Interventions for Tuberculosis Control and Elimination 2002

of the disease, as alternative drugs (other than the six essential drugs) are
not usually available in sufficient quantity.
The emergence of multidrug-resistant tuberculosis has been documented
in an increasing number of countries and has, in some countries, reached
levels that seriously threaten tuberculosis control. 621,622
The WHO has addressed this issue in both a formal publication 606 and
workshop proceedings. 608,609
Curative treatment of multidrug-resistant tuberculosis poses a multitude
of problems. Amongst these are:
• the high cost of the necessary drugs (currently up to 100 times as
expensive per course as a first-line regimen); 609
• the relative weak activity of most of these drugs against M. tuberculosis;
• the high frequency of adverse reactions requiring specialist expertise;
• the prolonged duration (21 months has been proposed as a minimum); 606
• the logistic difficulties anticipated in implementing such regimens in a
national tuberculosis program;
• difficulties in implementing standardized laboratory facilities to correctly
identify susceptibility patterns; 623
• gaps in knowledge as to what approach to treatment (individualized or
standardized) is most appropriate. 624
As there is an increasing demand to utilize such alternative medications,
and technical knowledge is generally poor about their proper usage in most
countries where the problem has emerged or is emerging, the danger of
uncontrolled usage is great. Resistance to these drugs is likely to emerge
quickly in unprepared settings. 625 It is hoped that the agenda set forth by
WHO 608 will generate sufficient information in an ordered and timely fashion
and appropriate technical expertise will accompany implementation of
any such project to ensure continued curability of tuberculosis in such settings.
Unfortunately, multidrug-resistant tuberculosis has emerged precisely
in areas of the world that have demonstrated poor tuberculosis control in
the first place, and whether a deterioration of the situation in such settings
can be prevented with the introduction of drugs potentially able to cure
multidrug-resistant tuberculosis remains to be seen.
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