MSF Crisis Alert:
The new face of an old disease: urgent actionneeded to tackle global drug-resistant TB threat

March 2014

Executive summary: Global drug-resistant TB crisis demands massmobilisation and new treatments
Tuberculosis is one of the gravest publichealth threats facing the world today, and is
all the more serious as drug resistance takes a
grip.

people swallowing well over 10,000 pills and having
eight months of painful injections, with potentiallyhorrific and long-lasting side effects.
As the numbers mount, developing countries faceinsurmountable drug costs, exacerbated by the long
periods of care and management of side effects. It isperhaps little wonder that, with the high costs andthe inadequate treatment, DR-TB care is so
minimally available worldwide. Meanwhile thecritical gap between the numbers of suspected DR-TB
cases and those successfully treated leaves theairborne killer to spread indiscriminately.

Tuberculosis (TB) is a curable disease, but an
inadequate global response has allowed the growing
epidemic of drug-resistant tuberculosis (DR-TB) totake hold. Drug-resistant forms of TB are muchharder to cure: standard TB drugs don’t work, anddoctors must turn to long, arduous, complex and
expensive treatment regimens that only cure half thepatients at best.

“

The DR-TB crisis is everybody’s problem anddemands an immediate international response. Eachyear we are diagnosing more patients with DR-TB,
but the current treatments aren’t good enough tomake a dent in the epidemic. It doesn’t matter where
you live; until new short and more effective
treatment combinations are found, the odds ofsurviving this disease today are dismal.

DR-TB originally developed because of improper useof anti-TB medicines, and now these deadlier DR-TB
strains are spreading from person to person, even to
people who’ve never had TB before. Today there arenearly half a million new cases of multidrug-resistant
TB a year, with drug-resistant forms of TB reported
in virtually all countries worldwide.

Sidney Wong,
MSF medical director

Tuberculosis and drug-resistant forms of TB
One-third of the world’s population, around two
billion people, is infected with the TB bacterium
but does not have active TB disease. This is often
referred to as dormant or ‘latent’ TB. About 10%of these people develop the active form of thedisease during their lifetime and become sick andpotentially infectious. Every year, around eight
million people worldwide fall ill from TB, and 1.3
million people die from the disease.1 TB isairborne and contagious, and now new forms
which cannot be cured with standard TB
treatments are appearing at an alarming rate. The
most widely reported strain is multidrug-resistant
TB (MDR-TB), which is resistant to the two mostpowerful anti-TB drugs. Extensively drugresistant TB (XDR-TB) is even harder to treat.

”

New short, safe and effective treatment combinations
are key to unlocking the global DR-TB crisis, andtoday there is reason for hope. The first new TB
drugs in 50 years, along with developments indiagnostic tests and new approaches to care, havereal potential to radically improve patient outcomes.
Yet no single drug can combat this disease, andmerely adding new drugs to today’s regimens won’t
solve the problems of complexity, toxicity, length andcost.
Unfortunately, patients remain years from getting thecures they desperately need unless governments,
pharmaceutical companies and researchers quickly
mobilise the necessary resources and political will.
Collaborative research is urgently needed to findmuch improved treatment combinations that are fit
for purpose, reasonably priced and able to be rolled
out rapidly in resource-limited settings. In themeantime, increased efforts must be made to
diagnose and treat more people with DR-TB today tosave lives and slow the spread of this virulent disease.

As new tools for diagnosing MDR-TB rapidly become
more widely used, more and more people are being
diagnosed, but only one in five people who need it
can obtain treatment. And no matter where you livein the world, the only treatments available entail

11. Drug-resistant TB: a global giant of a public health threat“

Every death from TB is avoidable. Every death from TB is not due to a medical reason. Forget for a second
about the technical nitty-gritty detail of tissue necrosis and compromised gas-exchange. In this modern age, alldeaths from TB boil down to a lack of commitment from the international political community and thepharmaceutical industry to address this disease.

