On most days, tuberculosis only crosses the average American’s awareness radar when he or she is watching Moulin Rouge! for the fifth time. Even then, the sight of the courtesan Satine (played by Nicole Kidman) coughing up blood after singing about diamonds gives the impression that TB is the problem of prostitutes living in elephants in 19th-century France. All of this changed in 2007, when Georgia lawyer Andrew Speaker snuck back into the U.S. through Canada after honeymooning in Europe – and being diagnosed with extensively-drug-resistant tuberculosis (XDR-TB).
As if regular TB were not bad enough, global health professionals are now grappling with the rising incidence of multi-drug-resistant (MDR-TB) and extensively-drug-resistant (XDR-TB) tuberculosis. MDR-TB is resistant at least to isoniazid and rifampicin, the two most powerful first-line antibiotics used to treat TB. It typically develops when patients being treated for fully sensitive TB stop their treatment course or do not follow it regularly (either because they feel better or forget to take their drugs, or because treatment supplies run out). When the treatment is interrupted before all of the bacteria are killed, the microbes develop resistance to the drugs. XDR-TB has all of this and more: it is also resistant to any fluoroquinolone and at least one of three injectable second-line drugs (capreomycin, kanamycin, and amikacin). If these drugs sound scary, it is because they are: most second-line drugs are less effective than isoniazid and rifampicin and can be moderately to highly toxic.
While the incidence of drug-resistant strains of TB is low for the moment, it is on the rise: a recent report by the WHO found that over two million people will contract some form of drug-resistant TB by 2015. The frequency of these infections is increasing fastest in India, China, and the former USSR. The WHO is asking countries to put their money where their mouths are and step up to fight the disease. “Commitments by some countries are too slow off the mark or simply stalled,” said Rifat Atun, director of strategy, performance and evaluation at the Global Fund. In the meantime, the greatest thing you’ll ever learn…is to finish your antibiotic course.