TUBERCULOSIS

CONTENTS

Preface ix
Neil W. Schluger

Global Epidemiology of Tuberculosis 167

Dermot Maher and Mario Raviglione
This article provides an overview of the current scale of the global tuberculosis epidemic.
It describes the global tuberculosis situation as measured by reported and estimated cases
and deaths. The increasing threats of HIV-related tuberculosis and drug-resistant tubercu-
losis receive particular attention. There is a brief review of the extent of implementation of
effective tuberculosis control using the directly observed treatment, short-course (DOTS)
strategy. The article ends with a summary of the approaches needed to accelerate progress
in global tuberculosis control.

Epidemiology of Tuberculosis in the United States 183

Eileen Schneider, Marisa Moore, and Kenneth G. Castro
After decades of decline, an unprecedented resurgence in tuberculosis occurred in the
late 1980s and early 1990s. Deterioration of tuberculosis program infrastructure, the
HIV/AIDS epidemic, drug-resistant tuberculosis, and tuberculosis among foreign-
born persons contributed to the resurgence. Since then, tuberculosis case numbers have
declined, but the decline in 2003 was the smallest since the resurgence. Key challenges
remain, and efforts must focus on identifying and targeting interventions for high-risk
populations, active involvement in the global effort against tuberculosis, developing new
tools, and maintaining adequate resources.

The DOTS Strategy for Controlling the Global Tuberculosis Epidemic 197
Thomas R. Frieden and Sonal S. Munsiff
This article reviews the principles, scientific basis, and experience with implementation
of the directly observed treatment, short-course (DOTS) strategy for tuberculosis. The rel-
evance of DOTS in the context of multidrug-resistant tuberculosis and the HIV epidemic
also is discussed.

The Origin and Evolution of Mycobacterium tuberculosis 207

Serge Mostowy and Marcel A. Behr
This article introduces the tools and terminology used for the classification of specific
isolates of the Mycobacterium tuberculosis complex (MTC). The utility of these tools and

VOLUME 26 • NUMBER 2 • JUNE 2005 v

 terminology is illustrated by discussing work from independent laboratories that have
established a genome-based phylogeny for the MTC. It considers the use of these mark-
ers to distinguish atypical isolates not conforming to attributes of traditional MTC
members. Finally, it discusses the current genomic evidence regarding the origin and
evolution of M. tuberculosis in the context of its relevance for tuberculosis control in
humans and other mammalian hosts.

Molecular Epidemiology: A Tool for Understanding Control of

Tuberculosis Transmission 217
Charles L. Daley
One of the primary goals of tuberculosis control programs is to interrupt the trans-
mission of Mycobacterium tuberculosis. The development of several genotyping tools
has allowed tracking of strains of M. tuberculosis as they spread through communities.
Studies that have combined the use of genotyping with conventional epidemiologic
investigation have increased the understanding of the transmission and pathogenesis of
tuberculosis. This article reviews some of the lessons learned using these new epidemi-
ologic tools.

Genetic Susceptibility to Tuberculosis 233

Richard Bellamy
Host genetic factors are important in determining susceptibility and resistance to
Mycobacterium tuberculosis. The etiology of tuberculosis is complex, and several host genes
have been shown to contribute to the development of clinical disease. The success of the
strategies used to investigate host genetic susceptibility to mycobacterial infections can
serve as a model for the investigation of host susceptibility to other infectious diseases.

The Diagnosis of Tuberculosis 247

Daniel Brodie and Neil W. Schluger
Diagnostic testing for tuberculosis has remained unchanged for nearly a century, but
newer technologies hold the promise of a true revolution in tuberculosis diagnostics.
New tests may well supplant the tuberculin skin test in diagnosing latent tuberculosis
infection in much of the world. Tests such as the nucleic acid amplification assays allow
more rapid and accurate diagnosing of pulmonary and extrapulmonary tuberculosis.
The appropriate and affordable use of any of these tests depends on the setting in which
they are employed.

Treatment of Active Tuberculosis: Challenges and Prospects 273

Behzad Sahbazian and Stephen E. Weis
This article reviews the basic principles of drug treatment of tuberculosis, individual
pharmacologic agents, current treatment recommendations, and several special situa-
tions that clinicians are likely to encounter in medical practice.

Issues in the Management of HIV-Related Tuberculosis 283

William J. Burman
This article focuses on the ways in which HIV infection and the associated immunodefi-
ciency affect the management of active tuberculosis. Controversies in the management of
HIV-related tuberculosis can be grouped into issues about tuberculosis treatment itself and

vi CONTENTS
 issues posed by the use of combination antiretroviral therapy. The author reviews these con-
troversies and makes recommendations for the management of HIV-related tuberculosis.

Tuberculosis in Children 295

Kristina Feja and Lisa Saiman
The epidemiology of pediatric tuberculosis (TB) is shaped by risk factors such as age, race,
immigration, poverty, overcrowding, and HIV/AIDS. Once infected, young children are
at increased risk of TB disease and progression to extrapulmonary disease. Primary dis-
ease and its complications are more common in children than in adults, leading to differ-
ences in clinical and radiographic manifestations. Difficulties in diagnosing children stem
from the low yield of mycobacteriology cultures and the subsequent reliance on clinical
case definitions. Inadequately treated TB infection and TB disease in children today is the
future source of disease in adults.

Treatment of Latent Tuberculosis Infection: Challenges and Prospects 313

Kelly E. Dooley and Timothy R. Sterling
This article reviews the treatment of latent tuberculosis infection in HIV-seropositive and
HIV-seronegative persons.

New Drugs for Tuberculosis: Current Status and Future Prospects 327
Richard J. O’Brien and Mel Spigelman
This article reviews two classes of compounds that have advanced into phase II and III
clinical trials, long-acting rifamycins and fluoroquinolones, and a number of other drugs
that have entered or may enter clinical development in the near future.

The Global Alliance for Tuberculosis Drug Development—Accomplishments

and Future Directions 341
Charles A. Gardner, Tara Acharya, and Ariel Pablos-Méndez
The Global Alliance for Tuberculosis Drug Development (TB Alliance) aims to stop the
spread of tuberculosis by developing new, faster-acting, and affordable tuberculosis
drugs. The TB Alliance is a public–private partnership, a not-for-profit enterprise, that
draws upon the resources of both private and public institutions to help address this
urgent health need. This article summarizes some of the achievements of the TB Alliance
to date and outlines potential future directions.

Index 349

CONTENTS vii
 Clin Chest Med 26 (2005) 349 – 353

Index

Note: Page numbers of article titles are in boldface type.

A tuberculosis in, 295 – 312

Age diagnosis of
as factor in tuberculosis, 186 smear for acid-fast bacilli and
mycobacterial culture, 306
Aminoglycoside(s) epidemiology of, 295 – 297
for active tuberculosis, 277 extrapulmonary, 300 – 302
Amplification in newborns, 302 – 303
phage latent
in pulmonary tuberculosis diagnosis, clinical and radiographic manifestations of,
261 – 262 299 – 303
diagnosis of, 303 – 306
Antimycobacterial agents infectious, 299
for active tuberculosis, 274 – 277 risk factors for, 297 – 298
treatment of, 306 – 309
Antiretroviral therapy pathogenesis of, 298 – 299
with tuberculosis treatment prevalence of, 295
challenges of, 286 – 292 public health aspects of, 309 – 310
pulmonary, 299 – 300
tuberculous disease, 299

B Culture(s)
Bacille Calmette-Guerin vaccination in pulmonary tuberculosis diagnosis,
effect on tuberculin skin test, 306 257 – 258

Bronchoscopy
fiberoptic D
in pulmonary tuberculosis diagnosis, Diarylquinolones (R207910)
256 – 257 for tuberculosis, 333
Dihydroimidazo-oxazoles (OPC-67683)
for tuberculosis, 335
C 1,25-Dihydroxyvitamin D3
Chemotherapy in genetic susceptibility to tuberculosis, 238
for active tuberculosis
axioms of, 273 – 274 Directly observed treatment, short-course
standardized short-course (DOTS) strategy
in DOTS strategy for controlling global for controlling global tuberculosis epidemic,
tuberculosis epidemic, 198 – 199 197 – 205
administrative commitment to, 197
Children drug quality in, 199
latent Mycobacterium tuberculosis infection in for multi-drug resistant TB, 200 – 201
treatment of, 322 HIV infection and, 201 – 202

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350 INDEX

political commitment to, 197 Global Alliance for Tuberculosis Drug Development,
results of, 200 341 – 347
sputum microscopy of patients attending described, 341 – 342
health facilities, 198 future directions for, 346
standardized short-course chemotherapy, global product development public – private
198 – 199 partnerships, 346
systemic monitoring and strategy of, 342 – 345
accountability, 200 Global product development public – private
DOTS. See Directly observed treatment, short-course partnerships
(DOTS) strategy. in Global Alliance for Tuberculosis Drug
Development, 345 – 346
Drug(s)
for tuberculosis, 327 – 340
new agents. See also specific drug and H
Tuberculosis, treatment of, drugs in. HIV. See Human immunodeficiency virus
tuberculosis resistant to, 175 – 176 (HIV) infection.
Drug resistance HLA-DR2
in pulmonary tuberculosis diagnosis in genetic susceptibility to tuberculosis, 238
rapid detection of, 261 – 262
tuberculosis effects of Human immunodeficiency virus (HIV) infection
transmission- and pathogenesis-related, 222 tuberculosis and. See Tuberculosis, HIV-related.

I
E Interferon gamma signaling pathway
Ethambutol in genetic susceptibility to tuberculosis, 237 – 238
for active tuberculosis, 276 Isoniazid
Ethnicity for active tuberculosis, 275
as factor in tuberculosis, 186 for latent Mycobacterium tuberculosis infection,
316 – 319
rifampin with
for latent Mycobacterium tuberculosis
F infection, 320 – 321
Fiberoptic bronchoscopy
in pulmonary tuberculosis diagnosis, 256 – 257
L
Fingerprinting patterns Large-sequence polymorphisms
in Mycobacterium tuberculosis complex in Mycobacterium tuberculosis complex study, 210
study, 208
Line probe assays
Fluoroquinolones in pulmonary tuberculosis diagnosis, 261
for active tuberculosis, 276 – 277
LL3858
for tuberculosis, 335
Luciferase reporter phages
G in pulmonary tuberculosis diagnosis, 262
Genetic susceptibility
to tuberculosis, 233 – 246. See also Tuberculosis,
genetic susceptibility to. M
Macrolide(s)
Genome(s)
for tuberculosis, 335 – 336
sequenced
in Mycobacterium tuberculosis complex Mannan-binding lectin (MBL)
study, 208 in genetic susceptibility to tuberculosis, 238
 INDEX 351