Emily Wise,MSF TB doctor, UK”

blogs.msf.org/emilyw/2013/05/the-darkest-hour/“

Mycobacterium tuberculosis (TB) is infamous for manyreasons, not least as the biggest infectious killer of all
time. Dating as far back as Ancient Egyptian times, thedisease is present in most countries worldwide. For
some, the spectre of TB may seem relegated to the past,enshrined in nineteenth century books and plays. For
many others, however, the disease is all too alive,
wreaking havoc in their bodies, their families and theircommunities. No matter how you view it, one thing isincontestable:

The problem is not in the future, it is here and now.
Drug-resistant TB is too widespread and, in many
places, too big of a problem to sit back and resignedly
wait for a solution. It is quite simply one of the foremost
public health threats the world faces today.

”

Grania Brigden,
MSF Access Campaign

MSF has treated people with TB around the world forthe past 30 years – from chronic conflict zones inSomalia and South Sudan, to high-burden TB countries
like Myanmar and Uzbekistan. In 2012, working closelywith national TB programmes in many countries, MSF
started 25,000 people on TB treatment in around 91
projects worldwide.

TB is one of the gravest public health threatsfacing the world today, and is all the more
serious as drug resistance takes a grip.
There are an estimated 450,000 new cases a year of
multidrug-resistant tuberculosis (MDR-TB) reported in
virtually all countries surveyed by the World HealthOrganization worldwide, and with extensively drugresistant tuberculosis (XDR-TB) reported in 92
countries.2

Our staff are witness to the breadth of the TB crisis as its
spans the globe, and in recent years to the growing
severity of DR-TB. In 2012, MSF treated 1,794 DR-TB
patients, around 1,500 of whom had MDR-TB.
As the result of the roll-out of a new rapid diagnostic
tool in MSF projects, we are diagnosing more and more
people. At the same time, we are also finding growing
numbers of people with XDR-TB.

Yet, many experts consider this estimate conservative
due to the limited availability of DR-TB diagnosis.
Without a proper diagnosis, conventional TB treatment
fails, which in turn allows drug resistance to develop.

““In countries where MSF works – like Armenia,
Uzbekistan, India, Myanmar, South Africa, Swaziland,
Ukraine and Lesotho – the number of people testing
positive for MDR-TB and XDR-TB is staggering. The
more MSF looks for DR-TB, the more we find it, alongwith a growing number of people presenting with DRTB for the first time, indicating the direct spread ofresistant forms from person to person.

Once diagnosed, patients face a gruelling course oftreatment. The current regimen recommended by theWorld Health Organization for treating MDR-TB3 takes
two years, including eight months of painful daily
injections and swallowing up to 20 tablets a day. These
medications are associated with horrible side effects,
ranging from debilitating nausea and skin rashes tomore serious side effects such as permanent deafness,
renal failure and psychosis, which in some cases have
driven patients to commit suicide. Even if a patient cantolerate all this, there is no guarantee of a cure, with
global figures showing cure rates of around 48%4 – inother words one in two people survive. This number is alot lower in many places, where the quality of care andthe availability of resources are lesser.

Bern-Thomas Nyang'wa,
HIV/TB specialist, MSF UK”

In parts of eastern Europe and central Asia, such as
Belarus and Kazakhstan, around one in three new TB
patients are testing positive for drug-resistance,suggesting they were directly infected by someone elsewith a resistant form of the disease. MSF sees a similar
proportion of first-time DR-TB patients at its project inArmenia, while in MSF’s project in Uzbekistan we find
MDR-TB in up to 40% of patients who have never had
TB treatment before.

On top of that, each course of therapy costs healthproviders around US$4,000 per patient,5 plus the
additional costs of long periods of care and managementof side effects.

2

In India, where MSF provides TB
care in Mumbai, Manipur,
Nagaland and Chhattisgarh, we
see different DR-TB epidemics,
the most startling of which is in
the megacity of Mumbai, where
60% of people live in slums.
Across the country, MSF is
diagnosing more and more DRTB among new cases, especiallyamong HIV-infected patients.

