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Dealing with established drug resistance
TubercleandLung Disease(1995) 76, I 154 © 1995 Pearson Professional Ltd
Tubercleand LungDisease obal Lung Hea 9-12 Sepl
SECTION 1: PLENARY SESSIONS How can basic scientific research contribute to tuberculosis programlnes? Cole, S., Unit~ de G~ngtique Mol~culaire Bactdrienne, Institut Pasteur, Paris, France
Although the ultimate solution to tuberculosis as a global public health problem will stem predominantly from improvements in socio-economic conditions, the insight and technological advances resulting from basic biomedical research can accelerate the process. During the past two decades there has been an explosion of knowledge and understanding of infectious diseases which, in many cases, has led to better diagnostic tools, interventions and therapies. The same period has seen little, if any, improvement in the situation concerning tuberculosis as the effects of the AIDS pandemic, worldwide economic depression, insecure chug supply and multidrug resistance have made inroads into control programmes. Hence, there is greater need than ever not only to use available resources as efficiently as possible but also to be aware of the developments in the fields of molecular mycobacteriology, immunomodulation, drug development and resistance, so that precious opportunities should not be squandered.
SECTION 2: SYMPOSIA 10 S e p t e m b e r 1995 Dealing with established drug resistance Kim, S.J. Korean Institute of Tuberculosis, Seoul ]37-140, Korea
Drug resistance of Mycobacterium tuberculosis is developed by permitting the selective growth of resistant mutants due to inappropriate and inadequate treatment by physicians lack of knowledge and by patients lack of compliance. No more influx of treatment failure cases into the patient pool as a result of improved cure rate is an exclusive way to reduce problem of drug resistant TB in the community. In Korea drug resistance was found in 20.1-30.6% of untreated patients and in 55.2-75.4% of
currently or previously treated patients in the nationwide TB prevalence surveys before 1985. Such high resistance, of course, has resulted from poor cure rate (41%) of NTP chemotherapy programme with drug regimens of SM/INH/PAS or EMB in 1970s. However the cure rate has been remarkably improved since introduction of the short course regimen into NTP in 1980s. In consequence both initial and acquired drug resistance remarkably decreased to 15.0% and 46.8% in 1990 survey. Further decrease was noticed in 1994 survey which was carried out as a part of the global drug resistance surveillance promoted by the WHO and IUATLD. Rigorous retreatment might also contributed to reduction of drug resistance in Korea.
Prevention of drug resistant tuberculosis Lambregts-van Weezenbeek, C.S.B. Royal Netherlands Tuberculosis Association, The Netherlands
The development of secondary drug resistant tuberculosis is caused by either direct or indirect monotherapy 1 and can thus be prevented. The necessity and quality of intervention depends on (a) the observed level of resistance and its origin (primary vs secondary, influence of migration) and (b) the outcome of the analysis of the treatment delivery process (TDP)? The description of the TDP is an essential tool for the management of an existing or the prevention of a future resistance problem. The TDP is the sum of 3 main processes: (i) drug prescription, (ii) drug supply from source to stock and (iii) drug supply from stock to patient. The involvement of the public health and private sector must be clarified for each of them. A detailed analysis of the TDP reveals possible causes of inadequate treatment. Often specific (and different) clusters of causes are observed in developed and developing countries, and intervention strategies vary accordingly. These clusters and intervention will be discussed. In low prevalence countries, even when resistance levels are low, it is useful to identify risk groups for both tuberculosis and resistance. In the Netherlands in 1993 809 bacteriologically confirmed cases were registered, of whom 16% were diagnosed by active case-finding. Among them 471 (58%) had a foreign nationality. Drug resistance was observed in 103 (13%) cases of whom 84 (81%) foreigners. Although the level of INH-resistance is low (5.3%; 1.8% in Dutch; 7.8% in foreigners) 2 the Dutch TDP should be analysed for weaknesses in order to prevent deterioration of the
Tubercleand LungDisease obal Lung Hea 9-12 Sepl
SECTION 1: PLENARY SESSIONS How can basic scientific research contribute to tuberculosis programlnes? Cole, S., Unit~ de G~ngtique Mol~culaire Bactdrienne, Institut Pasteur, Paris, France
Although the ultimate solution to tuberculosis as a global public health problem will stem predominantly from improvements in socio-economic conditions, the insight and technological advances resulting from basic biomedical research can accelerate the process. During the past two decades there has been an explosion of knowledge and understanding of infectious diseases which, in many cases, has led to better diagnostic tools, interventions and therapies. The same period has seen little, if any, improvement in the situation concerning tuberculosis as the effects of the AIDS pandemic, worldwide economic depression, insecure chug supply and multidrug resistance have made inroads into control programmes. Hence, there is greater need than ever not only to use available resources as efficiently as possible but also to be aware of the developments in the fields of molecular mycobacteriology, immunomodulation, drug development and resistance, so that precious opportunities should not be squandered.
SECTION 2: SYMPOSIA 10 S e p t e m b e r 1995 Dealing with established drug resistance Kim, S.J. Korean Institute of Tuberculosis, Seoul ]37-140, Korea
Drug resistance of Mycobacterium tuberculosis is developed by permitting the selective growth of resistant mutants due to inappropriate and inadequate treatment by physicians lack of knowledge and by patients lack of compliance. No more influx of treatment failure cases into the patient pool as a result of improved cure rate is an exclusive way to reduce problem of drug resistant TB in the community. In Korea drug resistance was found in 20.1-30.6% of untreated patients and in 55.2-75.4% of
currently or previously treated patients in the nationwide TB prevalence surveys before 1985. Such high resistance, of course, has resulted from poor cure rate (41%) of NTP chemotherapy programme with drug regimens of SM/INH/PAS or EMB in 1970s. However the cure rate has been remarkably improved since introduction of the short course regimen into NTP in 1980s. In consequence both initial and acquired drug resistance remarkably decreased to 15.0% and 46.8% in 1990 survey. Further decrease was noticed in 1994 survey which was carried out as a part of the global drug resistance surveillance promoted by the WHO and IUATLD. Rigorous retreatment might also contributed to reduction of drug resistance in Korea.
Prevention of drug resistant tuberculosis Lambregts-van Weezenbeek, C.S.B. Royal Netherlands Tuberculosis Association, The Netherlands
The development of secondary drug resistant tuberculosis is caused by either direct or indirect monotherapy 1 and can thus be prevented. The necessity and quality of intervention depends on (a) the observed level of resistance and its origin (primary vs secondary, influence of migration) and (b) the outcome of the analysis of the treatment delivery process (TDP)? The description of the TDP is an essential tool for the management of an existing or the prevention of a future resistance problem. The TDP is the sum of 3 main processes: (i) drug prescription, (ii) drug supply from source to stock and (iii) drug supply from stock to patient. The involvement of the public health and private sector must be clarified for each of them. A detailed analysis of the TDP reveals possible causes of inadequate treatment. Often specific (and different) clusters of causes are observed in developed and developing countries, and intervention strategies vary accordingly. These clusters and intervention will be discussed. In low prevalence countries, even when resistance levels are low, it is useful to identify risk groups for both tuberculosis and resistance. In the Netherlands in 1993 809 bacteriologically confirmed cases were registered, of whom 16% were diagnosed by active case-finding. Among them 471 (58%) had a foreign nationality. Drug resistance was observed in 103 (13%) cases of whom 84 (81%) foreigners. Although the level of INH-resistance is low (5.3%; 1.8% in Dutch; 7.8% in foreigners) 2 the Dutch TDP should be analysed for weaknesses in order to prevent deterioration of the