MBL. See Mannan-binding lectin (MBL). Newborn(s)

tuberculosis in, 302 – 303
Molecular beacons
in pulmonary tuberculosis diagnosis, 261 Nitroimidazopyran(s) (PA-824)
for tuberculosis, 333 – 335
Moxifloxacin
for tuberculosis, 331 – 333 Nucleic acid amplification assays
in pulmonary tuberculosis diagnosis, 258 – 260
Mycobacterium tuberculosis
dissemination of, 226
geographic distribution of, 226
origin and evolution of, 207 – 216 O
OPC-67683
Mycobacterium tuberculosis complex
for tuberculosis, 335
characteristics of, 207
deletions from, 212 – 214 Oxazolidinones
genetic resources in study of, 207 – 210 for tuberculosis
fingerprinting patterns, 208
large-sequence polymorphisms, 210
sequenced genomes, 208 P
single-nucleotide polymorphisms, 208 – 210
PA-284
origin and evolution of
for tuberculosis, 333 – 335
chronologic, 211 – 212
ecologic, 211 – 212 Phage(s)
genomic deletions and, 210 – 211 lucifer reporter
geographic, 211 – 212 in pulmonary tuberculosis diagnosis, 262
Mycobacterium tuberculosis infection Phage amplification
latent in pulmonary tuberculosis diagnosis, 261 – 262
diagnosis of, 223
Polymorphism(s)
treatment of, 313 – 326
large-sequence
challenges of, 322 – 323
in Mycobacterium tuberculosis complex
difficulties with, 322 – 323
study, 210
implementation-related issues in, 323
single-nucleotide
importance of, 314
in Mycobacterium tuberculosis complex study,
in children, 322
208 – 210
in contacts of persons with drug-resistant
tuberculosis, 322 Pyrazinamide
in special situations, 322 for active tuberculosis, 277
indications for, 313 – 314 rifampin with
isoniazid in, 316 – 319 for latent Mycobacterium tuberculosis
with rifampin, 320 – 320 infection, 319 – 320
monitoring for toxicity in, 323
Pyrrole (LL3858)
prospects for improvements in, 323
regimens in, 314 – 316 for tuberculosis, 335
rifampin in, 321
with pyrazinamide, 319 – 320
TNF-a antagonists and, 322 R
treatment completion rates in, 322 – 323 R207910
treatment initiation problems in, 322 for tuberculosis, 333
Race
N as factor in tuberculosis, 186
National tuberculosis surveillance system, 184
Rifampin
Natural resistance – associated macrophage protein for latent Mycobacterium tuberculosis
in genetic susceptibility to tuberculosis, 235 – 237 infection, 321
352 INDEX

isoniazid with control of, 214

for latent Mycobacterium tuberculosis diagnosis of, 247 – 271
infection, 320 – 321 rapid detection of drug resistance in, 261 – 262
pyrazinamide with drug-resistant, 175 – 176
for latent Mycobacterium tuberculosis contacts of persons with
infection, 319 – 320 latent Mycobacterium tuberculosis
infection treatment in, 322
Rifamycins
in U.S.
for active tuberculosis, 275 – 276
epidemiology of, 189 – 190
Rifapentine genetic susceptibility to, 233 – 246
for tuberculosis, 328 – 331 1,25-dihydroxyvitamin D3 and, 238
HLA-DR2 and, 238
host genetics in, 234 – 235
identification of, 235
S interferon gamma signaling pathway and,
237 – 238
Single-nucleotide polymorphisms
MBL and, 238
in Mycobacterium tuberculosis complex study,
natural resistance – associated macrophage
208 – 210
protein and, 235 – 237
Sputum global epidemic of
in pulmonary tuberculosis diagnosis, 255 – 256 control of
acceleration in progress of, 179 – 180
SQ109
DOTS strategy in, 197 – 205. See also
for tuberculosis, 336 – 338
Directly observed treatment, short-
course (DOTS) strategy, for controlling
global tuberculosis epidemic.
status of, 178 – 179
T deaths due to, 170 – 171, 175
TNF-a antagonists. See Tumor necrosis factor-a epidemiology of, 167 – 182
(TNF-a) antagonists. new cases, 176 – 178
Tuberculin skin test prevalence of, 170 – 171, 172 – 174
review of, 167 – 178
bacille Calmette-Guerin vaccination effects
HIV-related, 171 – 172, 190 – 191
on, 306
DOTS strategy in control of, 201 – 202
in active tuberculosis diagnosis, 255
treatment of
in latent tuberculosis diagnosis, 248 – 251
adherence to, 287
in latent tuberculosis in children, 305 – 306
antiretroviral therapy with, 286 – 292
Tuberculosis drug – drug interactions in, 288
active immune reconstitution inflammatory events
diagnosis of in, 289 – 290
tests in, 254 – 255 issues in, 283 – 294
treatment of, 273 – 282 optimal duration of therapy in, 284 – 286
aminoglycosides in, 277 overlapping adverse event profiles in,
antimycobacterial agents in 287 – 288
pharmacology and toxicity of, 274 – 277 recommendations in, 286, 292
chemotherapy in in children, 295 – 312. See also Children,
axioms of, 273 – 274 tuberculosis in.
ethambutol in, 276 in U.S.
fluoroquinolones in, 276 – 277 elimination of, 192
guidelines in, 277 – 280 epidemiology of, 183 – 195
in special situations, 279 – 280 age and, 186
isoniazid in, 275 foreign-born persons and, 186 – 189
pyrazinamide in, 277 historical background of, 183 – 184
rifamycins in, 275 – 276 post-resurgence, 185 – 192
 INDEX 353

race/ethnicity factors, 186 treatment of

resurgence, 184 – 185 diarylquinolones (R207910) in, 333
latent dihydroimidazo-oxazoles (OPC-67683)
diagnosis of in, 335
beyond tuberculin skin test in, 251 – 254 drug development for, 328
tests in, 248 – 254 Global Alliance for, 341 – 347. See also
tuberculin skin test in, 248 – 251 Global Alliance for Tuberculosis
multi-drug resistant Drug Development.
global epidemic of drug(s) in
control of new, 327 – 340
DOTS strategy in, 200 – 201 pipeline of, 333 – 338
new tools for, 191 – 192 macrolides in, 335 – 336
pathogenesis of moxifloxacin in, 331 – 333
drug resistance effects on, 222 nitroimidazopyrans (PA-284) in, 333 – 335
lessons learned regarding, 219 – 226 oxazolidinones in, 336
pulmonary pyrrole (LL3858) in, 335
diagnosis of rifapentine in, 328 – 331
cultures in, 257 – 258 SQ109 in, 336 – 338
fiberoptic bronchoscopy in, 256 – 257 widely spaced intermittent, 328 – 331
line probe assays in, 261
Tuberculosis control program
luciferase reporter phages in, 262
performance of
methods in, 255 – 260
measurement of, 224 – 226
molecular beacons in, 261
nucleic acid amplification assays in, 258–260 Tuberculosis disease
phage amplification in, 261 – 262 case definitions of, 303 – 305
sputum in, 255 – 256
Tuberculosis infection
tuberculin skin test in, 255
in children, 299 – 300 latent
transmission of treatment of, 313 – 326. See also
community epidemiology and, 224 Mycobacterium tuberculosis infection,
contact investigations, 222 – 223 latent, treatment of.
control of Tuberculosis/HIV coinfection, 190 – 191
genotyping methods in, 217 – 219
Tumor necrosis factor-a (TNF-a) antagonists
molecular epidemiology and, 217 – 231
future of, 226 latent Mycobacterium tuberculosis infection
drug resistance effects on, 222 treatment and, 322
exogenous reinfection and, 220 – 222
infectiousness of patients and, 219 – 220
lessons learned regarding, 219 – 226 V
mixed infection and, 220 – 222 Vaccination(s)
outbreak investigations, 222 – 223 bacille Calmette-Guerin
risk factors for clustering in, 224 effect on tuberculin skin test, 306
 Clin Chest Med 26 (2005) 183 – 195

Epidemiology of Tuberculosis in the United States

Eileen Schneider, MD, MPHa,*, Marisa Moore, MD, MPHa,b,
Kenneth G. Castro, MDa
a
Division of Tuberculosis and Elimination, Centers for Disease Control and Prevention, 1600 Clifton Road, MS E-10,
Atlanta, GA 30333, USA
b
TB Control Program, San Diego County Health and Human Services, Department of Public Health Services,
3851 Rosecrans Street, MS P511D, San Diego, CA 92110, USA

Historical background
The epidemiology of tuberculosis (TB) in the
United States has changed remarkably over the last
2 centuries. In the nineteenth century, TB was the
leading cause of death. As the nineteenth century prog-
ressed, TB mortality decreased, partly because of
improved socioeconomic conditions [1,2], especially
in urban settings, and partly owing to the natural
behavior of epidemics [3]. After the tubercle bacillus
was identified as the causative agent of TB by Robert
Koch in 1882, the approach to TB control changed
greatly, and the concepts of public health, prevention,
and segregation of TB patients gained more accep-
tance. As a result, in industrialized countries, the
prescribed treatment of rest, isolation, nutrition, and
fresh air for TB patients was achieved with long stays
in sanatoria [1,2].
By the late 1800s, TB was more than ever con-
sidered a public health issue, even though there were
few well established local or state public health
departments [1,2,4]. More resources became avail-
able, and public health programs dedicated to TB con-
trol were established. In 1904, the first voluntary
health agency dedicated to TB, the National Tuber-
culosis Association (now the American Lung Asso-
ciation), was organized [1,5]. TB surveillance and
This work was funded by the Division of Tuberculosis
and Elimination, Centers for Disease Control and Prevention.
* Corresponding author.
E-mail address: ees2@cdc.gov (E. Schneider).
data collection was a priority for the National Tu-
berculosis Association. As the mortality rate con-
tinued to decrease, attention focused on TB case
finding. Armed with a new diagnostic tool, the chest
roentgenogram, mass chest radiograph screenings
were conducted beginning in the early 1930s and
continuing into the 1950s, enabling the diagnosis of
TB patients before they became symptomatic [2].
The need to expand data collection to include TB
morbidity in addition to TB mortality was acknowl-
edged [1,2]. Reliable and complete morbidity data
would allow TB experts to measure more accurately
the magnitude of the TB problem and the effec-
tiveness of control efforts. In 1920, the National Tu-
berculosis Association published its first Diagnostic
Standards and Classifications of TB to assist health
care providers and standardize diagnostic criteria
[5,6]. National TB mortality and morbidity data,
coordinated by the National Tuberculosis Associa-
tion, became available in 1933. In 1944, a United
States Public Health Service Act mandated the crea-
tion of a national TB control program [1]. With
the introduction of the therapeutic agents streptomy-
cin (1947), p-aminosalicylic acid (1949), isoniazid
(1952), and pyrazinamide (1952) TB mortality rates
decreased dramatically. Between 1930 and 1960, the
mortality rate decreased by 92%, from 71 to 6 deaths
per 100,000 population.
Because of the widespread use of chemotherapy,
long hospitalizations for TB were no longer needed,
and TB sanatoria and hospitals began to close [1,2,5].
Having a standard definition for a reportable case of
TB for surveillance purposes became paramount [7],

