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XDR-TB: It's not only extensive, it's expensive
Costs could run as high as $1 million a case
Even though multidrug-resistant (MDR) and extensively drug resistant (XDR) TB are at extremely low levels in the United States, the cost of a single infection is staggering, Julie Gerberding, MD, MPH, director for the Centers for Disease Control and Prevention recently told Congress.
"While the total number of MDR and XDR-TB cases is relatively small, their impact on U.S. TB control programs can be significant in terms of human capital and financial resources," she said at a March 21, 2007, meeting of the Committee on Foreign Affairs Subcommittee on Africa and Global Health. "One patient with MDR or XDR-TB requires a minimum of 18-24 months of treatment. Recently collected data show that inpatient costs alone are $500,000 per case. The treatment of some individual cases has cost as much as $1 million. The cost of a potential resurgence, however, is far higher. In New York City alone, the estimated cost to control the MDR-TB epidemic of the late 1980s exceeded 1 billion dollars [in 1991-adjusted dollars]."
Noting that XDR-TB has been identified in 17 countries from all regions of the world, Gerberding said "the first line of defense to prevent importation of TB into the United States is the overseas medical screening of immigrants."
In sub-Saharan Africa, for example, TB rates have substantially increased over the past decade, which parallels the rising number of HIV/AIDS-immunocompromised patients, and makes it more difficult to diagnose and treat TB, she said. "More than 50 % of the people with TB in sub-Saharan Africa are HIV-infected," Gerberding said. "In countries with a high HIV burden, weak and underfunded TB Control Programs become strained by the influx of new TB patients. In most of these countries, the government does not regulate second-line drugs and they are not widely available."
However, XDR-TB also is a potentially dangerous problem even for countries with low HIV prevalence if they do not have adequate national TB programs, she added. The necessary conditions for programs to "grow" resistant TB occur where physicians routinely prescribe drug regimens were routinely prescribed without the benefit of drug susceptibility testing. Available data indicate the highest MDR-TB and XDR-TB prevalence occur in Eastern Europe and Asia in low-HIV-prevalence populations, she said.
"People in these countries who are treated effectively are cured of nonresistant TB, but if conditions exist in which MDR-TB is created, then the necessary widespread use of second-line drugs can rapidly foster development of XDR-TB as well," Gerberding said. "For example, an anesthesiologist in Russia developed MDR-TB after caring for a patient who had highly drug-resistant TB. She died soon after diagnosis, despite treatment with second-line TB drugs. As HIV spreads among these patients and other control conditions are not adequate, a country may face an outbreak of untreatable TB."
Gerberding said the CDC is working closely with other agencies to prevent TB globally through an action plan that includes the following measures: