Dr. Nils E Billo serves as executive director of the International Union against Tuberculosis and Lung Disease (The Union).

Some 440,000 cases of multidrug-resistant tuberculosis (MDR-TB) are identified each year, causing at least 150,000 deaths from a disease that should be curable. Extensively drug-resistant TB (XDR-TB), which has an even higher fatality rate, has now been reported in 69 countries. "Drug-resistant TB is the end result of a number of different failures, each of which, on its own, is solvable with existing tools. To address all of the issues and stop the spread of this disease requires a comprehensive, multi-pronged strategy, such as The Union has developed", says Dr Nils E Billo, Executive Director of the International Union Against Tuberculosis and Lung Disease (The Union).

The rising incidence of antimicrobial resistance will be the focus of this year's World Health Day, marked on Thursday, 7 April. The World Health Organization selected this theme to highlight the fact that many essential medicines are at risk of losing their effectiveness, due to inappropriate use, poor monitoring and other practices that jeopardise global advances against infectious disease. Tuberculosis is among the most dangerous diseases affected by this trend, according to The Union, which supports the WHO's emphasis on the problem.

When TB is misdiagnosed or the treatment is poorly managed, the doors open to drug resistance. Consequently training for people at every level of the health care system is central to The Union's approach. Each year courses are offered in high TB burden areas of Africa, Asia, Europe, Latin America and the Middle East designed to train clinicians and other health care workers about MDR-TB. The goal is for them not only to understand how to diagnose and treat the disease, but also how to put into place the practices that can prevent it from developing, such as improved infection control procedures and effective management of drug supplies.

Patients who do not correctly take the medicines required to complete their TB treatment are at high risk for developing drug-resistant tuberculosis and passing on these new strains of the disease to others. Strong programmes for case detection, diagnosis and patient monitoring are all critical to avoid this scenario. At the request of national tuberculosis programmes (NTPs), The Union's MDR-TB experts are helping them review plans, procedures, policies and systems and making suggestions for improvement. In recognition of the pivotal role of laboratories in diagnosing and monitoring drug-resistant strains of the disease, The Union has also helped develop an international network of TB reference laboratories.

Use of poor quality medicines and drug shortages are also leading causes of drug-resistant TB. If the quality of first-line TB drugs is not assured - or the supply is not adequate to meet the needs of those in treatment - patients will not be cured and may develop MDR-TB. They will then require treatment with the more expensive second-line drugs (SLD). The Union is regularly part of all discussions concerning TB medicines at the international level, and published a joint report with Médecins sans Frontières (MSF) on DR-TB medicines last month. The Union also works closely with NTPs to support them in the implementation of best practices for ordering, storing and distributing medicines, as well as to assure the quality of the medicines selected for national procurement and to monitor their quality.

Treating drug-resistant TB is much more expensive and can take up to two years - creating a strain on both patients and health systems. Through its operational research and clinical trials programmes, The Union continually seeks new solutions to issues of prevention, treatment and control. The STREAM study, part of the USAID-funded TREAT TB Initiative, will soon begin enrolling patients in an international clinical trial of a nine-month treatment regimen for MDR-TB that has been very successful in a smaller study. This new regimen holds the potential to revolutionise treatment for the disease.

"New miracle tools from faster diagnostic tests to TB vaccines are being sought", says Dr Billo, "and they may eventually address the issue of MDR-TB. But, in the meantime, it is absolutely essential to provide adequate funding for the well-trained staff, fully equipped health-care facilities and laboratories and quality-assured medicines that will allow us to take care of the patients who are sick today. These people can't wait for tomorrow's cures - and there is no reason they should have to." (CNS)