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Drug-Resistant TB Is Spreading Among the World's Poor

Patients in South Africa are being sent home to die after treatment options are exhausted.
A child is screened for TB in Colombia. Image: Pan American Health Organization

Cases of tuberculosis continue to fall in the United States, but internationally, the disease remains a huge deal, with health officials at a loss for what to do in certain TB-ravaged places such as South Africa and North Korea.

A series of new reports published in The Lancet sheds light on the issue, and the picture isn’t exactly pretty. It states that roughly one million children worldwide get the lung disease, which is twice previous estimates and three times the number who are diagnosed. Each year, three million of the estimated 8.6 million new cases of TB, go undiagnosed and untreated. And, despite declining deaths in many countries, the incidence of antibiotic-resistant cases of tuberculosis continues to climb (and those diagnosed become harder to treat).

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“Quite simply, unless large increases occur in tuberculosis case-finding and provision of high-quality treatment for both drug-sensitive and drug-resistant tuberculosis, we will never truly get a grip on the disease,” Nick Herbert, of the United Kingdom’s All Party Parliamentary Group on Global Tuberculosis, wrote in one of the Lancet papers. “In the past 21 years, tuberculosis has claimed many millions of lives, orphaned at least 10 million children, ruined the lives of hundreds of millions of people, and trapped individuals, families, and entire communities in poverty.”

The disease is a particularly hard one to get under control. It’s a poster child for what can happen when a disease begins to develop antibiotic resistance—treatment courses for even drug-susceptible tuberculosis generally take at least six months and have severe side effects. Patients all over the world begin feeling better much earlier than that and often quit their course of antibiotics because of the side effects. From there, the disease often comes back worse than ever, but is now more difficult to treat because it has developed resistance in the meantime.

What we’re faced with, then, is a growing epidemic of tough-to-treat TB and, in some places such as South Africa, the emergence of TDR tuberculosis—totally-drug-resistant.

Cases of TB have fallen over the past several decades, but drug-resistant TB remains a problem. Image: WHO

That moniker has been controversial, because the World Health Organization isn’t yet ready to accept that there have been complete treatment failures of tuberculosis patients (and two brand-new antibiotics might offer some new hope), but several case-studies have shown that TDR is a real thing, and health organizations in South Africa, India, and Iran are dealing with it. Survival rates for drug-susceptible TB can be as high at 95 percent with early intervention; survival rates for extremely drug-resistant TB can be as low as 20 percent.

Whether any strains of the disease are truly “untreatable” is almost beside the point—it’s a problem even if the individual cases can eventually be cured. Drug-resistant tuberculosis represents just 3 percent of all cases in South Africa, but money spent treating those cases takes up more than a third of the total budget.

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In that country, more than 100 people have been discharged from TB hospitals and sent back to their communities simply because all treatment options had been completely exhausted. From there, most patients died within two years and were at high risk of transmitting their disease to others.

“At present, no systematic program in South Africa is available to ensure that these patients have appropriate infection control in their home environments, and there are no reasonable alternatives (eg, long-stay community facilities) where they can live,” Keertan Dheda, a researcher in Cape Town, writes in another Lancet paper.

The whole situation raises some very difficult ethical questions, ones that the country really doesn’t have any answers for:

“Should these patients be left on treatment if they are deemed to be non-responsive to treatment for extensively drug-resistant tuberculosis? Should treatment be withdrawn for patients who do not adhere to regimens, to prevent the evolution of higher-grade drug resistance? What should be done with the small number of patients who continue to default their treatment, usually in the setting of substance abuse, and are a danger to fellow patients and health-care workers? Should there be facilities to incarcerate such patients in appropriate cases? What about the rights of communities and individuals to be protected from a virtually untreatable and potentially fatal disorder?,” Dheda asks.

Many different strains of drug-resistant TB have been found all over the world. Image: The Lancet

That’s why tuberculosis, a disease that’s close to nonexistent (and generally easily treated) in the United States and other western countries, is still a huge problem. It disproportionately affects the poor, often infects people with HIV or who already have immunocompromised systems, and is expensive, time-consuming, and taxing on the body to treat. The tuberculosis death rate has fallen by nearly half since 1990, but it still kills roughly a million people each year. There are two new antibiotics that have been approved to treat it, but researchers are already saying that it’s “only a matter of time before [TB] strains develop resistance to these new antibiotics.”

Until we figure out a good way to deal with increasingly deadly forms of the disease, health officials are going to keep making it up as they go, and lives and communities will be at risk during the process.