Fighting Multidrug-resistant Tuberculosis

Tuberculosis (TB) is a major global public health concern, especially in low-and middle-income countries. An infectious disease, TB, has plagued humankind for centuries, causing immense suffering and claiming millions of lives. Medical science has developed a cure for this infection; however, TB remains a formidable global public health challenge. 

In 2024, 1.23 million people died of tuberculosis, including 150,000 among people with HIV (WHO, 2026). Although there has been a treatment for tuberculosis, millions of people die of TB each year. The most alarming fact is the emergence of multidrug-resistant tuberculosis (MDR-TB). MDR-TB is a form of TB that does not respond to the first-line anti-TB drugs. It has posed a challenge to medical science and is also a social, economic, and policy crisis that demands urgent and immediate attention. 

Man-made problem

Basically, MDR-TB is a man-made problem. The emergence of MDR-TB is mainly due to incomplete treatment, improper use of antibiotics, misdiagnosis, and poor patient compliance to long and difficult treatment regimens. Oftentimes, patients stop taking medications after a few weeks of treatment when they start feeling better. In many settings, there is a lack of a consistent supply of quality medicines. In resource-constrained settings, the health system often struggles to ensure continuity of care. Therefore, MDR-TB is both a biological phenomenon and a health system failure. 

The burden of MDR-TB across the globe is not equally distributed. According to the World Health Organisation, thousands of new cases of MDR-TB are reported annually worldwide, and a significant proportion of those cases are from South Asia. Owing to its geographical challenges and limited healthcare infrastructure, Nepal remains vulnerable. People who are at risk are rural populations, migrant workers, and marginalised communities. A strong social stigma is attached to TB that often discourages patients from seeking early diagnosis and treatment. 

The treatment of MDR-TB involves an extended treatment period with antibiotics. The treatment often lasts 18-24 months in comparison to 6 months for drug-sensitive TB. Antibiotics used for the treatment of MDR-TB are more toxic, less effective, and more expensive. Antibiotics used for the treatment of MDR-TB frequently result in severe side effects such as hearing loss, kidney damage, and psychological distress. Hence, compliance becomes poor, which creates a vicious cycle of incomplete treatment and chances of further resistance. 

Just like drug-sensitive TB, MDR-TB spreads from person to person through the air when an infected person coughs or sneezes. Therefore, bacteria causing MDR-TB pose a serious threat as resistant bacteria can be directly transmitted from person to person, not just the resistant trait acquired during the treatment of drug-sensitive TB. The risk of transmission is particularly high in densely populated urban areas, and overcrowding, poor ventilation, and lack of awareness further contribute to the rapid spread of the disease. 

The gap still remains in the field of early diagnosis. Advanced diagnostic tools such as GeneXpert have significantly improved the detection of drug-resistant TB. However, access to these technologies is often limited to urban health centres, and many health facilities in remote parts of the country still rely on old diagnostic methods that cannot detect drug resistance promptly. Delay in diagnosis leads to delay in treatment, which increases the risk of complications as well as further spread. 

Besides medical implications, MDR-TB has profound economic implications. Treatment costs are substantially higher in comparison to drug-sensitive TB, placing a heavy burden on patients and the healthcare system. People who are from economically disadvantaged backgrounds suffer more as prolonged illness causes loss of income, and the family may fall into the vicious cycle of poverty. 

Addressing the issue of MDR-TB is also complex and requires a comprehensive and multi-sectoral approach involving many stakeholders. The most important thing is to strengthen the basic TB control programme targeted to early diagnosis, standardised treatment, and effective follow-up. These efforts can break the chain of transmission and prevent the emergence of drug resistance. 

Another important aspect is improving patient education and community awareness. In containing the emergence of MDR-TB, people need to understand the importance of completing the full course of the treatment. Large-scale public health campaigns should be conducted to reduce stigma and encourage people to engage in early health-seeking behaviour. In our country, Female Community Health Volunteers (FCHVs) should be mobilised to bridge the gap between healthcare providers and patients. 

It is also critical to invest in healthcare infrastructure. Access to modern diagnostic tools should be increased. Similarly, ensuring an uninterrupted supply of quality medicines and training of healthcare professionals are equally important. Integrating TB services with other health programmes, such as HIV care, helps increase efficiency and improve patient recovery. 

National agenda 

Strong political commitment and multi-sector involvement are essential to fight the challenge due to MDR-TB. The government must prioritise TB control as a national agenda by allocating sufficient funds and coordinating with other non-government and international organisations to fight the rapid emergence of MDR-TB. Social determinants of health, such as poverty, malnutrition, overcrowding, and low levels of awareness, all contribute to the emergence and spread of MDR-TB. Hence, it is important to address these aspects through policies to ensure effective TB control. 

In conclusion, MDR-TB results from biological as well as complex social determinants of health. The fight against MDR-TB requires sustained commitment, improved healthcare systems, and coordinated collective action. Hence, with a collective and coordinated approach, we can contain the spread of MDR-TB and move towards a TB-free world. 

(Dr. Lohani is the clinical director at the Nepal Poison Information Centre. lohanis@gmail.com)