“

Alarmingly, the patterns ofresistance we find in Mumbai
are increasingly extensive; morethan half of the MDR-TB
patients have resistance tofluoroquinolones, one of the mostpotent drugs currently available
for DR-TB. And as access to full
diagnosis is extremely limited,
the great majority of patientsremain undiagnosed or wrongly
diagnosed and remain either
untreated or put on
inappropriate treatment
regimens, thus fuelling theepidemic and worsening thesituation.

”

As the number of people presenting with DR-TB in
MSF’s projects grows, our staff are embracing new andpatient-friendly approaches to save the lives of as many
people as possible. Yet, in spite of these best efforts, wehave not been able to achieve higher than 54% curerates for MDR-TB, and far lower for XDR-TB.

Petros Isaakidis,
MSF epidemiologist,
Mumbai, India
In southern Africa, where countries have some of thehighest rates of new TB cases per capita worldwide,
the HIV epidemic is exacerbating the spread andvirulence of DR-TB. With compromised immune
systems, people living with HIV are up to 34 times
more likely to develop active TB than those who are
HIV-negative. TB remains a leading killer of HIVpositive people globally. In MSF's projects in
Swaziland, 200 patients were diagnosed with DR-TB
and began treatment in 2013, 85% of whom were coinfected with HIV. DR-TB cases accounted for 8% of
the total number of TB cases diagnosed.

As the DR-TB crisis becomes ever more pressing,
doctors worldwide are struggling to provide even themost limited response exactly when it is needed themost. This leaves a critical gap between the numbers ofsuspected cases and those successfully treated, allowing
the disease to spread relatively unchecked.

“

Anyone can get TB. You don’t know whose healthis in what condition; you don’t know who is sick, who
is not sick, who’s faithful to their medication andwho’s not. TB is just in the air. Whether you’re pooror rich you can’t stop it. There’s no way you can stopit.

This is no longer a choice; the problem of DR-TB is
staring us in the face. People are filling our clinics andthat number will only grow as rapid diagnosis isfurther rolled out. Medical providers need to do
everything possible to save the lives of people with DRTB today and prevent it spreading further. However,
it is clear that the current treatment will not allow us
tackle the scale of this problem. We desperately need
new far shorter and more effective regimens to scale
the mountain of DR-TB we see now.

Genenikele,
XDR-TB patient, Swaziland, since died of XDR-TB

Francis Varaine,
Head of MSF’s TB International Working Group

“

”

”

3

Jezza Neumann, True VisionChildren with DR-TB

Nokubegha and her elder brother. Nokubegha’s
mother died of DR-TB shortly before she wasdiagnosed with the disease, Swaziland

The needs of children with DR-TB continue to beparticularly neglected. Current methods of confirming thediagnosis of TB in children – who have difficulty coughing
up phlegm – are invasive and still end up missing mostcases. Research is urgently needed into methods that use
samples that are easier to collect (like urine, blood orstools). So too are better treatment options; with nopaediatric formulations available for DR-TB drugs,
children have to take adult pills which have been crushed
or split and then subdivided, with the risk of receiving thewrong dose. During treatment, children with DR-TB canfind themselves confined to adult hospital wards formonths at a time, far from their families, schools andother children.

However, it is possible to care for children morehumanely. In Tajikistan, MSF has been running a TB
programme for children since 2011. Hospital treatment –which can stunt children’s development and put enormous strains on the whole family – is avoided. Instead
they receive support from health staff and counsellors in their own homes, which makes the long course oftreatment easier to take. Once the children are out of the infectious phase, our staff help them get back tonormal life as soon as possible by educating their schools that it is safe for them to be back in the classroom.

“

What needs to change is that we should get better medicine so we can make all the people in thehospitals better.

”

Nokubegha, Swaziland

2. Patients and staff around the world call for urgent change
MSF’s commitment to push for better treatment
regimens for DR-TB has been driven by the insights
gained from patients into just how tough the current
treatment regimen is, as well as by our staff who strive
to save these people’s lives against the odds.

Since 2011, DR-TB patients have been sharing theirexperiences more widely through the TB&ME patient
blog, read by 140,000 people each year. Now patientsthemselves are calling for improved care and treatment
with the DR-TB Manifesto, a public petition demanding
urgent improvements to DR-TB care worldwide, which
has garnered global support.

