MDR-TB Treatment & Prevention

Dear Masoud Dara,

Greetings to you and all.

The topic you raise is of great relevance, more so now with MDR emerging to
be a great threat in public health parlance.

I am working in the largest ART center in South Asia which (strangely) is in
one of the largest and oldest TB hospitals of India.

But i guess that is India for you and Dr. Thomas Frieden (Director, CDC) put
across (two weeks back when he was giving a lecture in the Tuberculosis
Research Center, Chennai) beautifully that the whole world is benefiting
from DOTS, all except India, where the concept was developed and that his
decade long work in TB in India was one of his toughest yet most fruitful
part of his professional life.

Sorry for drifting from the topic, but i just wanted to emphasize that even
though the Revised National TB Control Program is termed a success having
already achieved what they aimed for in 2015, there are remote areas i have
worked where RNTCP has not really reached and then there are specialists in
better areas questioning (and not without reasons) alternate day regimes and
other principles of DOTS.

These highly experienced people whose ...

Dear Masoud Dara,

Greetings to you and all.

The topic you raise is of great relevance, more so now with MDR emerging to
be a great threat in public health parlance.

I am working in the largest ART center in South Asia which (strangely) is in
one of the largest and oldest TB hospitals of India.

But i guess that is India for you and Dr. Thomas Frieden (Director, CDC) put
across (two weeks back when he was giving a lecture in the Tuberculosis
Research Center, Chennai) beautifully that the whole world is benefiting
from DOTS, all except India, where the concept was developed and that his
decade long work in TB in India was one of his toughest yet most fruitful
part of his professional life.

Sorry for drifting from the topic, but i just wanted to emphasize that even
though the Revised National TB Control Program is termed a success having
already achieved what they aimed for in 2015, there are remote areas i have
worked where RNTCP has not really reached and then there are specialists in
better areas questioning (and not without reasons) alternate day regimes and
other principles of DOTS.

These highly experienced people whose bread and butter has been treating TB
in government settings (so there is no ulterior motive and no answer backs
on most their reasonings....and, i am coming to the topic now), have
different regimes even for MDR TB. Although 6+12 was the most followed, what
i saw was different clinicians used 9+12, 6+18 etc, according to their
clinical jugdement.

But, i being into public health and HIV, an uniform guideline practiced
strictly would be welcome from my side, except maybe a few sporadic cases
here and there been not adhered to strictly due to the particular case
scenario (that too from an experienced chest physician). So, i welcome the
8+12 regime if it really seems to help in MDR TB (and pull the success to
above the 45-55% the present situation that it is in).

I do have serious doubt of the number of MDR TB cases reported in India
presently and there is a lot of work to be done, the first of which is to
project the true prevalence.

Thanks. Regards to all.

P.S. please correct me if i have gone wrong somewhere, i will be looking
forward to the discussions to follow.

It would be useful to learn from those who have extensive first hand experience with moxifloxacin,what the duration may be with the use of moxifloxacin?

Dear colleagues,
in Niger we're having a successful experience using a shortened regimen of 12 months based on a fourth generation quinolone as gatifloxacin (4 months of intensive phase).
The updated 2011 guidelines speak about it in the 4th chapter (Duration of second line anti-TB regimens - benefits) and now evidence is not limited to data of only one setting (Bangladesh).
I would like to report the news of a meeting we recently had in Cameroon about this regimen.

12-MONTH SHORT-COURSE REGIMEN FOR MDR-TB SHOWS EXCELLENT RESULTS IN AFRICA
Four francophone African countries recently shared their successful experience using a shortened regimen for treating patients with MDR-TB with representatives of other francophone countries at a Union workshop in Douala, Cameroon. This was the third MDR-TB workshop offered to provide training and an opportunity to exchange news about progress in managing MDR-TB.
After the 2008 workshop in Burkina Faso, Benin, Cameroon, Niger and Togo decided to treat their MDR patients with a short-course regimen similar to the one used in Bangladesh with excellent results (Van Deun et al. Am J Respir Crit Care Med. 2010 Sep 1;182(5):684-92). The only differences are that the regimen used in the African ...

Dear colleagues,
in Niger we're having a successful experience using a shortened regimen of 12 months based on a fourth generation quinolone as gatifloxacin (4 months of intensive phase).
The updated 2011 guidelines speak about it in the 4th chapter (Duration of second line anti-TB regimens - benefits) and now evidence is not limited to data of only one setting (Bangladesh).
I would like to report the news of a meeting we recently had in Cameroon about this regimen.

12-MONTH SHORT-COURSE REGIMEN FOR MDR-TB SHOWS EXCELLENT RESULTS IN AFRICA
Four francophone African countries recently shared their successful experience using a shortened regimen for treating patients with MDR-TB with representatives of other francophone countries at a Union workshop in Douala, Cameroon. This was the third MDR-TB workshop offered to provide training and an opportunity to exchange news about progress in managing MDR-TB.
After the 2008 workshop in Burkina Faso, Benin, Cameroon, Niger and Togo decided to treat their MDR patients with a short-course regimen similar to the one used in Bangladesh with excellent results (Van Deun et al. Am J Respir Crit Care Med. 2010 Sep 1;182(5):684-92). The only differences are that the regimen used in the African countries lasts 12 months instead of the 9 months, and it includes prothionamide throughout the continuation phase.
The treatment results the countries reported generated great interest: 90% "cured" among the 120 patients (20% HIV positive) who received the short-course regimen versus a 59% "success" rate among the 339 patients who received the long-course regimen (17% "cured", 42% "treatment completed"). No failures and no relapses have been reported so far for the short-course regimen.
These results are very encouraging, and the sputum culture conversion arrives very early, so the four countries are planning to reduce the total length of the MDR treatment to 9 months, as in Bangladesh. And, last but not least, so far the cost of the drugs for the short-course regimen is only 180€ (as opposed to more than 2,000€ for long regimen).
All of the countries present at the workshop were impressed with these results and are willing to test these short-course regimens. The 32 participants came from 10 different francophone countries of sub-Saharan Africa – Benin, Burkina Faso, Burundi, Cameroon, Côte d'Ivoire, Mali, Niger, DR Congo, Rwanda and Togo. Two observers from the World Health Organization in Geneva also attended.
Funding for this workshop and other French-language educational activities and resources was provided by the Agence Française de Développement (AFD)(www.theunion.org; newsroom)

Best regards
Alberto Piubello
National TB program advisor of Niger

Dear collegues, i'm working in Swaziland, where the prevalence for HIV is very high. It means around 70% of our DR TB patients are coinfected.
Two questions:
What is your opinion about "short treatment" in high HIV prevalence settings?
What is your experience/opinion about 5 days/week injection regimen, instead of daily?

Regards Natalia

Dear Natalia,
short treatment is applied in three low HIV prevalence setting as Bangladesh, Niger and Benin and in one intermediate setting as Cameroon (5,3%). I know that our colleagues in Cameroon found an HIV prevalence of 21% among MDR patients and their cure rate is 93%.
There are no data about short treatment in high HIV settings.
We're successfully treating our MDR patients with 6days/week regimen.
Best regards
Alberto