photo: PATH/Nguyen Ba Quang.