TB&ME
In their own words, TB patients from Australia to Zimbabwe recounttheir experiences of living with the disease and the issues that affecttheir lives, describing frankly the lows and highs of treatment, fromdiscovering they have the disease, through side effects, relapses andstigma, to finally being cured. Currently there are 22 patients blogging
from 13 countries. Find TB&ME at blogs.msf.org/tb“

We keep on preaching that this infection is curable, and yes it is,but how many deaths should occur for our government to startputting a foot down and say NO to the infection and the re-infections
that occur in hospitals.

”

Xolelwa Joni, cured XDR-TB patient, South Africa.
blogs.msf.org/ tb/2014/02/ continuation-of-the-fight-against-normalmdr-and-xdr-tb/

4Lucky, UK“You may be wondering what makes me feel lucky? It’s the feelingthat I am alive and going to be with my family. If I flashback, thefeeling wasn’t the same. When I was admitted to the hospital, it was
the most dreadful day of my life. I had to leave my son who was four
years old and I was shattered. I packed my bag with all the basics,
like toothpaste and brush, and I still remember the moment my son
asked me, ‘mummy – where are we going, shall I get my bag?’ How
would I live without him? But finally the moment arrived and I left him behind in the car of
one of my husband’s friends. We reached the hospital and I was taken to the room, whichappeared just like a dungeon with one small window. The nurse came in wearing a mask andasked my husband to leave. I felt like I was deserted and with no hope.”

Gibson, Zimbabwe“A tree goes throughdifferent seasons andis affected by various
weather patterns.
Some trees had scars –just like the ones I
have on my heart – leftby the pain of being
abandoned by mymother. In life we see
similar situations
where people say hurtful things to us or about
us that scar us. In the community scores ofpeople say cruel, wounding things about people
receiving HIV or TB treatment. However someof these trees with scars also have fruits, lovely
flowers and bright green leaves. This supports
me and encourages me as it is an indicationthat just because one has been hurt in the pastby people’s words or actions, one can overcome
these obstacles and go on to live a beautiful,fruitful successful life.”

Countries where
MSF treats
TB
DR-TB

Zolelwa Sifumba, South Africa“Everything was going well for me and I was getting closer andcloser to my dream [of finishing my medical studies and qualifying
as a doctor], then TB got a hold of me. I could not believe it, parts ofme still can’t believe that this is what has happened to me and this is
who I am. I am one of the unfortunate students that got sick whileworking at the hospitals… I was told by other people that have had
MDR-TB that the depression was something that they struggled withtoo. So this was the treatment’s doing. Not the disease it was
treating but the treatment itself. MDR-TB almost took my life. The
sadness that came as a result of it almost took my life.”

5

Hosyat, Uzbekistan“I was in hospital for two weeks. I made new friends. There were somepatients who were on different periods of treatment among them. Talking
to them kept my spirits up. Everybody needs somebody. I forgot mypersonal and family problems. One day I went out for a walk in the street
with one girl who is the same age as me. We sang a Karakalpak
traditional song as loud as we could. I felt so relieved afterwards as if
something inside me had gone out. This song, which we sang together
where there was nobody to hear us, had brought us great joy.”

Ko Min Naing Oo, Myanmar“TB first came into my life in June 2000
and kept coming back over the next 13
years, getting harder and harder for the
doctors to treat it. I took many different
kinds of pills and injections over theyears, but nothing seemed to get thedisease out of my body for good. It kept
coming back, stronger than before. My
health kept going up and down and it
was really difficult. Finally I begantreatment for DR-TB.”