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184 schneider et al
and in 1951, a committee consisting of state TB con-
trol officers and sanatoria directors published recom-
mendations for TB case reporting and counting
procedures [8]. In 1952, the United States Public
Health Service (USPHS) Tuberculosis Control Pro-
gram instituted procedures to report new cases of
TB. Not until 1953, through the cooperation of the
states, did the USPHS receive reports from the entire
United States, heralding the birth of the national TB
surveillance system [1,2].
National tuberculosis surveillance system
Since 1953, the national TB surveillance system
has been modified several times to monitor and re-
spond better to changes in TB morbidity. Data are
collected on TB cases that have been verified and
have met the Centers for Disease Control and Pre-
vention (CDC) public health surveillance case defi-
nition for TB [9,10]. TB is a reportable disease in
each state [11]. In 1985, the national TB surveillance
system changed: originally collecting aggregate data,
the CDC began collecting individual case reports
on a form called the Report of Verified Case of
Tuberculosis (RVCT). Currently, data are collected
by reporting areas (the 50 states, the District of Co-
lumbia, New York City, Puerto Rico, and jurisdic-
tions in the Pacific and Caribbean) using the RVCT.
An RVCT is completed for each reported new TB
disease case and contains patient demographic, clini-
cal, and laboratory information. An RVCT is com-
pleted by the health department for each confirmed
TB case and transmitted to the CDC to be included
in the national TB surveillance database. The CDC
annually publishes a report summarizing national
TB statistics [10]. Also included in this annual report
are the ‘‘Recommendations for Counting Reported
TB Cases,’’ which were last revised in 1997.
The CDC has maintained a computer database
on TB surveillance data since 1985. State and local
TB programs have been able to collect, manage, and
transfer TB surveillance data (i.e., RVCT) electroni-
cally to the CDC first through software for expanded
TB surveillance (SURVS-TB, 1993 – 1997) and cur-
rently through the Tuberculosis Information Manage-
ment System (TIMS, 1998 – present). In 1993, the
RVCT was expanded to collect additional information
(eg, drug resistance, HIV infection) in response to the
TB epidemic of the mid-to-late 1980s and early
1990s. The most recent modification was imple-
mented in January 2003 to meet federal standards for
the classification of race and ethnicity. Additional
changes for the national TB surveillance system are
on the horizon with a revision of the RVCT.
Reporting of RVCT data to the CDC also will
be modified with the transitioning of the TIMS to
the Web-based National Electronic Disease Surveil-
lance System.
Tuberculosis resurgence
Noting that extraordinary strides against TB have
been made both in treatment and surveillance since
the 1950s, many TB experts have believed that TB
elimination in the United States is within reach [1,2].
In 1959, the historic Arden House Conference, spon-
sored by the National Tuberculosis Association and
the USPHS Tuberculosis Control Program, brought
together TB experts to formulate a plan on how to
eliminate TB; this plan served as a basis for future TB
control efforts [12]. TB incidence continued to
decrease. From 1953 through 1985, TB case numbers
decreased by 74%, from 84,304 to 22,201 cases,
and the case rate decreased by 82%, from 53.0 to
9.3 cases per 100,000 population. As a result, many
no longer considered TB to be a major problem.
In the early 1970s, federal funding allocated for
TB control began to decrease, and, as a result, many
TB control services were dismantled [13,14]. Al-
though TB funds were decreasing, the cost of treating
TB was increasing. In 1981, only $3.7 million was
appropriated to the CDC to fight TB nationally.
In 1987, the Advisory Committee (now Council)
for Elimination of Tuberculosis (ACET) was estab-
lished, and its membership was directed to develop a
strategic plan for TB elimination [15]. The ACET and
the CDC published this plan, proposing a TB in-
cidence interim goal for the year 2000 of 3.5 or fewer
TB cases per 100,000 population and an elimination
target of less than 1 TB case per million population
by 2010. In the mid-to-late 1980s, however, the
longstanding downward trend in TB incidence was
interrupted. In 1986, a 2.6% annual increase in the
case number was documented, signaling the begin-
ning of the TB resurgence (Fig. 1). In the late 1980s,
after decades of decreasing TB incidence, TB once
again became a major threat.
The resurgence had a significant impact on TB
control strategies in the United States. Because of
newly identified risk groups, the focus of many TB
control strategies had to be shifted, and many pro-
grams needed to be overhauled. CDC researchers
concluded that the resurgence had resulted in an es-
timated 52,100 excess TB cases from 1985 through
1992 [16]. Several factors have been linked to the
resurgence, including the deterioration of the TB
program infrastructure, the HIV/AIDS epidemic,
 epidemiology of tuberculosis in the united states
28,000
Number of TB Cases
26,000
24,000
22,000
20,000
18,000
16,000
14,000
12,000
1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003
Year
Fig. 1. Reported tuberculosis cases in the United States from 1981 to 2003.
drug-resistant TB, TB among foreign-born persons,
and an increase in transmission, especially in con-
gregate and institutional settings [16 – 19].
The degree to which each of these factors affected
TB control at the local level varied, but two of these
factors, the HIV/AIDS epidemic and TB among
foreign-born persons, strongly influenced the TB re-
surgence in the United States. HIV infection is con-
sidered to be the greatest risk factor known today
for TB. Several large outbreaks of multidrug-resistant
TB (MDR-TB) (ie, TB resistant to at least isoniazid
and rifampin) among persons infected with HIV were
documented in Florida and New York City [20 – 22].
In 1991, 41% of culture-positive TB patients in New
York City were also infected with HIV, and 19% had
MDR-TB [23]. Early diagnosis of TB among persons
infected with HIV was difficult because of the lack of
specific clinical findings, such as a positive tuberculin
skin test result and an abnormal chest radiograph.
Ineffective isolation precautions also contributed to
nosocomial transmission of MDR-TB among patients
and health care providers [24 – 26]. HIV-related TB
outbreaks were also documented in other congregate
settings [27] such as correctional facilities [28] and
homeless shelters [29,30]. Another important factor
fueling the TB resurgence was the immigration of
persons from countries that have high rates of TB
[19]. The proportion of reported TB cases among
foreign-born persons increased from 22% in 1986
(the first year birthplace data were collected by the
national TB surveillance system) to 30% in 1993.
In the early 1990s, the newly established Federal
Tuberculosis Task Force revaluated existing TB
strategies and formulated the National Action Plan
to Combat MDR-TB [31]. In the United States, a
monumental public health effort to control TB was
initiated [32,33]. Federal funding was increased and
used to rebuild the TB infrastructure, strengthen sur-
185
veillance, augment case finding and contact inves-
tigations, advance laboratory capacity (eg, drug-
susceptibility testing and new diagnostic tools), and
ensure each patient completed therapy through the
use of directly observed therapy (DOT).
After the tuberculosis resurgence, 1993 – 2003
During the resurgence, the national TB incidence
peaked in 1992 at 26,673 cases (10.5 cases per
100,000 population). The aggressive attack on TB in
the United States resulted in the annual TB case num-
ber and case rate decreasing in 1993 to 25,108 cases,
9.7 cases per 100,000 population. Tuberculosis be-
came more localized to well-defined risk groups and
geographic areas [34,35]. In response, strategic plans
were revised to help prioritize efforts and outline
updated recommendations for TB elimination in the
United States [36,37].
From 1993 to 2002, the average year-to-year de-
crease in TB rate was 6.9%. In 2003, however, the
CDC reported the smallest annual decrease in the TB
rate (1.9%) and TB case numbers (184) since the re-
surgence, raising concern about a possible slowing
of the progress against TB. For 2003, 14,874 TB
cases were reported in the United States, with a rate
of 5.1 per 100,000 population that remains higher
than the national interim goal of 3.5 cases per
100,000 population set for 2000. Moreover, despite
the decline in TB nationwide, rates have increased
in certain states, and elevated TB rates continue to be
reported in certain populations (eg, foreign-born per-
sons and racial/ethnic minorities). In 2003, 12 states
and the District of Columbia reported case rates
above the national average, and 20 states reported
increases in case number compared with 2002 [10].
186 schneider et al
Age
The distribution of TB cases and case rates
among age groups remained relatively stable. In
2003, 34.2% of TB patients were 25 to 44 years old,
28.9% were 45 to 64, 20.2% were 65 years and
older, 10.6% were 15 to 24 years, and 6.2% were
children under 15 years. In contrast, 2003 TB case
rates (cases per 100,000 population) were highest
(8.4) among persons 65 years and older, followed by
a rate of 6.3 for those 45 to 64, 6.0 for those 25 to
44 years, 3.8 for those 15 to 24 years, and 1.5 for
children under 15. Although TB case rates among
children under 15 are low, certain groups of children
(eg, younger children, racial and ethnic minorities,
and foreign-born children) are at higher risk for TB
[38]. Children pose unique challenges to TB control:
1. TB in children is considered a sentinel event,
usually indicating recent transmission.
2. TB diagnosis in children, especially in children
under 5 years of age, can be more difficult be-
cause they often have nonspecific signs and
symptoms and fewer positive bacteriologic
tests because of the paucity of mycobacteria.
3. Children, especially infants, are at an increased
risk for progressing from latent TB infection
(LTBI) to active and sometimes severe TB dis-
ease [38].
Race/ethnicity
Disparities in TB rates persist among racial and
ethnic minority populations (Table 1). Overall, the
highest TB rates are seen among Asian/Pacific
Islanders, in large part because of the high proportion
of foreign-born persons in this population. Among
foreign-born persons, non-Hispanic blacks had the
highest case rate in 2003 and were the only group
with an increase in case rate from 1998 to 2003. In
2003, among TB patients born in the United States,
case rates for non-Hispanic blacks and for American
Indian/Alaska Natives were 7.7 and 6.8 times, respec-
tively, that of non-Hispanic whites. Local, state, and
federal public health partners, including the CDC
and the ACET, are collaborating to develop effective
strategies to reduce racial disparities in TB [39].
Foreign-born tuberculosis patients
National TB surveillance for patient country of
birth began in 1986, when 4925 (21.8%) new cases
were reported among foreign-born persons. The pro-
portion of foreign-born TB patients remained rela-
tively stable at 22% to 23% until 1990, when the
proportion and number of cases among foreign-born
persons began to increase (Fig. 2). Since then, the
proportion has increased steadily, with foreign-born
persons accounting for 53.4% of the national case
total in 2003. This trend results from the relatively
stable case count in foreign-born persons since the
mid 1990s, with 7902 cases reported in 2003,
coupled with the significant decrease in cases among
US-born persons (Fig. 3). In 1992, 19,225 cases
among US-born persons were reported in the United
States; this number decreased to 6903 in 2003.
TB case rates among foreign-born persons have
been consistently higher than among US-born per-
sons [40]. The 2003 TB rate among all foreign-born
persons (23.6 cases per 100,000 population) was
8.8 times greater than that among US-born persons
(2.7 cases per 100,000 population). Six birth coun-
tries of foreign-born TB patients have consistently
accounted for approximately 60% of the foreign-
born TB cases reported in the United States annually.
In 2003, Mexico accounted for 25.6% of foreign-
born patients; the Philippines, 11.5%; Viet Nam,
8.4%; India, 7.6%; China 4.8%; and Haiti 3.3%. The
number of states reporting 50% or more of their
TB cases among foreign-born persons has also been
increasing, from two states in 1986, to 14 states in
1998, and to 25 states in 2003 (Fig. 4). Five states
have consistently reported the most foreign-born
TB patients: California, New York, Texas, Florida,
and New Jersey. In 2003, these states combined re-
ported almost two thirds of the total cases in foreign-
born TB persons (California, 30.6%; New York,
12.4%; Texas, 9.0%; Florida, 5.9%; and New Jersey,
4.4%). Within each state, the birth-country composi-
tion often varies. In 2003, the most common birth
country for reported foreign-born TB patients from
California and Texas was Mexico; for New York, it
was China; for Florida, it was Haiti; and for New
Jersey, it was India. In addition, TB patients from
certain countries were concentrated in certain states.
For example, in 2003, New York reported 63.5% of
the national total of TB patients born in the Do-
minican Republic and 55.7% of those born in Ecua-
dor. Florida reported 60.0% of the TB patients born
in Cuba and 49.2% of those born in Haiti; Califor-
nia reported 52.0% of the TB patients born in the
Philippines and 48.6% of the patients born in Laos;
and Minnesota reported 55.2% of TB patients born
in Somalia. This diversity poses unique challenges to
state and local TB control programs and must be
addressed to facilitate case finding and contact in-
vestigations and to ensure completion of therapy.
Table 1

