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. Last Updated: 07/27/2016

Treatment Needs New Strategy




International health officials and scientific experts say that strains of tuberculosis resistant to various drugs are spreading faster than anticipated overseas and that a new treatment strategy is needed to prevent what has already become an epidemic from spinning out of control.


For five years, the World Health Organization has recommended that patients with ordinary tuberculosis take up to four drugs, every day, for six to eight months, and that doctors and health workers watch them take their medicine and monitor them to ensure that they are cured. The strategy has become widely known as DOTS, or Directly Observed Therapy Short-Course.


But in a new report, doctors from the Harvard Medical School and the Open Society Institute, a foundation financed by George Soros, say more intensive treatment is needed in the former Soviet Union and other areas where rates of tuberculosis are relatively high.


In the intensive regimen, called DOTS-Plus, doctors watch patients take up to seven drugs daily, for 18 to 24 months, at far greater cost per cure.


Multidrug-resistant TB strains afflict on average 2 percent of victims, but as much as 30 percent in Russia's prisons.


The recommendation has been endorsed by WHO. But some health experts fear that new approach could make the situation worse.


The report, "The Global Impact of Drug-Resistant Tuberculosis," contains a forward offering an unusual endorsement from the WHO's leading specialists of the new treatment strategy. "In our zeal to implement DOTS everywhere," said Mario Raviglione, WHO's coordinator for bacterial and viral diseases, who signed the preface, "there was no clear policy in the program to take care of multidrug-resistant TB. Now we realize that something more must be done."


Opponents of the expanded strategy argued that it would shift desperately needed public health resources away from curing patients with non-drug-resistant tuberculosis.


"The WHO declared TB a global emergency in 1993," said Thomas Frieden, the WHO medical officer for TB for Southeast Asia, in a telephone interview in New Delhi. "But six years later fewer than 20 percent of patients get even basic treatment."


Frieden said efforts to combat multidrug-resistant TB should focus on its cause, inadequate treatment of ordinary TB.


Tuberculosis is known to acquire resistance to drugs that are being given to patients inefficiently. If the wrong drugs or doses are given for too short a time, or if the patients stop taking them, the tuberculosis bacteria that survive may become resistant to the drugs. Paul Farmer, director of the Program in Infectious Disease and Social Change at Harvard Medical School, the report's primary author, agreed that poor treatment has led to many cases of multidrug-resistant TB. But he said inadequate treatment was no longer the only cause of such strains.


He said new data suggest that in some areas drug-resistant strains are now spreading on their own, person-to-person, even in countries with good TB control programs.


He said multidrug-resistant tuberculosis now threatens not just poorer countries, but Europe and, eventually, the United States as well.


The study concludes that multidrug-resistant TB has now been reported in 100 countries and that its rates are rising faster in some countries than public health officials first anticipated.


For instance, in Russia's Ivanovo region, with a vast prison population and shoddy public health, the WHO reported in 1997 that 4 percent of TB patients had multidrug-resistant strains. According to the new report, such cases now total 8.9 percent of people with TB.


"Figures like these show that multidrug-resistant TB in some places is now out of control, and it shows we were doing something wrong, that more than DOTS is needed in such areas," said Raviglione.


But Frieden points out that two-thirds of people with multidrug-resistant TB developed it because the Ivanovo region program did not ensure that patients' took their medication. "If medicines aren't being taken, it doesn't matter if you're being given two or four or seven drugs," he warned. "And if resistance to reserve drugs emerges, our last line of defense against TB will be lost."


Farmer agreed that failure to take drugs was still a major problem in Russia and elsewhere. But, he added, the Ivanovo study had also shown that "the drugs patients received were inadequate," which is primarily why only 5 percent of multidrug-resistant cases were cured.


In one of its many ominous predictions, the study warns that even if the recommended DOTS treatment strategy is implemented, 171 million new cases and 60 million deaths can be expected between 1998 and 2030. The worst case scenario predicts 249 million new cases and 90 million deaths, even with the currently recommended treatment.