Christiaan, AKA the Fully Sick Rapper, Australia“The more that people share their own stories of TB, the more
quickly it will become accepted, then more conversations will
happen around it, and it will be more likely that governments
will open their eyes. The more people hear about thewidespread health problems being caused, the more likely
funding will be moved towards solving the problem! And
that’s good for everyone!”6

“Test Me, Treat Me” DR-TB Manifesto campaign launchedbattling the disease, supported by MSF staff, family
and friends. During this time, Phumeza and Jennifer
agreed to write a manifesto calling for better DR-TB
care worldwide. Plans are underway to have Phumeza
and Jenny present the DR-TB Manifesto this May at
the World Health Assembly, where the future of the
global TB response and care will be under discussion.
Sign now at: www.msfaccess.org/TBmanifesto/“
The DR-TB Manifesto brings together the voicesof patients, health staff and communities aroundthe world, and calls for urgent improvements to
DR-TB care worldwide.
The manifesto was born out of the experience offormer patient Phumeza Tisle and her doctor,
Jennifer Hughes, from South Africa. Phumeza, 24,
was diagnosed with MDR-TB in 2010. It was only
after she’d gone deaf from the treatment that she
discovered she had XDR-TB. She spent four years

Just a year ago I wrote the DR-TB manifesto, withthe help of doctors and fellow TB patients. It simply
states the demands that are needed: for one thecurrent TB drugs are a nightmare… perhaps we needto involve politicians? Perhaps summon people whoare highly respected, the likes of presidents? Maybethen those pleas and demands suddenly then will bethings getting done… I’ll be excited the day where
there will be ONE drug for DR-TB, non toxic, and the
day where there will be zero TB deaths. Now that day
I will call it, HAPPY WORLD TB DAY!!

”

Phumeza Tisile,
cured XDR-TB patient, South Africa
blogs.msf.org/tb/2014/02/approaching-world-tb-day

3. New ways of tackling DR-TB
However, the rapid diagnosis test is not perfect: itneeds electricity to run, so is unsuitable for off-gridrural health centres; it only detects resistance to asingle drug out of those most commonly used to treat
TB; and it still does not meet the needs of diagnosing
TB in children. A rapid point-of-care test, much likethat used for malaria, is still much needed.

Over the years, MSF has learned many lessons
tackling TB and is committed to continually
improving patient care. In our clinics we champion
new approaches, including integrated HIV/TB care,
rapid diagnosis, home-based care and counselling,working closely with national TB programmes. We
document the results and implement research toprovide evidence with which to advocate for betterand more accessible patient care.

We are always looking for ways of making treatment
easier for patients and therefore less likely to quit
their medication before the full course is over. The
ways we do this in our projects vary according to thecontext and patients’ needs, but generally involve
integrating HIV and TB services, and providing
outpatient care, delivered at patients’ homes orwithin the community, to avoid unnecessary or longstays in hospital. Patients benefit from the support offamily and friends, backed up by counsellors and bypeer support groups, while remaining a part of theircommunities and in many cases being able to work or
continue their education during treatment.

Rapid diagnosis, a test that can detect resistance torifampicin – one of the most common anti-TB drugs– within two hours, has made it far easier to identify
MDR-TB. MSF is rolling out the test as quickly as
possible. The sooner people receive the correct
treatment, the better their chance of cure and thesooner they cease to be infectious. Today, thisremains the best form of prevention, until aneffective vaccine can be found. The current available
vaccine, Bacillus Calmette Guerin (BCG), has only
limited effect.

To learn more about innovative ways to tackle DR-TB today, see Treating drug-resistant TB:
What does it take?
www.msf.org.uk/sites/uk/files/attachments/treating_dr_tb_low_res.pdf

7

4. New treatment regimens are key to turning the DR-TB crisis aroundAt the end of 2012, the first new TB drugs in nearly
half a century caused a surge of excitement. In 2012
and 2013, bedaquiline and then delamanid gained
conditional approval from the US Federal Drug
Agency and the European Medicines Agency to treat
the most severe forms of DR-TB. Along with a small
number of other new TB compounds in the final
stages of development, this signalled new hope for TB
treatment.

MSF, together with other leaders in the fieldof TB, has devised eight key principles fordesigning a future DR-TB regimen. It should:
1. contain at least one new class of drug (iethat combats the disease in a new way)
2. be applicable for use against MDR-TB and
XDR-TB
3. contain three to five effective drugs, eachfrom a different drug class

No single drug, however, will cure TB. If new drugs are
merely added to the current MDR-TB regimen, theresulting course of treatment will remain lengthy,
cumbersome and toxic. What is urgently needed is a
new combination of drugs that is shorter, moretolerable and capable of being implemented rapidly incountries where DR-TB is rife, containing medicinesthat TB has not had a chance to develop resistance to.
Developing a new regimen is a priority to ensure thatthe new drugs are used to their maximum potential.