epidemiology of tuberculosis in the united states

Number and rate per 100,000 population of tuberculosis cases in the United States in 1998 and 2003
US-born Foreign-born Totalb
1998 2003 1998 2003 1998 2003
% change % change % change
Race/ethnicitya No. Rate No. Rate 1998 – 2003 No. Rate No. Rate 1998 – 2003 No. Rate No. Rate 1998 – 2003
Hispanic 1282 6.6 1015 4.3 33.8 2785 26.0 3073 19.6 24.7 4091 13.5 4115 10.5 22.2
Non-Hispanic
Black 4968 16.0 3086 9.2 42.6 841 48.5 1048 52.0 7.2 5816 17.8 4145 11.7 34.4
Asian/Pacific Islanderc 213 5.8 204 5.4 6.9 3411 55.4 3288 41.2 25.6 3637 36.9 3510 29.8 19.3
Asian ... ... 155 4.4 ... ... ... 3252 41.1 ... ... ... 3425 30.0 ...
Native Hawaiian and Other ... ... 49 15.7 ... ... ... 36 48.6 ... ... ... 85 22.1 ...
Pacific Islander
White 3914 2.1 2358 1.2 40.6 550 8.5 427 6.1 27.7 4473 2.3 2790 1.4 38.6
American Indian/Alaska Native 248 12.6 173 8.1 36.3 ... ... ... ... ... 254 12.7 176 8.1 36.2
Totald 10,633 4.3 6903 2.7 38.2 7598 30.2 7902 23.6 21.8 18,287 6.8 14,874 5.1 24.4
a
In 2003, two modifications were made to the tuberculosis report form: (1) multiple race entries were allowed, with 0.3% selecting more than one race, and (2) the previous category of
Asian/Pacific Islander was divided into ‘‘Asian’’ and ‘‘Native Hawaiian or Other Pacific Islander.’’
b
Persons included for whom country of birth was unknown: 56 in 1998 and 69 in 2003.
c
For comparison with 1998, data for 2003 Asian/Pacific Islander = Asian plus Native Hawaiian and Other Pacific Islander.
d
Persons included for whom race/ethnicity was unknown: 16 for all, 8 for US-born, and 5 for foreign-born persons in 1998; 101 for all, 58 for US-born, and 35 for foreign-born
persons in 2003. In 2003, persons included who selected multiple races: 37 for all, 9 for US-born, 28 for foreign-born persons.

187
188 schneider et al

Number of Foreign-born Percentage of Foreign-born

TB Cases TB Cases
10,000 60

8,000 50

40
6,000
30
4,000
20
2,000 10

0 0
1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
Number of Foreign-born TB Cases Percentage of Foreign-born TB Cases

Fig. 2. Trends in tuberculosis cases in foreign-born persons in the United States from 1986 to 2003.

Most TB cases among foreign-born persons are
caused by Mycobacterium tuberculosis complex in-
fections acquired abroad [41]. Among foreign-born
children, aged younger than 15 years, who had TB,
60% were diagnosed within 18 months of arrival in
the United States [38]. Prompt evaluation of foreign-
born persons for TB following their arrival in the
United States can help identify persons who have
LTBI and are eligible for preventive therapy; prompt
evaluation can prevent development of active TB
disease [41,42]. Foreign-born TB patients are also
more likely to have drug resistance and are less likely
to be HIV infected than US-born TB patients [40].
The lower proportion of foreign-born TB patients
infected with HIV results in part from HIV screening
requirements for persons seeking permanent resi-
dency in the United States [43].
TB among foreign-born persons is a major com-
ponent of TB morbidity in the United States [40]
and reflects the global TB situation, defined in 1993
by the World Health Organization (WHO) as a
global emergency [44,45]. The WHO estimated that
in 2002 there were 8.8 million new cases of TB
(141 cases per 100,000 population) [46]. Among the
22 high-burden countries, India and China ac-
counted for 46% of the total. Among the 15 coun-
tries that have the highest TB rates (>400 cases per
100,000 population), 13 are in Africa, and 12 of
these had high TB/HIV incidence rates (>100 cases
per 100,000 population) among adults 15 to 49 years

Number of US-born Percentage of US-born

TB Cases TB Cases
20,000 100
90
80
15,000
70
60
10,000 50
40
30
5,000
20
10
0 0
1986 1988 1990 1992 1994 1996 1998 2000 2002
Year
Number of US-born TB Cases Percentage of US-born TB Cases

Fig. 3. Trends in tuberculosis cases in persons born in the United States from 1986 to 2003.
 epidemiology of tuberculosis in the united states 189

Number of states with ≥50% TB cases

30

in foreign-born persons
25
23
22 22
20
15 15
14

10
10 9
6
5
4 4
3 3
2 2 2
0
1986 1988 1990 1992 1994 1996 1998 2000 2002
Year

Fig. 4. Number of states with 50% or more of tuberculosis cases in foreign-born persons in the United States from 1986 to 2003.

