MDR-TB Treatment & Prevention

According to local DST pattern in my region of Russia 91 - 93% of new R resistant cases are H resistant (or actuallly have MDR TB). Taking into account that 22 - 30% of new cases in our settings are MDR TB, it seems highly cost effective to use Xpert MTB/Rif  for high probability TB suspects and all new TB cases (if SLD treatment is available) to accordingly separate patients and start 4th category treatment ASAP.
 
Would be interesting to have cost effectiveness study on thes topic.

Dr. Grigory V. Volchenkov

Head Doctor
Vladimir Oblast TB Dispansery

Sudogodskoe shosse, 63
Vladimir 600023 RUSSIA

There are many countries in the world where initial Rif-resistance result is almost always equal to MDR . There, it definitely makes a lot of sense not to waste time before starting appropriate treatment. At the same time, there is number of places where DR-TB is a rare event and one may be more cautious prescribing SLD regimen right away. It is important to say that these decisions are prerogative of countries having analysed their particular situation and striking right balance between cost-effectiveness vs. public health impact and patients' survival.
While considering these one shouldn't discard the following facts:
- the SLD treatment is effective not only against DR-TB but also against susceptible TB with a certain disadvantage of being more costly and causing more adverse effects;
- regimens for someone with MDR-TB and the one suffering from Rif-resistance only are not drastically different
- prescribing SLD treatment after Rif-res result is a temporary decision pending further and more final decision based on the results of the full DST triggered by Rif-res result.

If all recommended steps are done properly and DST is available promptly the disadvantage of the SLD regimen prescribed when it wasn't necessary will be minimised.
Let me also ...

There are many countries in the world where initial Rif-resistance result is almost always equal to MDR . There, it definitely makes a lot of sense not to waste time before starting appropriate treatment. At the same time, there is number of places where DR-TB is a rare event and one may be more cautious prescribing SLD regimen right away. It is important to say that these decisions are prerogative of countries having analysed their particular situation and striking right balance between cost-effectiveness vs. public health impact and patients' survival.
While considering these one shouldn't discard the following facts:
- the SLD treatment is effective not only against DR-TB but also against susceptible TB with a certain disadvantage of being more costly and causing more adverse effects;
- regimens for someone with MDR-TB and the one suffering from Rif-resistance only are not drastically different
- prescribing SLD treatment after Rif-res result is a temporary decision pending further and more final decision based on the results of the full DST triggered by Rif-res result.

If all recommended steps are done properly and DST is available promptly the disadvantage of the SLD regimen prescribed when it wasn't necessary will be minimised.
Let me also add that in the list of publications on Xpert MTB/RIF assay maintained on our website there are 7 studies focusing on cost-effectiveness. You can find them here: http://www.stoptb.org/wg/gli/assets/documents/map/XpertPublications.pdf