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(Chest. 2000;117:620-623.)
© 2000 American College of Chest Physicians

Preventing Multidrug-Resistant Tuberculosis and Errors in Tuberculosis Treatment Around the Globe

Lilia P. Manangan, RN, MPH and William R. Jarvis, MD(Atlanta, GA ).

Ms. Manangan and Dr. Jarvis are from the Hospital Infections Program, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA.

Correspondence to: Lilia P. Manangan, RN, MPH, Hospital Infections Program, Centers for Disease Control and Prevention, Mailstop E-69, 1600 Clifton Rd, Atlanta, GA 30333; e-mail: lpm2{at}cdc.gov

During the years 1989 to 1992, when tuberculosis (TB) emerged once again as a major problem in the United States, outbreaks of multidrug-resistant tuberculosis (MDR-TB) among persons in several hospitals1 and other institutional settings2 were reported. To prevent the spread of MDR-TB across the United States, the Centers for Disease Control and Prevention (CDC) developed a national action plan to combat MDR-TB,3 revised the guidelines for preventing the transmission of Mycobacterium tuberculosis in health care facilities,4 and recommended treatment strategies for TB.3 4 As a result of the collaborative effort of national and state agencies, professional organizations, and health care professionals, the incidence of TB in the United States has decreased.5

However, despite the decline of TB in the United States, almost 2 billion people (one third of the world’s population) around the globe are infected with M tuberculosis,6 and the emergence of MDR-TB in many countries is now becoming a major global problem. The World Health Organization’s (WHO) global surveillance for antituberculosis-drug resistance from 1994 to 1997 found resistance to antituberculosis drugs in 35 countries including Argentina, Asia, the Dominican Republic, and the former Soviet Union, which had high prevalence of MDR-TB.7 From 1998 to 1999 alone, there were repeated reports in the medical literature of MDR-TB in countries such as Australia,8 Azerbaijan,9 Canada,10 Estonia,11 Ethiopia,12 Guatemala,13 Hungary,14 India,15 Kenya,16 Korea,17 Russia,18 Scotland,19 Taiwan,20 Thailand,21 The Netherlands,22 and West Africa.23 If MDR-TB continues to spread unchecked in other nations, it also will continue to threaten the United States through transit of people around the world.

A pressing global health challenge is to improve TB treatment.6 Studies have shown that inconsistent or partial treatment of TB has been the main cause of MDR-TB2 6 24 and that the most effective strategy for ensuring completion of therapy is directly observed therapy (DOT).24 25 26 DOT, in which a health- care worker is present when the patient takes his or her medication, has proven to be an essential part of effective TB control strategies from New York City27 to Cambodia.28 Another important strategy is education of physicians or primary care providers in prescribing proper treatment for TB patients.3 4 29

From 1998 to 1999, two published studies in the United States documented errors by clinicians in their treatment of patients with TB.30 31 In addition, in this issue of CHEST (see page 734), Rao et al document errors in the treatment of TB patients in Baltimore, MD. In the international setting, two studies (Uplekar et al32 in India, and Arif et al33 in Pakistan) have documented poor clinicians’ compliance with WHO TB treatment guidelines, in particular with TB regimens. These studies support the need for further education of clinicians worldwide on the proper treatment of TB patients.

Since many TB patients suffer complications, including emergence of MDR-TB, due to errors in TB treatment, clinicians who are not familiar with the management of patients with M tuberculosis infection, including MDR-TB, should seek expert consultation.3 Prevention and treatment of either drug-susceptible or MDR-TB are possible with the vigilance of clinicians and public health practitioners.34

From 1998 to 1999, a study in Italy by Migliori et al35 found that the majority of 109 patients whose regimens were recorded on clinical records had received adequate TB regimens based on published recommendations. This shows that there are many clinicians who are prescribing proper treatments for TB patients. However, further studies are needed to determine clinicians’ prescribing practices for TB and MDR-TB patients in order to adequately address the educational needs of clinicians. Are inadequate treatment regimens due to clinicians not knowing the recommended treatment regimens? What are the appropriate drug doses or duration of therapy? Or, are they related to different treatment regimens (drugs and doses) made by different organizations? Design of focused educational efforts to enhance the appropriateness of clinicians’ treatment of TB patients is dependent on determining not just how frequent inadequate treatment is prescribed but why such regimens are used. Once such studies are conducted, the results need to be shared with those who are developing medical education programs for physicians around the globe so that we can better educate prospective and practicing clinicians.

As we start the new millennium, TB remains the leading cause of infectious disease morbidity and mortality and one of the most prevalent infectious diseases throughout the world. If we are to reduce the rate of this disease, prevention of errors in TB treatment through education of health-care workers about MDR-TB and TB infection control and recommended treatment regimens are critical elements. Global application of DOT, including education of clinicians and public health authorities about recommended treatment regimens, will be essential if we are to reduce the burden of TB during the 21st century. A collaborative national and international program to control the spread of TB and MDR-TB in the United States and throughout the world through rigorous infection control measures and appropriate TB treatment, especially using DOT, must be sustained. Furthermore, clinicians and public health authorities must actively participate in the TB infection control program in order to prevent or eliminate this deadly disease in the new millennium.

References

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  2. Dooley, SW, Jarvis, WR, Martone, WJ, et al (1992) Multi-drug resistant tuberculosis [editorial]. Ann Intern Med 117,257-258
  3. . Centers for Disease Control and Prevention (1992) National action plan to combat multidrug-resistant tuberculosis MMWR Morb Mortal Wkly Rep 41,1-60
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  6. Centers for Disease Control and Prevention. Statement from the Centers for Disease Control and Prevention in response to WHO World TB Day Report. Atlanta, GA: CDC Update; 1998
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