Interventions for Tuberculosis Control and Elimination 2002

Strains resistant to isoniazid alone can virtually always be killed when
regimens containing both rifampicin and pyrazinamide are used and
rifampicin is given throughout. 603 The introduction of the short-course regimens
in countries such as Algeria and Korea was accompanied by a clear
decline in resistance to isoniazid and chronic excretors for this reason. 639,640
However, in the case of Algeria, the introduction of short-course regimens
was associated with the appearance of and slow increase in cases with multidrug
resistance among previously treated patients, possibly related to the
fact that directly-observed treatment was not the policy. The rate of decline
in cases of tuberculosis (and particularly of re-treatment cases) in that community
was greater than the rate of appearance of multidrug resistance, thus
outpacing the drug resistance. However, if this community had experienced
a rise in the numbers of cases, rather than a decline (as would have
occurred if the community was affected heavily by HIV infection), this
might not have been the case.
This is one of the main reasons why the IUATLD has preserved a
very conservative policy with respect to treatment regimens, in order to
preserve the usefulness of rifampicin as an efficacious agent in the overall
scheme of treatment policy.
The approach to management of adverse drug events
The major clinical presentations of adverse drug events that may occur in
a patient treated with the essential drugs and the approach to managing
them will be discussed here. Adverse drug events from second-line drugs
should always be dealt with by a specialist in the field. The discussion is
limited to the major clinical syndromes occurring in the routine management
of tuberculosis in clinical practice.
In any patient who takes prolonged treatment, episodes of ill health
may occur which may be ascribed by the patient or the health care provider
to adverse effects of the treatment given. This is not necessarily the case.
In the large clinical trials of preventive chemotherapy carried out by the
US Public Health Service among household contacts of tuberculosis patients,
one group of patients was assigned to the treatment arm and another to a
placebo in which identical tablets were given which contained no active
medication. 641 Neither the patient nor the care provider knew the type of
pills that individual patients were taking. The events that occurred during
treatment were thus observed without knowledge of the treatment. In a
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