MDR TB –Great Human Concern Covering drug developement, dots, drugs used in treatment

1. Drug Resistant Tuberculosis A Great Human Concern Dr.T.V.Rao MD

2. MDR TB –Great Human Concern

4. A Tribute to Robert Koch Discoverer of Mycobacterium Tuberculosis

7. Nobody is absolutely Immune to Tuberculosis

9. Selman Abraham Waksman Nobel Prize for his discovery in 1952 .

13. Multi Drug Resistant Tuberculosis MDR-TB

15. MDR-TB & XDR-TB THE 2008 REPORT % of MDR-TB among new TB cases 1994-2007

17. Several Drugs becoming resistant

23. Global Estimates 16,000 27,000 XDR TB 1,16,000, 4,24,000 MDR TB 1.6 million 8.8 million All forms TB Estimated Number of Deaths Estimated Number of Cases Classification

25. Global incidence of tuberculosis Still rising as a result of the growing epidemic in Africa 0 100 200 300 400 500 600 1990 1995 2000 2005 2010 2015 Incidence per 100,000 per year World Cent. Euro, East. Europe Est Market East. Medit. Lat. America West. Pacific Sth East Asia AFR high HIV AFR low HIV

26. Are we Returning to a Pre-antibiotic Era Drug susceptible TB*§ MDR-TB 1990§ XDR-TB 2006§ Total DR ? Resistance to H&R – Treatable with 2 nd line drugs Resistance to 2 nd line drugs – Treatment options seriously restricted Resistance to all available drugs – No treatment options *or limited resistance manageable with 4 drug regimen - DOTS

27. WHO Surveillance and Incidence of MDR TB Dye et al. Global Burden of Multidrug-Resistant TB. JID 185(8), 2002 5.3 Ivory Cost 6.6 Dominican 5.8 Iran 3.4 India 6.0 Russia 2.8 China (DOTS) 7.7 China (non-DOTS) 9.0 Latvia 14.1 Estonia % MDR TB of all new cases Country

29. Strains with genetic drug resistance Wild M. TB strain Acquired drug resistance Primary drug resistance Spontaneous mutation Selection: inadequate treatment Transmission Development of anti-tuberculosis drug resistance Pablos-Mendez et al. WHO, 1997

34. Drug Susceptibility Testing

43. MODS M icroscopic O bservation of D rug Susceptibility T esting

54. Sample layout on MODS plate (2 samples per plate) No plate contained 2 samples from the same patient

57. In MODS growth is identified by cording on Microscopy

63. PCR: Molecular susceptibility testing RMP resistance INH resistance Hain Genotype MTBDR Hain Genotype MTBDR INNO-LiPA Rif.TB assay

68. Lower Grade Biosafety is adequate

69. N 95 mask protects from Biohazard

71. Computer pattern recognition of Mycobacterium tuberculosis in MODS culture

72. Automation in MODS

73. M . tuberculosis in MODS x10 objective (sputum sample inoculation ) Day 6 Day 16 Day 17 Day 7 Day 8 Day 9 Day 10 Day 11 Day 12 Day 13 Day 14 Day 15

74. MODS can be used in Extra pulmonary Tuberculosis

82. Microscopy and Culturing still a top priority

84. No testing method replaces clinical assessment

87. Czech Republic The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.  WHO 2005. All rights reserved Ecuador Georgia Argentina Bangladesh Germany Republic of Korea Armenia Russian Federation South Africa Portugal Latvia Mexico Peru USA Brazil UK Sweden Thailand Chile Based on information provided to WHO Stop TB Department 13 September 2007 Spain Islamic Republic of Iran China, Hong Kong SAR France Japan Norway Canada Italy Netherlands Estonia Lithuania Ireland Romania Israel Azerbaijan Poland Slovenia India Australia Mozambique Vietnam Countries with confirmed XDR-TB cases as of September 2007

91. Are there any solutions for effective Diagnosis in TB ?

92. Many more powerful hands needed to Control Tuberculosis

93. Contribute your Knowledge, Wisdom, to prevent spread and control of Tuberculosis

94. Created by Dr.T.V.Rao MD for ‘e’ learning Programme Email [email_address]