Outdated Policies and Practices Contributing to Rise of Drug-Resistant TB Must End

Pierre-Yves Bernard/MSF

GENEVA/CAPE TOWNDoctors Without Borders/Médecins Sans Frontières (MSF) and the Stop TB Partnership today released the second edition of the Out of Step report, a 24-country survey of policies and practices used today to guide the diagnosis and treatment of tuberculosis (TB). If countries are to meet globally endorsed goals to reduce TB incidence and death by more than 90 percent over the next 20 years, aggressive efforts must start now to adopt and implement the 14 key policies and practices identified in the report, which are currently recommended by the World Health Organization (WHO). TB is curable, but remains the world’s deadliest infectious disease, claiming 1.5 million lives each year.

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"Outdated policies for TB treatment that put people at risk of increased suffering and death should be banished, including re-treatment regimens that potentially increase drug resistance, and mandatory hospitalization during treatment," said Dr. Grania Brigden, MSF Access Campaign TB advisor. "The use of rapid molecular tests that can effectively diagnose drug resistance hasn’t yet reached the broad coverage needed. We won’t be able to close the huge gaps in TB diagnosis and treatment unless the policies and practices known to reduce illness, death, and transmission are fully adopted and implemented in every country, including the best use of every effective tool available today."

In October, WHO revealed that only one in four (26 percent) of the 480,000 people estimated to have developed multidrug-resistant TB (MDR-TB) in 2014 was diagnosed, with 111,000 people (23 percent) started on treatment and less than half of them successfully treated. Yet of the 24 countries surveyed for Out of Step, only about 30 percent of countries (8 out of 24) have put in place policies to ensure that rapid molecular tests for detection of TB and drug resistance are used as the initial test for everyone being evaluated for TB. Despite the upfront financial challenges related to this strategy, countries should consider expanding access to rapid molecular diagnostics in order to ensure early diagnosis and early treatment initiation; reduce the chain of transmission; reduce cost implications in the long run; and reduce the emergence of drug-resistant TB cases and the overall global burden of TB.

"To meet the targets in the Stop TB Partnership’s Global Plan to End TB 2016-2020 and the longer-term goals outlined in WHO’s End TB Strategy, country programs need to urgently bring their national policies and practices in step with international recommendations for optimal diagnosis and treatment of TB," said Lucica Ditiu, executive director of the Stop TB Partnership

"We recognize that the adoption of TB policies to national and local situations can take time, but many countries are leading the way. Just one year after new pediatric guidelines were released, the report found that 30 percent of countries surveyed have already adopted the new guidelines, which benefits all children with TB. We hope the Out of Step report will bring a renewed focus on the importance of TB policies as the starting point for ensuring countries are equipped to scale up TB efforts," said Dr. Ditiu.

Almost 60 percent of countries surveyed (14 out of 24) continue to offer the "Category II" re-treatment regimen, which has poor outcomes in countries with high rates of MDR-TB and HIV/TB co-infection. Once countries upgrade their diagnostic protocols to rapid molecular testing for all TB patients, this treatment should be phased out completely in line with WHO recommendations. The survey also highlighted that nine countries still require DR-TB patients to be hospitalized for all or part of their illness.

"In MSF projects and beyond, we’ve shown that hospitalizing people with drug-resistant TB is not necessary, and that people can receive treatment while living at home, even in resource-limited settings," said Vivian Cox, deputy medical field coordinator for MSF in South Africa. "Decentralized drug-resistant TB care is cost-effective for treatment programs, as medically effective as centralized care, and is much, much better for patients, their families, and their communities. We also know it’s critical for clinicians to have access to the full toolbox of new and existing TB drugs so they can give people the best chance to survive drug-resistant TB. When access to needed TB drugs is blocked, the results are too often deadly."

Only about 12 percent of countries surveyed are confirmed to have all of the existing drugs used to treat drug-resistant TB on their national essential medicine lists. While 65 percent of countries surveyed do have a process in place to access the newest TB drugs for patients who have run out of other treatment options, it is vital that drug companies submit their drugs for registration in the countries that need them the most, so that use of new and re-purposed drugs in treating drug-resistant forms of TB can be scaled up.

"As a first step, all countries with a high TB burden should implement rapid diagnostics, phase out the obsolete re-treatment regimen within a year, and do away with compulsory hospitalization," said Dr. Brigden. "We need all countries to upgrade their national policies and practices to fully meet WHO recommendations within the next three years to really address TB illness and death head-on."

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MSF team visiting a TB patient at home
Pierre-Yves Bernard/MSF