old, highlighting the magnitude of the TB/HIV epi- Drug-resistant tuberculosis

demic and the influence of HIV/AIDS on TB [46].
Therefore, immigration from regions that have high Drug-resistant TB, especially MDR-TB, places
rates of drug-resistant TB (eg, Eastern Europe) as an increased burden on all aspects of TB control,
well as from regions that have high rates of HIV in- including diagnosis, case management, treatment,
fection (eg, sub-Saharan Africa) substantially affect the and cost [52 – 54]. MDR-TB is defined as resistance
epidemiology of TB in the United States. The CDC to at least isoniazid and rifampin, two of the most
is collaborating with partners such as the US Agency effective antituberculosis agents in the TB arsenal.
for International Development, the International When used in conjunction with other antitubercu-
Union Against TB and Lung Disease (IUATLD), the losis agents, rifampin can significantly shorten the
KNCV TB Foundation (formerly the Royal Nether- treatment course of TB. Although many factors
lands Tuberculosis Association), and WHO to assist have been associated with the development of drug
countries that have high burdens of TB. Collabora- resistance, including naturally occurring spontaneous
tions have focused on building program capacity, mutations, two of the most commonly encountered
operational research, and programmatic evaluation to and preventable factors are nonadherence to therapy
address problems such as TB/HIV and drug resis- and inappropriate use of antituberculosis drugs. Poor
tance in TB patients. TB screening among immigrant infection-control practices within hospitals caring
and refugee visa applicants is being improved through for patients who have drug-resistant TB have also
the development of new diagnostic tools [47] and played an important role in the nosocomial trans-
updated medical screening guidelines [43]. In addi- mission of MDR-TB [20 – 22].
tion, because Mexico contributes the largest number Collection of drug-susceptibility results became
of foreign-born TB patients in the United States, part of routine national TB surveillance in 1993, in
the CDC has been collaborating with partners in the part because of the recommendations outlined by
United States and Mexico to help control TB along the National Action Plan to Combat MDR-TB [31].
the United States – Mexico border. These efforts in- Before 1993, several regional and national drug sus-
clude an innovative new initiative that uses a bina- ceptibility surveys on TB patients were conducted
tional health card to track and manage binational [52]. In 1991, findings of a nationwide survey re-
TB patients who cross the border to ensure continuity vealed 14.2% of cases were resistant to at least one
of TB care and completion of treatment [48,49]. drug and 3.5% were resistant to at least isoniazid
Worldwide, TB is a recognized cause of morbidity and rifampin (MDR-TB) [55]. The strongest risk
and mortality in children. A renewed interest by factor for drug resistance was geographic location.
domestic and international health agencies has New York City had the highest MDR-TB rate (13%)
focused on mobilizing and strengthening global and accounted for 61% of the total MDR-TB cases
efforts to improve surveillance, and to promote reported in the United States.
program and research initiatives to reduce the bur- Analysis of national TB surveillance data col-
den of TB on children [50,51]. lected from 1993 through 1996 revealed a 13.5%,
190 schneider et al
incidence of resistance to at least one drug, and the
incidence of MDR-TB was 2.2% [56]. Higher drug-
resistance rates were seen among TB patients who
have had a previous episode of TB, foreign-born
persons, HIV-infected persons, and persons residing
in specific geographic areas (eg, New York City).
In the mid-to-late 1990s, several outbreaks involv-
ing highly drug-resistant strains of M. tuberculosis
(ie, strain W) were investigated [57 – 59]. These
strains share a common drug resistance to first-line
antituberculosis medications (eg, isoniazid, rifampin,
ethambutol, and, at that time, streptomycin) as well
as resistance to some second-line medications, mak-
ing treatment difficult and costly. The majority of
strain W TB cases were reported by New York City
[57,59], although outbreaks have occurred elsewhere,
including one that was attributed to bronchoscope
contamination in South Carolina [58]. To facilitate
early detection of strain W isolates, the CDC began
recommending that health departments notify the
CDC of all M. tuberculosis isolates that have
strain W – resistance patterns [59].
Since 1998, overall multidrug resistance among
culture-positive TB patients, who do not have a prior
history of TB, has been relatively stable (~1%)
(Fig. 5), although outbreaks and regional differ-
ences continue to occur. Historically, overall drug-
resistance rates among those who have a previous
history of TB have been higher than for those who
do not have a previous history of TB. In 2003,
among TB patients who had a prior history of TB,
12.6% had resistance to at least isoniazid and 3.6%
had MDR-TB, whereas 7.9% of TB patients who
did not have a prior history of TB had resistance to
Number of MDR TB Cases
450
400
350
300
250
200
150
100
50
0 0.0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
Year
Number of MDR TB Cases
Fig. 5. MDR-TB among persons without a history of tuberculosis in the United States from 1993 to 2003. MDR-TB is defined
as resistance to at least isoniazid and rifampin.
at least isoniazid and 0.9% had MDR-TB. Addition-
ally, drug resistance (MDR-TB and resistance to at
least isoniazid) has been seen more commonly in
foreign-born TB patients (2003: MDR-TB, 1.2%;
isoniazid, 10.6%) than in US-born TB patients (2003:
MDR-TB, 0.6%; isoniazid, 4.6%).
Knowledge of drug-resistance rates worldwide
is critical to controlling the global epidemic and has
direct implications for TB control in the United States
[60,61]. A more comprehensive understanding of
global drug resistance was made possible with the
formation of the Supranational Reference Labora-
tory Network in 1994 and the WHO/IUATLD Global
Project on Anti-Tuberculosis Drug Resistance Sur-
veillance. Newly released data reveal that TB patients
in parts of Eastern Europe and Central Asia are
10 times more likely to have MDR-TB than patients
in the rest of the world, with some MDR-TB inci-
dence rates higher than 10% (Israel, 14.2%; Kazakh-
stan,14.2%; Tomsk Oblast [Russian Federation],
13.7%; Uzbekistan, 13.2%; Estonia, 12.2%; and
Liaoning [China], 10.4%) [61].
Tuberculosis/HIV coinfection
Today, any discussion about TB is incomplete
without a discussion about HIV/AIDS. Knowing a
TB patient’s HIV status is critical to management,
treatment, contact investigation, and prevention
[62 – 67]. The CDC recommends that all TB patients,
independent of risk factors, should undergo voluntary
HIV counseling, testing, and referral [64,65,67].
Nonetheless, HIV status is not reported nationally
for many TB patients in the United States. This in-
Percentage of MDR TB Cases
3.0
2.0
1.0
Percentage of MDR TB Cases
 epidemiology of tuberculosis in the united states
complete reporting of HIV status probably reflects
several factors including concerns about confiden-
tiality, interpretation of laws and regulations in cer-
tain states and local jurisdictions, and reluctance by
health care providers to report HIV test results to the
TB surveillance program staff [10]. Information on
HIV status was added to the national TB surveillance
system in 1993, in response to the TB resurgence.
HIV test results (ie, negative, positive, or indeter-
minate) were reported for 45.7% of TB patients aged
25 to 44 years in 1993 and for 65.3% in 2002. In
this group, positive HIV test results were reported for
29.1% in 1993 and for 15.9% in 2002. Historically,
reported TB/HIV coinfection rates and case numbers
have been relatively high in a few states and urban
areas. In 2002, 60% of the positive HIV test results
among TB patients aged 25 to 44 years were reported
from five areas: California, Florida, Georgia, New
York City, and Texas. Crossmatching of state TB
registries and HIV/AIDS registries in 1993 and 1994
revealed that 14% (range, 0% – 31%) of persons
reported to have TB in the United States were also
listed in HIV/AIDS registries [68]. TB-AIDS cases
were more likely to be in persons aged 25 to 44 years,
male, culture-positive for M. tuberculosis, and US-
born. In geographic areas where the prevalence rates
of HIV-infected persons were high, drug resistance,
especially MDR-TB (6%) and rifampin monoresis-
tance (3%), was reported among TB-AIDS patients.
HIV coinfection has several key implications for
the overall treatment and management of TB. HIV
infection increases the risk of (1) TB disease pro-
gression among persons who have LTBI, (2) rapid
progression of those newly infected with M. tuber-
culosis to active TB disease, and (3) reinfection with
M. tuberculosis [67,69]. Many of the TB outbreaks
among persons infected with HIV that occurred
during the resurgence were complicated by high
drug-resistance rates and resulted in mortality rates
reaching 70% [21 – 23]. TB outbreaks among HIV-
infected persons have illustrated the continued need
for appropriate treatment and monitoring of this
population [70 – 73]. The use of antiretroviral ther-
apy has significantly decreased mortality and mor-
bidity, including the development of opportunistic
infections (eg, TB) among HIV-infected persons.
New concerns have developed, however, concern-
ing the potential for drug – drug interactions, develop-
ment of resistance to rifamycin, and paradoxical
reactions. Drug – drug interactions, primarily between
rifamycin and protease inhibitors and nonnucleoside
reverse transcriptase inhibitors, have resulted in new
treatment guidelines and recommendations [66,66a].
Acquired rifampin monoresistance has been docu-
191
mented in HIV-infected patients who have low CD4+
T-lymphocyte counts, extrapulmonary disease, and
concomitant antifungal therapy [74,75]. Clinicians
treating TB-HIV – coinfected persons should be fa-
miliar with current diagnostic, management (eg, DOT),
and treatment modalities to maximize therapeutic
success and minimize TB transmission, drug resis-
tance, adverse effects, and treatment failures [64,67].
Globally, the HIV/AIDS epidemic has had an
immense impact on TB control, especially in sub-
Saharan Africa, where an estimated two thirds of
persons who have HIV/AIDS live, and has contrib-
uted significantly to TB morbidity and mortality
[76 – 78]. In these countries, TB incidence and case
fatality are strongly associated with HIV prevalence.
The prevalence of drug-resistant TB is expected to
increase greatly as the HIV epidemic spreads to areas
of the world where drug-resistant TB is more
prevalent (eg, Asia, Eastern Europe) [61,76]. The
scaling up of treatment programs providing anti-
retroviral therapy will require patient and health care
provider education and close monitoring to opti-
mize therapy, reduce transmission, and reduce drug-
resistant TB [79].
Development of new tools
An important component of disease control is the
development of new diagnostic tests, pharmacologic
agents, and vaccines. The resurgence of TB in the
mid-to-late 1980s to 1992 was associated with delays
in the diagnosis and identification of drug resistance.
This situation generated renewed interest in the de-
velopment of several new diagnostic tools and the
subsequent genomic sequencing of M. tuberculosis.
During the past few years, TB diagnostic capabili-
ties have improved through new techniques for
the rapid detection of M. tuberculosis complex (eg,
nucleic acid amplification tests) [80], identification
of M. tuberculosis (eg, nucleic acid probe), rapid de-
tection of latent TB infection (eg, whole-blood inter-
feron gamma assay [QuantiFERON (Cellestis Inc.,
Valencia, California)]) [81,82], the investigational
enzyme-linked immunospot test (ELISPOT) [83],
and differentiation of M. tuberculosis strains (eg,
DNA fingerprinting) [84,85].
In the 1990s, molecular genetic typing (genotyp-
ing) of M. tuberculosis strains became a commonly
used tool to understand outbreaks and transmission
dynamics. In 1996, the CDC established the National
TB Genotyping and Surveillance Network to deter-
mine the usefulness of molecular genotyping in more
routine TB control settings using the IS6110-based
restriction fragment length polymorphism (RFLP)
192 schneider et al
technique supplemented with spacer oligonucleotide
typing (spoligotyping) on M. tuberculosis isolates
[86,87]. Genotyping, in conjunction with epidemio-
logic investigation, has proven a useful adjunct to
epidemiologic investigations in tracing the chain of
transmission [88]. The techniques are particularly
useful in outbreaks and institutional settings, identi-
fying groups at risk for TB (eg, homeless persons),
identifying contacts and social networks, under-
standing exogenous reinfection, and confirming labo-
ratory cross-contamination [89,90]. To refine the
understanding of TB transmission and epidemiol-
ogy and to advance TB control, the CDC has
launched the National TB Genotyping Program,
which provides the capacity to genotype M. tuber-
culosis isolates from all culture-positive TB patients
in the United States. Two polymerase chain reaction –
based genotyping tests (spoligotyping, mycobacterial
interspersed repetitive units analysis) will be supple-
mented with IS6110 RFLP testing for selected speci-
mens [91]. The goal of this program is to improve
the characterization of TB transmission dynamics and
to use the results to improve the efficiency of public
health interventions.
In 1995, following a several-year hiatus in the
USPHS-sponsored clinical trials, the CDC reinstated
clinical TB research, creating the TB Trials Con-
sortium (TBTC). The TBTC currently is coordinat-
ing several studies, including efficacy trials for the
use of moxifloxcin as a first-line drug in the treat-
ment of TB disease. Information gained from the
earliest of these studies contributed to the Food and
Drug Administration licensure of rifapentine, a long-
acting rifampin and the first anti-TB drug approved
in 25 years [92]. Additional studies include a com-
parison of several generations of QuantiFERON
with the tuberculin skin test in the diagnosis of LTBI
[81]. In 2001, the CDC established the TB Epide-
miologic Studies Consortium to conduct multicenter
epidemiologic, behavioral, and operational research
studies. Furthermore, recognizing the need for TB
prevention globally, a renewed interest, fueled by
generous funding has resulted in actively revisiting
vaccine development [93,94]. Numerous organiza-
tions, both in the public and private sectors, are con-
ducting major research efforts to develop a safe and
effective TB vaccine.
Elimination of tuberculosis in the United States:
remaining challenges
After decades of decline, an unprecedented re-
surgence in TB began in 1986 and continued through
1992, with case numbers increasing by 20%. Follow-
ing an intensive campaign and mobilization of new
resources, TB cases once again began to decline.
Remarkable gains have been made since the early
1990s, with efforts being concentrated on maintain-
ing control of TB, speeding the decline of TB, and
developing new tools [37]. Key TB epidemiologic
features that have been identified include an increas-
ing proportion of TB cases among persons born in
countries where TB is endemic, racial and ethnic
disparities, and localized unique epidemiologic pro-
files in areas throughout the United States. Develop-
ment of new tools, such as vaccines, antituberculosis
drugs, and rapid diagnostic tests have also been
identified as vital measures needed to eliminate TB
in the United States.
The smallest decline since the resurgence was
seen in 2003, raising the concern about a possible
slowing of the progress against TB or even a reversal
of the decline. Despite increasing health care costs
and demands for increased programmatic and opera-
tional efforts, funding for TB control has not in-
creased [95]. The elimination of TB in the United
States will require sustained efforts such as identify-
ing and targeting populations at high risk for TB,
remaining actively involved in the global effort
against TB, and maintaining adequate resources.
Acknowledgments
The authors thank the state and local tuberculosis
control officials in health departments throughout
the United States who collected and reported the
national surveillance data presented in this article,
the surveillance staff at the Division of TB Elimi-
nation, Centers for Disease Control and Prevention,
who maintain the database, Ann H. Lanner for her
editorial review of the manuscript, and Dr. Thomas
Navin and Dr. Michael Iademarco for their critical
review of the manuscript.
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 Clin Chest Med 26 (2005) 233 – 246
Genetic Susceptibility to Tuberculosis
Richard Bellamy, MRCP, DPhil
James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK
Genetic factors are important contributors to the
development of a wide range of complex or multi-
factorial diseases. For example, if one has a close
relative who died of ischemic heart disease, one will
be at increased risk of developing ischemic heart dis-
ease oneself. It is not inevitable that one will develop
the same condition, because other factors such as
cigarette smoking, diet, exercise, and ‘‘bad luck’’ also
contribute to the risk of developing ischemic heart
disease. A positive family history simply indicates
that one is at increased risk of developing heart dis-
ease compared with a person of the same age and sex
who does not have a positive family history.
Patients and their doctors recognize the impor-
tance of family history for a wide range of multi-
factorial, noncommunicable diseases such as cancer,
cardiovascular disease, and diabetes mellitus. Much
of the clustering in families that occurs in these con-
ditions, however, probably results from shared en-
vironmental risk factors. Although there is much
debate about the importance of nature versus nurture,
