Global Tuberculosis Report -- 2012.pdf

FIGURE 4.6 Number of MDR-TB cases estimated to occur among notified pulmonary TB cases, 2011MDR-TB cases0–299300–29993000–29 99930 000–59 999≥ 60 000No dataNot applicableBOX 4.2“Totally drug-resistant TB” and developments in India in 2012In December 2011, clinicians in Mumbai, India reported TB patients with what was termed “total drug resistance”. 1 As a result of theintense public interest generated by this episode, in March 2012 WHO convened 40 experts to discuss its implications, whether currentevidence makes it possible to defi ne patterns of drug resistance beyond extensively drug resistance TB (XDR-TB) and if better guidanceon appropriate treatment options for these patients was possible. While the group acknowledged that patients such as those described inMumbai pose a formidable challenge to clinicians and public health authorities, no reliable defi nition beyond XDR-TB could be proposed.Without having a better evidence base, no changes to the current guidelines on how to design treatment regimens for patients with broadpatterns of resistance could be recommended. Improvements in the accuracy of drug susceptibility testing to certain drugs and the releaseof innovative new drugs will, however, change this position in future.Since December 2011, several important measures have been taken by the Indian government. In Mumbai, laboratory and hospitalfacilities were improved, contact-tracing stepped up and efforts made to train staff on drug-resistant TB and infection control. Medicalstaff and funding were increased substantially. Access to second-line drugs was provided to eligible patients. National regulationsgoverning private sales of anti-TB medication were strengthened. By the end of 2012, all 35 states in the country are expected to provideprogrammatic management of drug-resistant TB. In May 2012, India made TB a notifi able disease and data collection on TB using a webbasedsystem was initiated. 21Udwadia ZF et al. Totally drug-resistant tuberculosis in India. Clinical Infectious Diseases, 2012, 54(4):579–581.2Press Information Bureau English Releases (available from: http://pib.nic.in/newsite/erelease.aspx?relid=83486).in the total number of MDR-TB cases notified between2010 and 2011 in 19 of the high MDR-TB countries and inall WHO regions except the Eastern Mediterranean andEuropean regions.The ratio of notified MDR-TB cases to numbers ofpatients starting treatment with second-line drug regimensfor MDR-TB was almost 1:1 globally, but lower inthe African and South-East Asia regions in 2011, possiblyreflecting the empiric treatment of TB patients at riskof MDR-TB without a laboratory confirmation or enrolmenton treatment of MDR-TB patients detected before2011 (Table 4.2). Enrolments in the high MDR-TB burdencountries nearly doubled between 2009 and 2011 asa result of steady annual increases in 12 of the countries,including India, the Philippines, the Russian Federation,South Africa and Ukraine, each of which reportedenrolling more than 2000 patients in 2011. Among 120countries reporting sex-disaggregated data, the medianmale:female ratio was 2. Most countries providing MDR-TB enrolment data did not report the inclusion of anyGLOBAL TUBERCULOSIS REPORT 2012 47