MDR-, XDR-TB Treatment Should Emphasize Community Care, Not Confinement, Opinion Piece Says

Although many tuberculosis experts advise that people with multi-drug resistant TB or extensively drug-resistant TB be "quarantined," in high-burden countries the "costly hospitalization and isolation of these patients has often backfired," reporter Eliza Barclay writes in a Slate opinion piece. According to Barclay, "locking up XDR patients in virtual prisons" has not controlled the spread of TB, because "desperate patients, many of whom are breadwinners and parents, break out to see their families, putting their loved ones and communities at risk." She continues that many health workers have reported "similar difficulties in forcing MDR-TB patients to quit work, stay out of public places and adhere to the physically taxing treatment regimen."

Barclay writes that two recent studies have demonstrated that community-care models could be more effective at controlling MDR- and XDR-TB than forced isolation. For one study -- published in August 2008 in the New England Journal of Medicine -- researchers led by Carole Mitnick at the Department of Social Medicine at Harvard Medical School found that implementing comprehensive community-based care among MDR- and XDR-TB patients in Lima, Peru, achieved a 60% treatment success rate. Barclay writes that community health workers, who "supervised the patients' adherence to the drug regimen and were able to help patients get immediate medical care when necessary," were "[c]rucial" to the program's success. For the second study, published in October 2008 in the journal Lancet, researchers found that a care model similar to Mitnick's achieved a 48% treatment success rate among XDR-TB patients and a 67% treatment success rate among MDR-TB patients in Siberia. This "ambulatory" approach "allowed patients a degree of freedom to live their lives while also receiving personal attention," she writes.

According to Barclay, Mitnick has said that the cost of keeping TB patients under guarded isolation could be better spent on providing additional drugs, monitoring treatment adherence, and providing social and economic support. She writes that the World Health Organization, which was "previously mum on the issue of community-based TB care," has added a community component to its Stop TB Strategy and released a report containing guidelines on community involvement in TB prevention and care. Barclay concludes that this shift "is wise, because there's no way" that countries can meet the "ambitious" United Nations Millennium Development Goals target of reducing TB prevalence and mortality by 50% by 2015 if drug-resistant TB patients are treated "exclusively in prison-like hospitals that make patients want to escape" (Barclay, Slate, 1/13).