few scientists would dismiss the importance of host
genetics in the development of chronic noncommu-
nicable diseases. In contrast, host genetic factors
are often given little attention in infectious disease.
The familial clustering that is frequently observed for
infectious diseases is commonly dismissed as the
result of transmission of infection among household
members. This assumption is unfair, because host
genetic factors are probably at least as important in
determining the outcome of infection as they are in
other complex diseases.
Studies on adoptees are sometimes used to help
eliminate the effects of shared environment when
E-mail address: bellamyrj2000@yahoo.co.uk
0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.006
considering the contribution of genetic factors to ob-
served familial clustering of disease. In a study of
almost 1000 adoptees, Sorensen et al [1] found that
the host genetic component of susceptibility to pre-
mature death from infection was greater than for
cancer or cardiovascular disease. This finding does
not mean that if one’s father dies of tuberculosis, one
inevitably will succumb to the same disease. Rather,
it indicates that a person who has such a family
history has a higher probability of dying from tuber-
culosis than a person who does not have a positive
family history. Thus the statement that host genetic
factors make a person susceptible to a particular in-
fectious disease simply means that the risk of devel-
oping the disease is higher than for someone who has
not inherited the genetic risk factor (ie, who can be
described as resistant). Someone whose genetic
constitution makes him or her susceptible to Myco-
bacterium tuberculosis will not necessarily develop
clinical disease after exposure to the microorganism.
Conversely someone whose genetic constitution
makes him or her resistant to M. tuberculosis may
still develop clinical disease after exposure. The term
‘‘susceptible’’ simply indicates a genetic make-up
with a higher risk of developing tuberculosis than
a resistant one.
In 1949, Haldane [2] suggested that microorgan-
isms have been the main agents of natural selection
among human populations for the past 5000 years.
He believed that the recent evolution of the human
genome was driven primarily by the need to resist
pathogens because infectious diseases were the most
important cause of premature death. This hypothesis
proposes that most of the genetic diversity found
within human populations has been selected for
and maintained by pathogenic microorganisms. Until
recently, progress in identifying the host genes con-
chestmed.theclinics.com
234 bellamy
ferring resistance to infectious diseases was limited
to malaria. Geographic variations in the prevalence
of malaria facilitated the identification of several gene
variants conferring resistance to malaria, including
sickle cell hemoglobin, a- and b-hemoglobin, and
glucose-6-phosphate dehydrogenase deficiency [3,4].
Genetic mutations conferring malaria resistance are
common in populations originating in areas where
malaria is endemic and are rare among populations
where malaria does not occur.
Historically, tuberculosis has not shown the
marked geographic variation shown by malaria. This
lack of variation has made the task of identifying the
host genes conferring tuberculosis susceptibility and
resistance more difficult to identify. It has been esti-
mated that M. tuberculosis was responsible for more
than one fifth of all deaths in Western Europe after
the industrial revolution [5]. It is therefore logical to
expect that M. tuberculosis would have been among
the microorganisms that have had the most important
effects on the evolution of the human genome. It
has been estimated that approximately one third of
the world’s population is infected with mycobacteria,
but among those infected only about 10% will ever
develop clinical disease [6]. Much scientific research
has focused on proving that host genetic factors
are important in determining why only a minority of
those infected by M. tuberculosis develops clinical
disease. This article provides a brief summary of this
research and describes the strategies that have been
used to identify the host genes involved in tuber-
culosis resistance.
Evidence showing the importance of host genetics
in tuberculosis susceptibility
In 1926, in Lubeck, Germany, a tragic accident
occurred during the bacille Calmette-Guerin (BCG)
vaccination program: 249 babies were injected with
the same live dose of virulent M. tuberculosis bac-
teria. Seventy-six babies died; 173 babies survived
[7]. This experience showed that there is wide
variation in the degree of innate immunity against
M. tuberculosis. The babies who died presumably had
weaker resistance to M. tuberculosis than the babies
who managed to clear the infection. This difference in
host immunity could not have resulted from variation
in acquired resistance to M. tuberculosis, because the
babies were too young to have had significant prior
exposure to mycobacteria, and they had not pre-
viously been vaccinated with BCG. The difference
could also not be explained by variation in virulence
or infectivity of the bacteria, because all the infants
received direct inoculation with the same dose of
the same strain of M. tuberculosis. Therefore the dif-
ference in outcome of the infection is probably ex-
plained by host genetic factors.
It has been suggested that a population’s resis-
tance to M. tuberculosis is determined by its history
of previous exposure [8]. Resistance is built up over a
number of generations by selection pressure in favor
of mycobacteria-resistant gene variants. When the
selection pressure is strong, gene variants conferring
disease-resistance can rise to high population fre-
quencies in relatively short periods of time. The most
striking example of a population acquiring resistance
to tuberculosis has been described by Motulsky [9].
At the end of the nineteenth century the Qu’Appelle
Indians suffered their first cases of tuberculosis. The
disease spread rapidly through the population and
caused the deaths of 10% of the total population
annually. After two generations (40 years), half of the
families had been lost, but the annual death rate from
tuberculosis had fallen to 0.2% [9]. This striking
reduction in tuberculosis-specific mortality is be-
lieved to have resulted from the strong selection
pressure in favor of M. tuberculosis – resistant gene
variants [9].
Tuberculosis has been a major cause of premature
death in Europe since the Industrial Revolution. In
Africa it is believed that tuberculosis did not become
widespread until the start of the twentieth century
[10 – 12], when the building of densely populated
towns and cities facilitated the spread of M. tuber-
culosis. Haldane’s theory would therefore predict
that present-day people of European origin would
have greater resistance to tuberculosis than people
of African origin. A study of 25,000 nursing home
residents in Arkansas confirmed that black resi-
dents were twice as likely to become infected with
M. tuberculosis as white residents of the same nurs-
ing homes [13]. This difference could not be ex-
plained by environmental or social factors, indicating
that it was most likely caused by host genetics [13].
Twin studies are the most reliable method of
determining whether genetic factors are involved
in determining who will develop a particular dis-
ease. Monozygotic twins inherit identical genomes,
whereas dizygotic twins share only 50% of the genes
they inherit. If monozygotic twins have higher
concordance for a disease than dizygotic twins, this
finding indicates that genetic factors are important
in the etiology of the disease. Several studies have
compared the concordance for tuberculosis in mono-
zygotic twins with that in dizygotic twins. These
studies have shown concordance rates among mono-
zygotic twins to be approximately twice as high as
 genetic susceptibility to tuberculosis
concordance rates among dizygotic twins [14 – 16].
This evidence that host genes are important in de-
termining susceptibility/resistance to tuberculosis has
led to the development of several strategies to attempt
to identify the genes involved.
Strategies to identify host genes determining
tuberculosis susceptibility
Identifying the genes influencing susceptibility
to multifactorial diseases is a complex process. No
single strategy could identify all of the genes of
interest, because each study design has advantages
and limitations.
Genome-wide linkage studies are used to identify
regions of the genome that contain major disease-
susceptibility loci. This approach involves typing a
large number of genetic markers (usually more than
300) covering the whole human genome. Sibling-pair
families that contain two or more siblings affected
by the disease of interest are usually used in studies
of multifactorial diseases. These families are pre-
ferred to large, extended families (which are generally
used for single-gene Mendelian disorders), because
they are believed to be more representative of the
disease in the general population. Large numbers
of sibling-pair families must be typed to provide suf-
ficient power to detect genes exerting a large effect
on population-wide disease risk. The approach is
systematic and comprehensive and in theory should
detect any genomic region that contains a major
disease-susceptibility locus. This approach has rela-
tively low power, however, and it cannot detect
gene loci that confer only a moderate effect on
population-wide disease risk. For example if a
disease-susceptibility allele has a frequency of 0.5
(ie, 50% of the alleles in the population are of
this type) and exerts a twofold increased risk of dis-
ease compared with the resistant wild-type allele,
2498 sibling-pair families are required to provide
an 80% probability of identifying this effect by
linkage analysis [17]. It would be difficult to col-
lect and type this number of families in a genome-
wide screen.
Association-based candidate gene studies have
much greater power. Only 340 cases are required to
have the power to detect the effect of the disease-
susceptibility locus described previously [17]. Asso-
ciation-based candidate gene studies can therefore
detect genetic effects that would be overlooked in
a genome-wide linkage study. The simplest form of
association study is the case-control study, but more
235
complex, family-based designs are also occasionally
used. Association studies generally involve typing
individual gene variants that are believed to be poten-
tially important because of previous work on animal
models of the disease or for theoretical reasons. As-
sociation between a genetic marker and a disease can
be caused by either the genetic variant itself confer-
ring disease susceptibility/resistance or the genetic
variant being in linkage disequilibrium with the true
disease-susceptibility locus. Linkage disequilibrium
occurs only when two gene variants are located close
together (within 1 centi-Morgan) on the same chro-
mosome. A genome-wide association study would
require typing more than 3000 genetic markers; this
approach would be time-consuming and expensive
and therefore generally is not feasible. Because as-
sociation studies are usually restricted to candidate
genes, this approach cannot be used alone. Regard-
less of how many candidate genes are typed, the
genes that exert the largest effects on population-wide
disease risk could be overlooked. Candidate gene
studies and genome-wide linkage studies are there-
fore complementary, and both are generally required
when investigating a multifactorial disease.
Animal models have several advantages for the
study of multifactorial diseases. Animal models can
be used in breeding experiments, targeted gene dis-
ruption can be performed, and the animals can be
challenged with pathogens. Identifying genes that
confer susceptibility to individual pathogens in animal
species is a useful strategy for identifying candidate
genes for case-control studies in human populations.
Human patients who suffer from extreme suscep-
tibility to specific opportunistic infections can also
provide insight into the host immune response to
common infectious disease. For example, individuals
who have developed overwhelming infection follow-
ing BCG infection or who have developed dissemi-
nated atypical mycobacterial infections have provided
insight into host resistance to M. tuberculosis. This
article describes how several of these methods have
been used to identify some of the host genes involved
in susceptibility to tuberculosis.
Natural resistance – associated macrophage
protein
More than 20 years ago, innate susceptibility to
infection with M. bovis BCG was shown to be de-
termined by a single genetic factor in inbred strains
of mice [18]. Gros and colleagues [18] named this
putative gene Bcg. Following a single inoculation
236
with BCG-Montreal, mice carrying the resistant allele
(Bcgr ) had between 100- and 1000-fold fewer splenic
colony-forming units than mice carrying the suscep-
tible gene variant (Bcgs ) [19]. The Bcgr allele was
found to be dominant over the Bcgs allele [18]. The
Bcg locus was mapped to murine chromosome 1 by
linkage analysis [20]. Linkage analysis also showed
that Bcg was the same gene that determined resis-
tance to Leishmania, salmonella, and other myco-
bacterial species such as M. lepraemurium and
M. intracellulare [21 – 28]. In vitro studies showed
that macrophages from mice carrying the Bcgs allele
had decreased ability to restrict the growth of myco-
bacteria, salmonella, and Leishmania compared with
Bcgr macrophages [29 – 32]. As a result, Bcgs mice
had impaired ability to control the initial stage of
mycobacterial infection, but the genetic suscepti-
bility does not affect the later stages of an infection,
which are determined by the acquired immune re-
sponse [19].
A high-resolution linkage map of murine chro-
mosome 1 enabled the Bcg locus to be pin-pointed
to a 0.3 – centi-Morgan region [33,34]. The search
for the Bcg gene itself was then vigorously pursued
by Gros’ group. They produced a 400 – kg-base (kb)
bacteriophage and cosmid contig of the region
surrounding the Bcg gene [35] and used a molecular
method called exon trapping to isolate potential
candidate genes for Bcg [36]. One gene was ex-
pressed solely in macrophage populations and en-
coded a polypeptide with characteristics suggestive
of a transport protein. This gene was believed to be
the Bcg gene, because it contained a nonconservative
base change (glycine to aspartic acid at position 169:
designated G169D) in the Bcgs strains studied [36].
The group named this gene the natural resistance-
associated macrophage protein gene (Nramp, later
re-named Nramp1) [36]. Three experiments were then
performed to demonstrate that Nramp1 is the putative
Bcg gene. Twenty inbred strains of mice with the
Bcgr phenotype and seven inbred strains of mice with
the Bcgs phenotype were typed for the Nramp1
G169D variant [37]. All 20 strains with the Bcgr
phenotype were found to be Nramp1G169/G169 wild-
type homozygotes, and all seven Bcgs strains were
Nramp1D169/D169 gene-variant homozygotes [37]. The
second experiment involved the production of an
Nramp1 gene-disrupted knock-out mouse [38].
This knock-out mouse, designated Nramp1
/
, was
mated with the homozygous gene-variant mouse
Nramp1 D169/D169 . The resulting offspring all had
the compound genotype Nramp1D169/- [38]. If the
Nramp1D169 allele is a nonfunctional (or null)
allele, mice with the genotypes Nramp1D169/D169 ,
bellamy
Nramp1D169/
, and Nramp1
/
should have identical
phenotypes. Gros’ group found that mice with these
three Nramp1 genotypes had indistinguishable resis-
tance to mycobacteria, confirming that Nramp1D169
is a null allele [38]. In the third experiment the
normal Nramp1G169 allele was transferred onto the
background of a mouse with the homozygous
Nramp1D169/D169 genotype [39]. Macrophages from
this transgenic mouse expressed the Nramp1 protein,
and the BCG-resistant phenotype was restored [39].
These experiments proved beyond doubt that Nramp1
is the putative Bcg gene.
The Nramp1 gene consists of 15 exons spanning
11.5 kb. The gene encodes a 90- to 100-kiloDalton
membrane-bound protein containing 12 hydrophobic
transmembrane domains [36,40,41]. Macrophages
from Nramp1D169/D169 mice do not produce detect-
able Nramp1 protein [42]. The human homolog of
Nramp1 was originally designated NRAMP1 but
has now been renamed Slc11a1 (solute carrier family
11 member 1). In this article the name NRAMP1 is
retained to avoid confusion. NRAMP1 maps to chro-
mosome 2q35, contains 15 exons spanning 12 kb
of DNA, and encodes a polypeptide consisting of
550 amino acids [43,44]. There are several Nramp-
related proteins in humans, mice, and many other
species. In mice, Nramp2 and Nramp-rs have been
mapped to chromosomes 15 and 17, respectively [45,
46]. The human homologue of Nramp2 (NRAMP2)
has been cloned and mapped to chromosome 12q13
[47,48].
Evidence is now accumulating to suggest that
the NRAMP1 protein is a transmembrane iron trans-
porter. It was first suggested in 1996 that Nramp1
may be a metal cation transporter because of its
structural similarity to a known manganese trans-
porter in Saccharomyces cerevisiae [49]. A missense
mutation in the Nramp2 gene (glycine to arginine
at position 185; G185D) was subsequently found to
be responsible for microcytic anemia in a murine
model [50]. The same Nramp2G185D mutation is also
responsible for microcytic anemia in the Belgrade
rat [51]. Murine Nramp2 and human NRAMP2
are integral membrane glycoproteins located at the
plasma membrane and at recycling endosomes
[52,53]. In contrast, Nramp1 is localized to the late
endosomal compartment of resting macrophages and
is recruited to the phagosome on phagocytosis [54].
In the presence of excess iron, macrophages from
Nramp1D169/D169 mice have the same ability to limit
intracellular M. avium replication as macrophages
from wild-type Nramp1G169/G169 mice [55]. This
finding suggests that Nramp1 may be an iron trans-
porter that becomes saturated at high concentration.
 genetic susceptibility to tuberculosis 237

