Multi-Drug-Resistant Tuberculosis

by

Nora Engel

• LAST REVIEWED: 15 January 2015
• LAST MODIFIED: 15 January 2015
• DOI: 10.1093/obo/9780199756797-0148

Introduction

Multi-drug resistant tuberculosis (MDR-TB) has been framed by the World Health Organization as a pressing, global public health problem. Tuberculosis (TB) is an infectious disease caused by the Mycobacterium tuberculosis, which is commonly transmitted through inhalation of bacteria into the lungs. In its most common form of pulmonary TB, the disease, if left untreated, will lead to gradual destruction of lungs, causing incapacity of bodily functions and eventually death. The disease is curable with a cocktail of anti-TB drugs that have to be taken for at least six months. Patients who suffer from TB that is resistant to at least rifampicin and isoniazid, two of the most important standard anti-TB drugs, are defined as “MDR-TB” patients. MDR-TB develops from an infection with a resistant strain or from poor treatment with inadequate drugs or irregular drug intake. MDR-TB patients have only a 60 percent chance of being cured and both diagnosis and treatment (which takes 24 to 29 months) become more complicated and costly. Although MDR-TB has always existed along with TB, its occurrence has increased substantially due to emerging and interlinked challenges to TB control, such as weakening health systems, migration, poverty, globalization, co-infection with HIV/AIDS, urbanization, and a growth in unregulated private sector providers. These aspects make MDR-TB especially hard to prevent and control in resource-constrained settings. MDR-TB has also gained much more international attention in the policy arena. The sections discussed in this article deal with, among other things, these shifts in policy responses and the debates on the magnitude and causes of MDR-TB. Public health control strategies have focused on preventing MDR-TB by standardizing diagnosis and treatment of routine TB control (through the WHOs strategy of direct observation of treatment, DOTS), and treating existing MDR-TB cases with more or less standardized regimens. Although diagnostic tools and treatment regimens have been upgraded in recent years, those services are difficult to provide in resource-constrained settings. Not only is MDR-TB a biomedical problem, it is also a social problem and closely related to poverty and societal system challenges. This article begins with a section on introductory works on MDR-TB, followed by a section with reference works, including policy reports and guidelines and a consideration of related journals. The remaining citations are grouped under the main challenges involved in coping with MDR-TB: responding to MDR-TB (including the debates on magnitude and causes of MDR-TB), diagnosis and treatment of MDR-TB, MDR-TB and inequality, and extreme forms of drug-resistant TB.

General Overviews

Multidrug-Resistant Tuberculosis and International Union Against Tuberculosis and Lung Disease provide a good starting point to understand policy aspects of TB and MDR-TB control and the related technical details and data on diagnosis, treatment, prevention, and surveillance, including guidelines and frameworks. Although the introductory books in this section are all from the early 2000s, they provide an important background reading for anyone interested in the range of aspects associated with MDR-TB. They also reflect an increasing concern of the rise of MDR-TB at the beginning of the century. Reichman and Hopkins-Tanne 2002 and Gandy and Zumla 2003 both describe the emergence of MDR-TB, written by eminent scholars and important voices in the field of TB. The former does so by highlighting geopolitical causes and the latter by examining effects of poverty, migration, and HIV co-infection. Zumla, et al. 2013 updated this a few years later in the New England Journal of Medicine. Davies 2001 offers an introduction into the different public health aspects of MDR-TB diagnosis and management. It is based on a two-day meeting in 2001 of 200 medical doctors, scientists, legal experts, anthropologists, nurses, and others who discussed the challenges of MDR-TB. Porter and Grange 1999 is not solely focused on MDR-TB but also introduces concerns of social scientists related to TB more broadly. Since the two are closely linked, it is a necessary read for anyone interested in the dynamics of MDR-TB and its management. The WHO website offers an overview of different initiatives related to MDR-TB. Among these are the Global Project on Anti-Tuberculosis Drug Resistance Surveillance, the Working Group on MDR-TB of the Stop TB Partnership, and the Green Light Committee Initiative to support treatment uptake. Furthermore, the WHO regional offices also provide data and background information on MDR-TB in Africa, the western Pacific, Europe, Southeast Asia, the Americas, and eastern Mediterranean respectively, the International Union Against Tuberculosis and Lung Disease is a dedicated network of experts and advocates that provides technical assistance, education, and research in seventy-five countries. Both these websites offer resources in different languages.

• Davies, Peter. 2001. Introduction. Annals of the New York Academy of Science 953b.1: 87.

  DOI: 10.1111/j.1749-6632.2001.tb11363.x

  Introduction to a collection of articles that covers a wide range of important aspects related to MDR-TB: from genetics, disease burden, public health strategies, and diagnostics, to ethics, cost, clinical management, prevention, co-infection with HIV, and country reports of India and South Africa.

• Gandy, M., and A. Zumla. 2003. The return of the white plague: Global poverty and the “new” tuberculosis. New York: Verso.

  This edited volume describes the emergence of the “new tuberculosis” due to additional challenges and combined effects of poverty, migration, HIV, co-infection, and the development of drug resistance. Additionally, it offers chapters on history and advocacy.

• International Union Against Tuberculosis and Lung Disease.

  The union publishes the International Journal of Tuberculosis and Lung Disease. It also convenes the Union World Conference on Lung Health, the largest annual meeting focusing on TB. The journal and the conferences provide a wealth of technical information and overview of the state of the art of TB research.

• Multidrug-Resistant Tuberculosis (MDR-TB).

  The World Health Organization’s website offers links to different documents, guidelines, trainings, maps, reports, and working groups related to MDR-TB. Together these serve as a platform for country, regional, and global level evaluation and updates of magnitudes, trends, frameworks, and management of MDR-TB.

• Porter, J. D. H., and J. M. Grange. 1999. Tuberculosis: An interdisciplinary perspective. London: Imperial College Press.

  This edited volume offers a good, albeit slightly dated introduction to social sciences debates and research on TB, covering a range of concerns that are also valid for MDR-TB.

• Reichman, L. B., and J. Hopkins-Tanne. 2002. Timebomb: The global epidemic of multi-drug-resistant tuberculosis. Martinsburg, WV: McGraw-Hill.

  A warning account of the global epidemic of MDR-TB, mixed with personal experiences, revealing links between geopolitics, science and (public) health (such as f.ex. the Russian response to TB and MDR-TB).

• Zumla, A., M. Raviglione, R. Hafner, and C. Fordham von Reyn. 2013. Tuberculosis. New England Journal of Medicine 368.8: 745–755.

  DOI: 10.1056/NEJMra1200894

  This introductory article on TB reviews recent advances in TB diagnostics, drugs, and vaccines and enhanced implementation of existing interventions. It argues that those advances have increased the prospects for improved clinical care and global tuberculosis control.