4. be in the form of pills, to be taken orally,rather than injections
5. have a simple dosing schedule
6. have few side effects which require limited
monitoring
7. have a maximum duration of six months
8. have minimal interaction with antiretroviraldrugs for treating HIV

Today, however, a new drug regimen is a distant
dream, as traditionally run clinical trials are years fromfinding an answer, and none, as yet, are combining thetwo newest and most promising drugs. There is anurgent need for research into new treatment regimens,
designed to work best for patients in the lower to
middle-income countries where they are most needed.
A radical re-think into how new TB drug regimens aredeveloped and tested is necessary to achieve this end assafely and swiftly as possible. An important first step
will be to determine the compatibility of the new drugs.

With the TB bacteria’s tendency to rapidly develop
resistance, a robust pipeline of new drugs is needed.
Right now the options are limited and the pipelinerisks running dry. Overall, TB research anddevelopment is chronically underfunded – only 30%of the necessary funding is available today. MSF, withothers, is looking at ways of re-defining the way TB
research and development is conducted and funded
so as to meet urgent medical priorities, rather thanbeing driven by profit. www.msfaccess. org/pushpull-pool-who-tb-demo-project“

If it were at all possible for those who make thepills to come up with drugs with a shorter period oftreatment, then she would have held on and finished
her treatment and survived.

“”

I feel sorry that, in this era of globalisation, we
still use old, old drugs and we cannot eliminate
TB.

Gogo, whose daughter died of DR-TB and whose son
is now infected with the disease, Swaziland”

Jezza Neumann, True Vision

Erkin Chanasylova,
MSF doctor, Swaziland
Many patients, however, don’t have the luxury oftime to await a new regimen, especially those withXDR-TB and those who are virtually untreatable. For
these people, “compassionate use” programmes
utilise the new drugs on patients for whom all othertreatment has failed, giving them their only chance ofsurvival. In Armenia, where MSF is running its firstcompassionate use programme using bedaquiline,
patients and staff are enthused by the prospect of
having new treatment options. MSF is now looking
forward to initiating its second compassionate use
programme using delamanid.

8

“In Armenia, before 2013, there were notreatment options for those failing MDR-TB
treatment. That means a patient fails and ends up
on the streets or in a palliative care centre or athome, waiting to die. But that has changed with thecompassionate use programme.

suitable in places where people may be displaced
from their homes due to conflict or other crises, andso may not have consistent access to medical care.
However, the nine-month regimen uses the same
drugs as current treatments so can only be a stopgap
solution while better treatments are being developed.

Saiful Qayyum,
MSF medical coordinator in Armenia“”

Every day patients ask our staff why the treatment
is so long, with so many drugs, so painful, with somany side effects. Because of this, while waiting for
new drugs, in January 2014 MSF started treatment
with a short-course DR-TB regimen which lasts nine to
12 months. Though an improvement in time, the side
effects of the drugs used for this regimen continue tocause problems for the patients. People showenormous resilience in taking the toxic and painful
treatment; however there is an urgent need for shorterand better treatment.

Until a new and effective treatment regimen is found,a potential interim solution for certain countries
could be the ‘short course regimen for MDR-TB’,
trialled on patients in Bangladesh in 2010.6 This
study showed promising results for this nine-month
regimen as compared to the two-year regimen. MSF
is currently trialling this in Swaziland andUzbekistan, and looks forward to reporting on the
results in the near future. MSF is also implementing
it in Chad, South Sudan and Democratic Republic ofCongo, as the shorter treatment period is more”

Kees Keus,
MSF medical coordinator, Swaziland

9

MDR-TB patient, Swaziland. Sven Torfinn

5. No time to lose: act now to curb the TB time bomb“

upon governments, donors, pharmaceuticalcompanies and researchers to mobilise urgently:

I feel like tuberculosis at present is like a timebomb. And it will blast at any time.
Samsuddin Khan,
MSF TB doctor, Mumbai, India”■ High-burden TB countries must lead the fightagainst DR-TB: ensuring the political will andfunding necessary to save more lives today and lay
the foundations for new treatment regimens;
facilitating the registration of new drugs,
implementing compassionate use programmes, andsupporting research into new treatment
combinations.