Nramp2 function in epithelial Nramp1 function in macrophages

and other cells

Iron Iron

Transferrin receptor Bacteria

Nramp2

H+ Iron H+

Nramp2 Iron

Nramp1

Iron
Iron
Nramp2
H+ Nramp1 H+

Fig. 1. Nramp1 and Nramp2 function as hypothesized by Gruenheid et al [52]. The ubiquitous Nramp2 is a membrane
glycoprotein that becomes internalized to endosomes with iron. Acidification of the endosome activates Nramp2 resulting in the
transport of iron and protons into the cytoplasm. Nramp1 is recruited to the macrophage phagosome after bacteria and iron are
ingested. Following acidification, Nramp1 transports iron and protons out of the phagosome into the macrophage cytoplasm.
Presumably mycobacterial Mramp competes with Nramp1 for the available intraphagosomal iron.

M. tuberculosis possesses a member of the Nramp
protein family called Mramp [56]. Mramp is a trans-
porter of iron and other divalent metal cations [56].
Mycobacterial Mramp is probably competing with
host Nramp for control of the iron concentration
within the host phagosome (Fig. 1).
The identification of several polymorphisms in
the human NRAMP1 gene [57] has enabled linkage
and association studies to be used to study the im-
portance of the NRAMP1 gene in explaining individ-
ual variability in susceptibility to tuberculosis in
human populations. Weak evidence of linkage was
found between NRAMP1 polymorphisms and tuber-
culosis in 98 Brazilian families [58] and 173 African
sibling-pairs [59]. Strong evidence of linkage between
NRAMP1 and tuberculosis was found in a single
large aboriginal Canadian family [60]. These results
suggested that NRAMP1 is involved in susceptibility
to tuberculosis in humans, but that the effect is too
small for NRAMP1 to be the major gene involved.
Association studies have greater power than linkage
studies to evaluate the effects of a candidate gene on
disease susceptibility. Association-based case-control
studies are therefore more useful than linkage-based
family studies for assessing the effects of NRAMP1
on the population-wide variability in risk of tuber-
culosis. In a case-control study of more than 800 per-
sons from Gambia, West Africa, individuals that
had tuberculosis had more than four times the odds of
carrying the disease-associated NRAMP1 genotype
than ethnically matched controls [61]. The associa-
tion between NRAMP1 polymorphisms and tuber-
culosis has since been confirmed in further patient
populations from Gambia [62], Japan [63], Korea [64,
65], and Guinea-Conakry [66]. One of the NRAMP1
polymorphisms, a (GT)n repeat in the 50-untranslated
region, influences gene expression following lipo-
polysaccharide or interferon gamma (IFNg) stimula-
tion [67]. Persons who possess the less actively
expressed allele are more likely to develop tubercu-
losis. Although these studies confirm that NRAMP1
influences susceptibility to tuberculosis in human
populations, it is likely that NRAMP1 accounts for
only a small proportion of the total genetic compo-
nent of tuberculosis susceptibility.
Interferon gamma signaling pathway
In 1995, Levin et al [68] described four children
from a village in Malta who had suffered from severe
238 bellamy
and recurrent infections with the atypical myco-
bacteria M. fortuitum, M. chelonae, and M. avium-
intracellulare. Three of the children were related,
suggesting that they had inherited the same genetic
immune defect [68]. Leukocytes from the affected
children had impaired IFNg production in response to
mycobacterial antigens [68]. A genome-wide screen
identified a single region of homozygosity on chro-
mosome 6q in the three related children [69]. The
region identified contains the gene encoding the IFNg
receptor ligand binding chain (IFNgR1). Sequencing
the IFNcR1 gene identified a single-base transver-
sion at position 395 of the coding sequence, which
produced a premature stop codon. The three related
children were all homozygous for this single-base
transversions, and the IFNgR protein was absent from
the children’s leukocytes. This finding established
that IFNgR1 deficiency could be a cause of increased
susceptibility to mycobacterial infections.
Independently of Levin’s group, Casanova and
colleagues [70] identified IFNgR1 deficiency as a
cause of disseminated BCG infection. They identified
121 French children who developed disseminated
BCG infection following vaccination. Sixty-one of
the children had an identifiable underlying immune
defect such as severe combined immune deficiency,
chronic granulomatous disease, Di George syndrome,
or HIV infection. Casanova and colleagues attempted
to find an underlying immune deficiency in the re-
maining 60 children. They screened a number of
candidate genes and found that autosomal recessively
inherited mutations in the IFNcR1 gene could lead
to disseminated BCG infection following vaccina-
tion [71]. Complete IFNgR1 deficiency is caused by
gene mutations that abolish receptor expression [69,
71 – 76] or binding of the receptor to IFNg [77,78].
There are two reports of dominant IFNcR1 gene mu-
tations in patients suffering from disseminated atypi-
cal mycobacterial infections [79,80]. There is also a
report of partial IFNgR1 deficiency in two siblings,
one of whom developed disseminated BCG infection
and the other tuberculosis [81]. This report led to
speculation that the existence of other common gene
variants of the IFNcR1 gene might explain the popu-
lation variability in susceptibility to tuberculosis.
When six common IFNcR1 gene polymorphisms were
typed in a case-control study of 640 persons from
Gambia, however, no association with tuberculosis
was found [82].
Mutations in four other genes in the interleukin-12
(IL-12) – IFNg signaling pathway have been found
to lead to disseminated mycobacterial infections.
Patients have been identified who have complete or
partial deficiency of the IFNgR signal transduction
chain (IFNgR2) because of IFNcR2 gene mutations
[83,84]. Deficiency of signal transducer and activator
of transcription-1 (STAT-1) protein can lead to de-
creased response to IFNg stimulation [85]. A patient
was described who had a dominant mutation in the
STAT1 gene causing partial STAT1 deficiency result-
ing in impaired immunity to atypical mycobacteria
[85]. Some patients who have disseminated atypical
mycobacterial infections have been found to have
abnormal IFNg production in response to IL-12
stimulation but normal cellular responses to IFNg.
This result can be caused by complete deficiency of
the IL-12 receptor b1 chain (IL12Rb1) caused by
recessive mutations in the IL12Rb1 gene [86 – 91] or
by deficiency of the IL-12 p40 subunit caused by
mutations in the IL12B gene [92,93].
Patients inheriting one of the gene mutations
causing abnormal IL-12 – IFNg signaling suffer re-
current infections with mycobacteria that are usually
nonpathogenic, such as M. bovis BCG, M. avium-
intracellulare, M. kansasii, M. chelonae, and M. smeg-
matis [94]. The immune deficiency is relatively
specific, because, although recurrent salmonella in-
fections occur, there does not seem to be increased
susceptibility to a wider range of pathogens [94].
Mendelian susceptibility to mycobacterial infections
is rare. Most persons who develop tuberculosis do
not have a recognized IL-12 – IFNg signaling path-
way defect. Although common gene variants in the
IFNcR1 gene were not found to be associated with
tuberculosis [82], mutations in other IL-12 – IFNg
signaling pathway genes might partly explain popu-
lation variation in susceptibility to tuberculosis [95].
Lio et al [96] genotyped 45 Sicilian patients who had
tuberculosis and 97 controls for a single nucleotide
polymorphism in the INFc gene and found the
genotype associated with high IFNg production was
under-represented among the tuberculosis patients.
Case-control studies of the same gene variant in tu-
berculosis patients from Spain [97] and South Africa
[98] found results consistent with this finding,
indicating it is unlikely to result from chance. The
population-wide effect of the IFNc gene polymor-
phism on susceptibility to tuberculosis is comparable
to that of NRAMP1 [99]. Therefore these gene
variants can explain only a small percentage of the
total genetic component of the host variability in
susceptibility to tuberculosis. A provisional associa-
tion has also been described between common
IL-12Rb1 gene variants and tuberculosis in Japanese
patients [100]. It is therefore possible that several
genes in the IL-12 – IFNg signaling pathway may
contribute to the population-wide variability in tuber-
culosis susceptibility.
 genetic susceptibility to tuberculosis
Other candidate genes
Several genes have now been suggested to have
a role in host variability in susceptibility to tuber-
culosis. This section focuses on the gene loci for
which there is the most convincing evidence.
Mannan-binding lectin (MBL) is an important
component of the innate immune system. MBL is a
calcium-dependent C-type lectin that forms a bou-
quetlike structure similar to C1q [101]. The lectin
domain of MBL can bind to repetitive carbohydrate
structures on microorganisms. This action activates
complement independently of the classic and alter-
native pathways and promotes opsonophagocytosis
[102]. Deficiency of MBL has been described as the
world’s most common immune deficiency [103]. It
is caused by one of three nonconservative single-
nucleotide polymorphisms at codons 52, 54, or 57 of
the gene encoding MBL protein, which is called mbl2
[104 – 106]. These polymorphisms produce variant
MBL polypeptides that are unstable and nonfunc-
tional [104 – 106]. MBL deficiency does not have a
close relationship with susceptibility to specific patho-
gens [107]. Rather, it seems to confer an increased
risk of susceptibility to a wide range of pathogens
during infancy [108,109] and possibly also during
adulthood [110,111].
If MBL deficiency predisposes a person to a large
number of potentially fatal diseases, there must be
some selective advantage in carriage of the variant
alleles to explain their high population frequency.
The most plausible explanation is that heterozygote
carriers of mbl2 variant alleles have some protection
against mycobacterial infections [112]. This theory
has been given support from case-control studies of
tuberculosis [113 – 116], leprosy [112], and M. avium
[117]. There is also, however, some limited con-
tradictory evidence that MBL deficiency is a risk
factor for tuberculosis [118,119]. Further work is
required to confirm whether mbl2 variant alleles con-
fer resistance against tuberculosis and other myco-
bacterial infections.
1,25 Dihydroxyvitamin D3 (1,25(OH)2D3) is an
important immunomodulatory hormone that activates
monocytes and suppresses lymphocyte proliferation,
immunoglobulin production, and cytokine synthesis
[120 – 122]. In vitro, 1,25(OH)2D3 enhances the
ability of human monocytes to restrict the growth
of M. tuberculosis [120,123,124]. Epidemiologic
evidence suggests that vitamin D deficiency may be
a risk factor for tuberculosis [125 – 127]. Vitamin D
exerts its effects through the vitamin D receptor
(VDR), which is present on monocytes and on acti-
vated T and B lymphocytes [128,129]. If vitamin D
239
deficiency is a risk factor for tuberculosis, VDR
gene polymorphisms could contribute to genetic
variability in susceptibility to tuberculosis. VDR
gene polymorphisms were analyzed in the Gambian
case-control study in which NRAMP1 variants were
found to be associated with tuberculosis. The VDR
genotype that produces higher circulating levels
of 1,25(OH)D3 [130] was significantly underrepre-
sented among patients who had tuberculosis com-
pared with ethnically matched controls [131]. VDR
gene polymorphisms were also found to be asso-
ciated with tuberculosis among Gujerati Indians in
London [132] and with leprosy type in patients
from India [133]. Further work is required to inves-
tigate the association between VDR gene polymor-
phisms, vitamin D intake, and host susceptibility
to tuberculosis.
The class II HLA DR2 has been found to be
associated with tuberculosis and leprosy in several
populations [134 – 137], but HLA-DR2 has not
been associated with tuberculosis in all populations
studied [138]. In Cambodia, a provisional association
has been described between HLA-DQB1*0503
and tuberculosis [139]. In India, multidrug-resistant
tuberculosis also has been found to be associated
with HLA-DQB1*0503 as well as with HLA-
DQB1*0502 and HLA-DRB1*14 [140]. In a further
case-control study, Indian patients who had pulmo-
nary or miliary tuberculosis were found to be more
likely to possess HLA-A3 – like peptide-binding
motifs [141]. The mechanisms underlying these asso-
ciations are uncertain. HLA associations with tuber-
culosis could be explained by particular HLA types
being more effective at recognizing specific myco-
bacterial antigens. Alternatively, the observed asso-
ciations may be cause by linkage disequilibrium with
other genes in the major histocompatibility complex
region of chromosome 6, such as the gene for tumor
necrosis factor-a.
Genome-wide linkage studies are an effective
way of screening for the genes that exert the great-
est population-wide effect on variability in suscep-
tibility to a multifactorial disease. A genome-wide
screen on 173 sibling-pairs from Gambia and South
Africa found evidence suggestive of linkage to tu-
berculosis for markers on chromosomes 15q11-13
and Xq26 [59]. The size of the observed linkage
effect would suggest that the putative tuberculosis-
susceptibility genes in these regions would exert a
much greater population-wide effect than that
caused by NRAMP1 or IFNg signaling pathway gene
variants. Ongoing studies are attempting to iden-
tify the tuberculosis-susceptibility genes in these re-
gions [142].
 240
Table 1
Putative mycobacteria-susceptibility genes/loci
Gene or Source of information suggesting the gene
chromosome Description of genetic variation is involved in susceptibility to tuberculosis Relevance to susceptibility to tuberculosis
Referencesa

