University College London, Centre for Clinical Microbiology, Division of Infection and Immunity, London, UK.
J Infect Dis. 2012 May 15;205 Suppl 2:S228-40. doi: 10.1093/infdis/jir858. Epub 2012 Apr 3.
Tuberculosis was declared a global emergency by the World Health Organization (WHO) in 1993. Following the declaration and the promotion in 1995 of directly observed treatment short course (DOTS), a cost-effective strategy to contain the tuberculosis epidemic, nearly 7 million lives have been saved compared with the pre-DOTS era, high cure rates have been achieved in most countries worldwide, and the global incidence of tuberculosis has been in a slow decline since the early 2000s. However, the emergence and spread of multidrug-resistant (MDR) tuberculosis, extensively drug-resistant (XDR) tuberculosis, and more recently, totally drug-resistant tuberculosis pose a threat to global tuberculosis control. Multidrug-resistant tuberculosis is a man-made problem. Laboratory facilities for drug susceptibility testing are inadequate in most tuberculosis-endemic countries, especially in Africa; thus diagnosis is missed, routine surveillance is not implemented, and the actual numbers of global drug-resistant tuberculosis cases have yet to be estimated. This exposes an ominous situation and reveals an urgent need for commitment by national programs to health system improvement because the response to MDR tuberculosis requires strong health services in general. Multidrug-resistant tuberculosis and XDR tuberculosis greatly complicate patient management within resource-poor national tuberculosis programs, reducing treatment efficacy and increasing the cost of treatment to the extent that it could bankrupt healthcare financing in tuberculosis-endemic areas. Why, despite nearly 20 years of WHO-promoted activity and >12 years of MDR tuberculosis-specific activity, has the country response to the drug-resistant tuberculosis epidemic been so ineffectual? The current dilemmas, unanswered questions, operational issues, challenges, and priority needs for global drug resistance screening and surveillance, improved treatment regimens, and management of outcomes and prevention of DR tuberculosis are discussed.
1993 年，世界卫生组织（WHO）宣布结核病为全球紧急情况。在宣布这一情况以及 1995 年推广直接观察治疗短期疗程（DOTS）之后，这是一种控制结核病流行的具有成本效益的策略，与 DOTS 前时代相比，近 700 万人的生命得以挽救，全球大多数国家都实现了高治愈率，自 21 世纪初以来，全球结核病发病率一直在缓慢下降。然而，耐多药结核病（MDR-TB）、广泛耐药结核病（XDR-TB）以及最近出现的完全耐药结核病的出现和传播对全球结核病控制构成了威胁。耐多药结核病是人为造成的问题。大多数结核病流行国家，特别是非洲国家，药物敏感性检测的实验室设施不足；因此，诊断被遗漏，常规监测没有实施，全球耐药结核病病例的实际数量尚未得到估计。这暴露了一个不祥的情况，并迫切需要国家卫生系统改善计划的承诺，因为对耐多药结核病的应对需要总体上有强大的卫生服务。耐多药结核病和广泛耐药结核病使资源匮乏的国家结核病规划中的患者管理变得非常复杂，降低了治疗效果，并增加了治疗成本，以至于结核病流行地区的医疗保健融资可能破产。为什么在 WHO 倡导近 20 年和针对耐多药结核病的专门活动 12 多年之后，对耐药结核病流行的国家应对措施仍然如此无效？本文讨论了全球耐药性筛查和监测、改进治疗方案以及管理结果和预防耐多药结核病方面的当前困境、未解决的问题、运营问题、挑战和优先需求。
