ArticlesUniversal access to care for multidrug-resistant tuberculosis: an analysis of surveillance data
Introduction
For a disease that is largely curable with drugs, which have been available for several decades, inequalities in access to health care still exist globally–8·7 million people developed tuberculosis and 1·4 million died as a result in 2011.1 Substantial progress in prevention and treatment of tuberculosis has nonetheless been achieved in recent years through effective public health action driven by political commitment and the required mobilisation of resources. Between 1995 and 2011, 51 million patients with tuberculosis were cured, saving an estimated 20 million lives.1 These gains are now threatened by the emergence and dissemination of multidrug-resistant (MDR) strains of Mycobacterium tuberculosis, which have lost susceptibility to the two most effective antituberculosis drugs, isoniazid and rifampicin. Whereas most patients with tuberculosis can still be cured with a low-cost, 6 month course of antibiotics, those with MDR-tuberculosis require a much longer and complicated treatment to ensure cure.2 Globally, about 5% of patients with tuberculosis have the MDR form, but in countries including Belarus, parts of Russia, and Uzbekistan the proportion is up to 32% in previously untreated cases and at least two times higher in previously treated individuals.3, 4 Some of these cases of MDR-tuberculosis have strains resistant to other antituberculosis drugs in addition to isoniazid and rifampicin,5 and, since 2007, cases of tuberculosis with strains resistant to most or all of the antituberculosis drugs tested have been reported from different countries.6, 7, 8, 9 Clinicians and public health authorities alike are now troubled by the prospect that tuberculosis is sliding inexorably back to the preantibiotic era, when it was not amenable to drug treatment.10
In 2009, the World Health Assembly agreed on a multipronged approach to rein in drug-resistant tuberculosis worldwide.11 In its resolution, the World Health Assembly urged countries to ensure that by 2015 all patients with tuberculosis receive the appropriate care to prevent, diagnose, and treat MDR-tuberculosis. In 2010, WHO and its partners elaborated the Global Plan to Stop TB and a set of indicators to measure progress from 2011 to 2015.12 In this Article, we look at the progress achieved by the end of 2011—the first year of the Global Plan to Stop TB—and draw attention to the key decisions that countries and donors have to make to achieve the 2015 targets.
Section snippets
Definitions
MDR-tuberculosis is in-vitro resistance to, at least, rifampicin and isoniazid. Extensively drug resistant (XDR) tuberculosis is MDR-tuberculosis with additional resistance to any fluoroquinolone and to at least one of three injectable second-line antituberculosis drugs used in the treatment (capreomycin, kanamycin, and amikacin).13 A new case is a patient with tuberculosis who has no history of tuberculosis treatment or who received antituberculosis drugs for less than 1 month.14 A previously
Results
The table shows the numbers of cases of MDR-tuberculosis detected and cases of tuberculosis enrolled on second-line treatment regimens between 2009 and 2011 in the 30 countries with the highest expected number of cases of MDR-tuberculosis in 2011. Four large Asian countries (China, India, Pakistan, and the Philippines) and Russia and Ukraine had more than 9000 estimated MDR-tuberculosis cases in 2011.
Figure 1 shows countries ranked according to their detection ratios in 2011. Seven countries
Discussion
The latest data reported to WHO allowed us to classify the 30 countries with more than 1000 estimated cases of MDR-tuberculosis according to the progress that they had achieved in diagnosis and treatment. Three broad patterns can be discerned. In 2011, in six countries—Belarus, Brazil, Kazakhstan, Peru, South Africa, and Ukraine—both detection and enrolment on treatment exceeded 50% of the estimated cases of MDR-tuberculosis in each country (figure 1). In three of these countries (Brazil, South
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