On 2016 Jun 11, Madhavi Bhargava commented:

MDR-TB household contacts in 2016

Madhavi Bhargava, Dept of Community Medicine, Yenepoya Medical College, Yenepoya University, Mangaluru-575018, Karnataka, India

The opinion piece by David Moore (Moore DA, 2016) regarding multidrug resistant tuberculosis (MDR-TB) is a very important document for caregivers and policy makers alike. One cannot agree more with the author that pending the results of three drug trials until 2020 the alternative to preventive therapy is not to do nothing at all. There is indisputable scientific merit in registering MDR-TB contacts, screening them for active disease, drug-susceptibility testing in co-incident cases and follow-up of remaining MDR-exposed household contacts. The subsequent dilemma of deciding what, if more can be offered to the remaining MDR-exposed household contacts is what is discussed in this comment.

• Learning from the experiences in treating drug-sensitive tuberculosis (DS-TB) is last but not the least of the seven guiding principles of the policy brief of November 2015 (http://sentinel-project.org/wp-content/uploads/2015/11/Harvard-Policy-Brief_revised-10Nov2015.pdf). Contacts of MDR-TB cases are no different from contacts of DS-TB cases of pre-chemotherapy era. Which means that addressing the social determinants such as reduced stress, reduced intensity of TB exposure, proper housing and adequate food supply cannot be ignored (Bhargava A, 2012).

Moreover, the guidance on prevention of MDR-TB from World Health Organization (“(1) Early detection and high quality treatment of drug susceptible TB, (2) early detection and high quality treatment if drug resistant TB, (3) effective implementation of infection control measures, (4) strengthening and regulation of health systems. (5) Addressing underlying risk factors and social determinants)” needs careful consideration.

• Regarding effective implementation of infection control, one of the most cost-effective measures is airborne infection control (AIC) and cough-hygiene. In countries like India, AIC systems are found to be poorly developed and implemented (Parmar MM, 2015). Provision for safe sputum disposal and adequate patient education for the same at individual and family level, often gets neglected in chemotherapy centered approach in high-burden developing countries.This has obvious implications on the burden of MDR-TB in a country.

• Lastly, undernutrition which is often considered a social determinant, should be considered a biological risk factor of tuberculosis (resistant or sensitive) since it has definite influence on immune mechanism of an individual (Schaible UE, 2007). Nutritional support at family level can be added in the battery of interventions for household contacts of MDR-TB patients pending much desired definitive chemotherapeutic agents.

Conflict of interest: Author declares no conflict of interest

On 2016 Jun 11, Madhavi Bhargava commented:

MDR-TB household contacts in 2016

Madhavi Bhargava, Dept of Community Medicine, Yenepoya Medical College, Yenepoya University, Mangaluru-575018, Karnataka, India

The opinion piece by David Moore (Moore DA, 2016) regarding multidrug resistant tuberculosis (MDR-TB) is a very important document for caregivers and policy makers alike. One cannot agree more with the author that pending the results of three drug trials until 2020 the alternative to preventive therapy is not to do nothing at all. There is indisputable scientific merit in registering MDR-TB contacts, screening them for active disease, drug-susceptibility testing in co-incident cases and follow-up of remaining MDR-exposed household contacts. The subsequent dilemma of deciding what, if more can be offered to the remaining MDR-exposed household contacts is what is discussed in this comment.

• Learning from the experiences in treating drug-sensitive tuberculosis (DS-TB) is last but not the least of the seven guiding principles of the policy brief of November 2015 (http://sentinel-project.org/wp-content/uploads/2015/11/Harvard-Policy-Brief_revised-10Nov2015.pdf). Contacts of MDR-TB cases are no different from contacts of DS-TB cases of pre-chemotherapy era. Which means that addressing the social determinants such as reduced stress, reduced intensity of TB exposure, proper housing and adequate food supply cannot be ignored (Bhargava A, 2012).

Moreover, the guidance on prevention of MDR-TB from World Health Organization (“(1) Early detection and high quality treatment of drug susceptible TB, (2) early detection and high quality treatment if drug resistant TB, (3) effective implementation of infection control measures, (4) strengthening and regulation of health systems. (5) Addressing underlying risk factors and social determinants)” needs careful consideration.

• Regarding effective implementation of infection control, one of the most cost-effective measures is airborne infection control (AIC) and cough-hygiene. In countries like India, AIC systems are found to be poorly developed and implemented (Parmar MM, 2015). Provision for safe sputum disposal and adequate patient education for the same at individual and family level, often gets neglected in chemotherapy centered approach in high-burden developing countries.This has obvious implications on the burden of MDR-TB in a country.

• Lastly, undernutrition which is often considered a social determinant, should be considered a biological risk factor of tuberculosis (resistant or sensitive) since it has definite influence on immune mechanism of an individual (Schaible UE, 2007). Nutritional support at family level can be added in the battery of interventions for household contacts of MDR-TB patients pending much desired definitive chemotherapeutic agents.

Conflict of interest: Author declares no conflict of interest