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Published ahead of print on March 27, 2008, doi:10.1164/rccm.200801-175PP

Am. J. Respir. Crit. Care Med., Volume 177, Number 12, June 2008, 1302-1306

A more recent version of this article appeared on June 15, 2008
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Submitted on January 29, 2008
Accepted on March 27, 2008

Challenges in Estimating the Total Burden of Drug Resistant Tuberculosis

Ted Cohen1*, Caroline Colijn2, Abigail Wright3, Matteo Zignol3, Alexander Pym4, and Megan Murray5

1 Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA, 2 Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA, 3 STOP TB Department, World Health Organization, Geneva, Switzerland, 4 Clinical and Biomedical TB Research Unit, South African MRC, Durban, South Africa, 5 Division of Social Medicine and Health Inequalities, Brigham and Women's Hospital, Boston, MA, USA; Department of Epidemiology, Harvard School of Public Health, Boston, MA, USA; Division of Infectious Diseases, Massachusetts General Hospital, Boston, MA, USA

* To whom correspondence should be addressed. E-mail: tcohen{at}hsph.harvard.edu.

The International Union Against Tuberculosis and Lung Disease/World Health Organization Global Project on Anti-Tuberculosis Drug Resistance Surveillance recently released the fourth global survey which documents the highest burden of multidrug resistant tuberculosis yet reported. The best estimate of the number of new cases of multidrug resistant disease occurring in 2006 is close to half a million and the recent recognition of extensively drug resistant tuberculosis underscores the need for expanded surveillance, especially in areas in which TB control programs have been compromised by an escalating burden of TB and HIV. We review current methods used for drug resistance surveillance and describe methodological obstacles for estimating the true extent of the problem, particularly in settings where HIV/TB coinfection is common or where a substantial portion of TB cases are treated in the private sector. We highlight practical challenges to the validity of surveillance studies and discuss how additional investment in laboratory capacity, diagnostic technologies, and sentinel site surveillance can improve our ability to estimate of the burden of drug resistant TB.
Key words: public health surveillance, drug resistance, epidemiology, bias (epidemiology), HIV






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