Immediate action is required to save more
lives today and prevent a far worse
emergency tomorrow.
MSF’s work treating DR-TB shows that lives can besaved now, assisted by rapid diagnosis, by new
approaches to care, and – for those with no otherhope – by compassionate use programmes. There is adesperate need for increased efforts to diagnose andtreat DR-TB cases; governments and theinternational community have a responsibility toscale up existing programmes to close the yawning
treatment gap that currently allows the disease to
spread unhindered.

■ Donor governments must make it a priority todrive forward TB programmes and research andprovide the necessary support and funding. The
majority of international funding comes through the
Global Fund to fight AIDS, TB and Malaria (GFATM),
which must set ambitious targets to support national
programmes to increase care and to implement themost effective new approaches.

At the same time, it is clear that current treatments
are failing patients and impeding medical
programmes from increasing care to meet the scaleand severity of the DR-TB crisis. The numbers ofpeople affected are simply too big, and the current
treatments too impractical and too costly.

■ Pharmaceutical companies and researchers must
speed up efforts to find better treatment
combinations through innovation and collaboration,
making the most of new drugs. Treatments must be
made affordable and accessible to middle and lowerincome countries where they are most urgently
needed.

A NEW, SHORT, TOLERABLE, MUCH LESSTOXIC, MORE EFFECTIVE AND
AFFORDABLE TREATMENT REGIMEN IS
KEY TO TURNING THE DR-TB CRISISAROUND.

“Let us accept the fact we are faced with a TB
epidemic. We need to get together and fight for oursurvival so that there can be a future for the next
generation. Because if we give up the fight now, thechildren are finished.

”

Patients, medical staff and communities around theworld are demanding this, and MSF, with decades oftackling TB, is convinced of it. To this end, MSF calls

Gogo, whose daughter died of DR-TB and whose son
is now infected with the disease, Swaziland

10

To learn more about what
can be done to tackle the DRTB crisis see ‘The Final
Frontier: Treating drugresistant TB’ Policy Film http://www.msf.org.uk/
final-frontier-treating-drugresistant-tb

How many pills does it take...

You have a role too! Each andevery individual can raiseawareness of this issue anddemand that those responsible
for guarding national andinternational public health are
doing all they can to tackle DRTB. You can show your support
by signing our DR-TB
Manifesto, to be presented to
the World Health Assembly in
May 2014, at www.msfaccess.
org/TBmanifesto/

Notes
1 TB factsheet 104, World Health Organization,
March 2014. Available at:www.who.int/mediacentre/factsheets/fs104/en/
2 MDR-TB factsheet, World Health Organization,
October 2013. Available at:www.who.int/tb/challenges/mdr/mdr_tb_factsheet.pdf?ua=1
3 Principles for designing future regimens for
multidrug-resistant tuberculosis, World Heath
Organization bulletin, March 2013. Available at:www.who.int/bulletin/volumes/92/1/13122028/en/
4 MDR-TB factsheet, World Health Organization,
October 2013. Available at:www.who.int/tb/challenges/mdr/mdr_tb_factsheet.pdf?ua=1
5 DRTB drugs under the microscope, MSF AccessCampaign and International Union Against
Tuberculosis and Lung Disease, 3rd edition,
October 2013. Available at:www.msf.org.br/arquivos/Doc/Publicacoes/msf_tb_report_utm3rdedition-2013.pdf
6 Known as the ‘Van Deun study’. Available at:www.ncbi.nlm.nih.gov/pubmed/20442432

Front cover photo: Jezza Neumann, True Vision.
Design/artwork: Sue Grant 01848 200331....
TOTAL PILL COUNT: 14,600