New Tools and Technologies: The Way Forward?

The marked increase in TB among HIV-infected persons and the expanding epidemic of multidrug-resistant TB (MDR-TB) threaten global control. Recent events in South Africa illustrate the public health emergency when these two threats collide – dramatic outbreaks of a lethal disease among a highly-susceptible population. Clearly, new tools are needed to regain control of TB. First, better diagnostic tests are needed. The sputum smear, the standard test to diagnose TB in high-burden countries, is insensitive. Drug resistance testing is not available in high-burden settings, meaning that most patients with MDR-TB die without a diagnosis or appropriate treatment. Lack of drug resistance testing in sub-Saharan Africa allowed an epidemic of MDR-TB to spread widely before its presence was detected. Second, new drugs are needed to treat both drug-resistant and drug-susceptible TB. Current therapy for MDR-TB has marginal activity, is toxic and requires tremendous resources to provide 2 years of daily therapy. Finally, a vaccine with greater efficacy than the BCG vaccine would greatly help regain TB control. After years of inactivity, there are now well-organized research efforts to improve TB diagnostics, drugs, and vaccines. A number of challenges remain: retaining industry involvement when the market is large but high-burden countries are poor, assuring the involvement of key subgroups of patients in research (children, patients with HIV and/or drug-resistant TB). With recognition of these barriers and creative efforts on the part of governments, non-governmental organizations and industry, major progress will be made to regain control of TB within the next decade.