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MDR and XDR in Africa: A wake-up call for the Global engagement of the TB epidemic.

Posted by plosmedicine on 31 Mar 2009 at 00:08 GMT

Author: Wayengera Misaki
Position: M.B, Ch.B,
Institution: Graduate Student
Additional Authors: None
Submitted Date: April 26, 2007
Published Date: April 27, 2007
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Following the development in the 1950s and 60s of effective therapy against TB, many thought tuberculosis would soon be eradicated. However, with the advent of HIV in the 1980s, this picture was distorted; and in 1999, the WHO ranked tuberculosis among the most serious health threats to the world. The WHO subsequently developed and adopted the DOTS strategy as a means to control and possibly eradicate this scourge. Gradually, however, DOTs gave way as many studies come to reveal. [1.-6]

The current surge in drug resistant TB in sub-Saharan Africa thus comes not as a surprise, given that the programs here have already been overburden by the increased TB incidence in association with HIV. What we ought to consider are the possible consequences of this burden of TB on global health, given that TB is airborne, and many citizens in the developed world are non-immune. In my view, this picture calls for a consensual approach by global partners in prevention, control and care for TB patients in the high burden areas like sub-Saharan Africa, and although the GFATM is such an initiative, there are still speculations surrounding the reality of MDR TB within the sub-Saharan setting.

First, it may be important to realize that the general picture of TB control and treatment globally has widely been distorted and magnified by the HIV epidemic, and that MDR epidemics have occurred, and been controlled elsewhere. In this regard, the final realization of this picture in Africa was expected. The real challenge is how to we transfer the strategies that controlled MDR in the developed world setting such as New York, into a resource limited setting. In an observational study we conducted between 2003 to 2006, we found that, within the sub-Saharan setting, the WHO-DOTS strategy had faced many shortcomings for over a decade inclusive, but not limited to:1) HIV-associated raises in prevalence, (2) inadequate infrastructure to allow for a 70% catchment, and 85% treatment success rate, (3) default from treatment, and (4) emergence of drug resistance. These four interplay to yield a vicious cycle of TB propagation and evolution that not even adopting the STOP TB strategy alone may break.

So, today, as the International Union against TB and Lung disease(IUATBLD), together with its partners viz WHO, UNAIDS adapt the STOP-TB strategy to replace DOTS, its time I believe for 1) the Green Lights committee(GLC) to ease up on access to second line TB chemotherapy 2) Transfer knowledge, skills and technology that worked in the North to the South Only then can we soundly discuss detention for non-complaint patients with no ethical, legal or social breaches in the code.


1. Haas F., Haas SS. The origin of mycobacterium tuberculosis and notion of
Its contagiousness. In: Rom WN, Garay SM (eds) Tuberculosis, NY: Little, Bloom and Company; 1996:3-19.
2.Haas DW, des RM, Dolin R (eds), Mandell, Douglas and Bennett’s Principles and practices of infectious Diseases, 4th Edn. NY: Churchill
Livingstone; 1995:2213-2243.
3. UNAIDS. Report on the Global HIV/AIDS , July 2006
4. WHO. Global plan to stop TB 2006-2015
5.WHO/IUATLD. Anti-tuberculosis Drug Resistance in the world Geneva: WHO/UATLD; 1997.
6. Espinal Marcos A, Kim Sang Jae, Suarrez Pedro G, et al. Standard short course chemotherapy for resistant tuberculosis JAMA 2000; Vol. 283(19): 2537.
7. Andrews J, Basu S, Scales D, Maru DSR, Subbaraman R XDR-TB in South Africa: Theory and practice. PLoS Medicine Vol. 4, No. 4, e163 doi:10.1371/journal.pmed.0040163

No competing interests declared.