16 ⁄ hea lth a nd development 67 ⁄ June 13
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FIGURE / PERCENTAGE OF NEW CASES OF TUBERCULOSIS WITH MDR-TB
ged, highly toxic treatment regimens. Other novel antibiotics are still being tested and could radically change the approach to the patient. What is needed in primary prevention in public health is an effective vaccine to prevent pulmonary forms of tuberculosis. A clinically proven, safe, effective product could radically impact the disease and infecPercentage tion, as in the case of smallpox and of cases polio, particularly in destitute settings 0–2.9 3–5.9 as the ones where Doctors with Africa 6–11.9 CUAMM provide important clinical and 12–17.9 ≥ 18 public health support. Currently, apNo data proximately twelve vaccines are in the Subnational data only Source: Who, Global tuberculosis advanced stages of development. Not applicable report, 2012 Further substantial funding, both from domestic government sources and international cooperation desistant forms of tuberculosis (XDR-TB; caused by MDR strains velopment agencies, is needed to control the disease, particularly also having resistance to fluoroquinolones and to at least one of in low- and middle-income countries. At the international agency the three second-line injectable drugs) are cause for great con- level, above all the World Fund to Fight HIV/AIDS, Tuberculosis cern and have to date been notified in 84 countries, accounting and Malaria and currently the leading external financier, financial for 9% of MDR-TB forms. Only about one third of the 107 coun- aid should be concentrated in low-income countries not currentries affected by MDR-TB have managed to achieve a therapeutic tly in a position to finance themselves. Conversely, domestic success rate of ≥75%. Currently available, expensive treatment should rapidly replace external funding in countries experiencing regimens are characterized by the use of less effective second- rapid economic growth, in order to ensure sustainability and ecoline drugs, which are more toxic and require prolonged admini- nomic independence. Infrastructure, primary healthcare services, stration of up to two years. human resources, the drug information and procurement system The financial crisis of the new republics born from the ashes of and laboratories are some of the essential means of controlling the communist regime has produced systems characterized by tuberculosis that depend on the presence of an efficient health serious health and social problems (decline in hospitals, lack of system. Preventing and controlling MDR-TB, for example, depharmacological support for the sick, rise in HIV/AIDS cases, mands more extensive interventions than normally envisaged by etc.), providing tuberculosis, particularly MDR-TB, with the pernational programmes. Some essential interventions, as the rafect breeding ground. The example of the former USSR confirms tional use of antibiotics, drug quality control or the installation of what WHO has continued to maintain in its global strategy: the mechanisms for curbing hospital transmission, have to be imlack of political commitment and support is the starting point for plemented through ministerial policy makers, with a view to optithe uncontrolled proliferation of tuberculosis in a specific national mizing available resources and services. setting. In countries with a high incidence of tuberculosis, as those of the There are, however, promising signs on the horizon, particularly in former USSR, it is paramount to strengthen primary care, adopt the research and development field. At present, numerous labointernational diagnosis and treatment standards and improve treratories in many geographical areas are performing new rapid moatment models, thereby avoiding long, costly, pointless hospital lecular diagnostic tests, particularly to detect MDR-TB. WHO stays. New problems, as the rise in the incidence of non-commuendorsement of Xpert MTB/Rif, for instance, has provided many nicable diseases that increase the risk of tuberculosis (e.g. diacountries with a technique for rapidly detecting cases of tubercubetes mellitus and tobacco use) could undermine the already losis, including less contagious forms and those caused by bacte- weak capacity of many health systems to manage tuberculosis. ria resistant to rifampicin (indicating probable MDR-TB). This gives The evidence-based approach, recommended by WHO in several patients access to immediate treatment designed to improve the settings, may help downscale the tuberculosis epidemic through prognosis and reduce disease transmission. Moreover, two novel novel operational interventions, associated with a general improdrugs (bedaquiline and delamanid), tested in MDR forms, could vement in socioeconomic setting, which has been a key determiimprove the present scenario characterized by expensive, prolon- nant of this disease over the centuries.