National Academy of Medicine

A High School Outbreak of Multidrug-Resistant or Extensively Drug-Resistant Tuberculosis: Is Your Local Health Department Ready?

By Randall Reves
April 12, 2013 | Commentary

The obvious answer of “no” to the question of readiness is not just due to the ongoing loss of experienced staff. Loss of infrastructure is bad enough, but even an well-staffed health department needs safe and effective treatment tools when more than 100 high school students become infected with Mycobacterium tuberculosis following exposure to an infected student and/or staff member at school. There are no drugs known to be safe and effective for children infected with multidrug-resistant (MDR) tuberculosis.

The failure to fully implement the 1989 plan to eliminate tuberculosis in the United States has left local health departments poorly prepared to deal with the Myco-bacterium tuberculosis strains resistant to at least isoniazid and rifampin.  MDR strains account for 310,000 of the 8.7 million cases of tuberculosis globally with about 28,000 of those being extensively drug-resistant (XDR).  A key recommendation from the tuberculosis elimination plan in 1989 was to “rapidly develop and implement new tools for the diagnosis and treatment of tuberculosis and tuberculosis infection.”  Instead of benefiting from the implementation of new safe and effective short-course regimens for active tuberculosis, including drug-resistant strains, health departments still use the four-drug regimen for drug-susceptible tuberculosis that became the standard for the United States in 1993.  This regimen, developed after more than 40 years of clinical research, was rendered useless for the hundreds of cases of MDR tuberculosis in U.S. cities in the 1980s and 1990s. For treating MDR cases, physicians reverted to old, 18- to 24-month regimens, with the addition of off-label use of fluoroquinolones in the 1990s. These are the same regimens your local health department uses today.

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Disclaimer: The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.