Philipp du Cros on drug resistant tuberculosis

Philipp du Cros My name is Philipp du Cros and I work in the Manson Unit of Médecins Sans Frontières UK, providing assistance to our programmes treating tuberculosis (TB). This year I have worked in five countries in Africa and Asia, with a particular focus on trying to improve care for patients with drug resistant TB. I wanted my guest blog entry to show how the generous donations* we receive are spent in a not so typical context.

To do this, I would like to relate to you the case of a young patient who presented to a rural hospital after several weeks of coughing and was appropriately diagnosed as having tuberculosis after a sputum sample demonstrated acid fast bacilli. The patient was started on first-line TB drugs but didn’t improve and after several months was changed to standard category 2 treatment, which adds an injection to the standard four first line drugs. After a few more months without significant improvement, the patient visited a private doctor, who suggested a sputum test for culture and drug sensitivity testing. Luckily, the patient’s family had some money and were able to afford this. The diagnosis was multi-drug resistant TB (MDR TB) – TB resistant to isoniazid and rifampicin, the two most important drugs in the standard first-line treatment. Treatment for MDR TB with second-line drugs is more expensive, has significantly more side effects, and requires a longer duration of treatment than standard first-line TB treatment. The patient could not afford all of the medications, but started paying for the drugs they could afford. Soon the patient’s family had to start dipping into their savings to pay for the treatment.

Eight months passed and the family’s savings were all but gone – but the patient was sicker than ever, now confined to a bed in hospital,. The doctor confided that the drugs were not working and that the family could not afford further medications, and the hospital did not have any other TB medications to give. The family, including the patient’s children, would visit regularly, spending time at the bedside, in a poorly ventilated room, while the patient grew weaker and continued to cough, potentially spreading the resistant TB to other patients and their relatives in the same hospital ward.

This case is far from a one-off, and this year in central Asia, South East Asia, and Africa I have heard similar stories from many other people, who, unlike the patient above, did not have access to appropriate diagnosis and could not afford the drugs if they are available. The World Health Organization estimated there were nearly 490,000 new cases of MDR TB in 2006, and less than 10% of these have access to care. However, bringing appropriate treatment for MDR TB to people living in remote areas in resource limited settings is difficult to say the least. The cases I have seen this year illustrate to me the importance of providing free and appropriate TB treatment. When patients are required to pay for their own drugs as is often the only option for patients who fail standard TB treatment, then it is very likely that they will not be able to afford all of them or be able to take them for the full required duration. Not only is this tragic for the patient, but it risks escalating resistance and spreading MDR TB among their family and community.

MSF has initiated MDR TB programmes in several countries, but this is proving a complicated process. The obstacles faced are numerous, ranging from the logistics of transporting samples from rural Africa to quality controlled laboratories that can perform drug sensitivity testing, to developing context specific support programmes that help patients continue to take five to seven medications with numerous side effects for up to two years and sometimes longer. However, seeing a small party celebrate the completion of treatment by some patients is a reminder of what can be achieved in difficult circumstances.

*The BMJ/MSF appeal has raised more than £12 000 so far.