bellamy
region associated with disease or other mycobacterial infections or other mycobacterial infections
NRAMP1 Several polymorphisms described Studies of inbred strains of mice with increased Common gene polymorphisms are associated [61 – 66]
function of these remains uncertain susceptibility to mycobacterial infections with susceptibility to tuberculosis

IFNcR1 Gene mutations result in severe Maltese family with Mendelian susceptibility The rare condition of partial or complete [69,71 – 81]
deficiency of the protein to mycobacterial infections and rare individuals deficiency leads to disseminated infections with
with disseminated BCG infections BCG and atypical mycobacteria

IFNcR2 Gene mutations result in severe Rare individuals with disseminated BCG and The rare condition of partial or complete [83,84]
deficiency of the protein atypical mycobacterial infections deficiency leads to disseminated infections with
BCG and atypical mycobacteria

STAT1 Gene mutations result in severe Single individual with disseminated atypical The rare condition of partial deficiency leads to [85]
deficiency of the protein mycobacterial infection disseminated infections with atypical mycobacteria

IL12Rb1 Gene mutations result in severe Rare individuals with disseminated BCG and The rare condition of partial or complete [86 – 91]
deficiency of the protein atypical mycobacterial infections deficiency leads to disseminated infections with
BCG and atypical mycobacteria

IL12B Gene mutations result in severe Rare individuals with disseminated BCG and The rare condition of partial or complete [92,93]
deficiency of the protein atypical mycobacterial infections deficiency leads to disseminated infections with
BCG and atypical mycobacteria
IFNc Gene polymorphism described, Rare individuals with IFNgR1 deficiency A common gene polymorphism is associated with [96 – 98]
function of this remains uncertain suggested IFNg is important in tuberculosis susceptibility to tuberculosis

Mbl2 Gene mutations result in severe Children with recurrent infections and inability Carriers of MBL-variant alleles have been found [112 – 117]
deficiency of the protein to opsonize Baker’s yeast to have increased resistance to tuberculosis,
leprosy and M. avium

VDR Several polymorphisms described Epidemiologic and in vitro data suggested Common gene polymorphisms are associated with [131 – 133]
function of these remains uncertain vitamin D is important in immunity to tuberculosis susceptibility to tuberculosis

HLA class II Large number of different Case-control studies performed because the HLA HLA-DR2 associated with tuberculosis and leprosy [134 – 137]
HLA types system is known to be a key component of the in several populations
acquired immune system

genetic susceptibility to tuberculosis

HLA class I Large number of different Case-control studies performed because the HLA Several different HLA class I types have been [139 – 141]
HLA types system is known to be a key component of found to be associated with tuberculosis
the acquired immune system

X chromosome Minisatellite markers on Genome-wide linkage analysis carried out on Suggestive evidence of linkage to tuberculosis for [59]
chromosome Xq26 sibling-pair families with tuberculosis Xq26 in Africans

Chromosome 15 Minisatellite markers on Genome-wide linkage analysis carried out on Suggestive evidence of linkage to tuberculosis for [59]
chromosome 15q11-13 sibling-pair families with tuberculosis 15q11-13 in Africans
Abbreviations: BCG, bacille Calmette-Guerin; IFNgR1, interferon-g receptor ligand binding chain; MBL, mannan-binding lectin.
a
Studies assessing the relevance of the gene to susceptibility to tuberculosis or to other mycobacterial infections.

241
242 bellamy
Summary
The development of disease following infection
with M. tuberculosis depends on a complex inter-
action between the host, the pathogen, and environ-
mental factors. Many host genes are likely to be
involved in the complex etiology of clinical tuber-
culosis. Substantial progress has already been made
in advancing the understanding of genetic suscepti-
bility to tuberculosis (Table 1). The host genes iden-
tified to date, however, account for only a small part
of the total component of the genetic variability in
individual susceptibility to tuberculosis. It is likely
that there are many more tuberculosis-susceptibility
genes remain to be identified, and several of these
may have much greater importance than those that
have been discovered to date.
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 Clin Chest Med 26 (2005) 167 – 182
Global Epidemiology of Tuberculosis
Dermot Maher, BM, BCh, DM, Mario Raviglione, MD*
Stop TB Department, World Health Organization, Avenue Appia, CH1211 Geneva 27, Switzerland
In 1993, the World Health Organization (WHO)
declared tuberculosis a global emergency because of
the scale of the epidemic and the urgent need to
improve global tuberculosis control [1,1a]. Since
then, WHO has promoted the strategy for global
tuberculosis control known as DOTS (a name derived
originally from directly observed treatment, short-
course) [2,3] and its adaptations (eg, as part of a
strategy of expanded scope where HIV prevalence
is high [4] and as DOTS-Plus in areas where the
prevalence of multidrug-resistant [MDR] tuberculosis
is high) [5]. This article provides an overview of the
current scale of the global tuberculosis epidemic. It
describes the global tuberculosis situation as mea-
sured by reported and estimated cases and deaths.
The increasing threats of HIV-related tuberculosis
and drug-resistant tuberculosis receive particular
attention. There is a brief review of the extent of im-
plementation of effective tuberculosis control using
the DOTS strategy. The article ends with a summary
of the approaches needed to accelerate progress in
global tuberculosis control.
Review of the global tuberculosis epidemic
As part of the description of the global tuber-
culosis epidemic, the size of the burden of tuber-
culosis indicates progress in tuberculosis control and
draws attention to the scale of the problem, thereby
helping to mobilize resources for tuberculosis control.
* Corresponding author.
E-mail address: raviglionem@who.ch (M. Raviglione).
0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.009
The size of the burden of tuberculosis
Tuberculosis case notifications and reported deaths
Tuberculosis notification data are important and
are routinely reported by WHO [6]. At the country
level, a system of recording and reporting tuber-
culosis cases and their treatment outcomes (including
death) is an intrinsic part of the DOTS strategy
(Box 1). Therefore as the number of countries
implementing the DOTS strategy increases, routine
national tuberculosis program (NTP) data on tuber-
culosis cases and deaths are becoming more widely
available [6]. Notification data reflect health ser-
vice coverage and the efficiency of case-finding and
reporting activities of NTPs. Thus, in the developing
countries where tuberculosis incidence is generally
high, where access to health services may be limited,
and where NTP performance may be suboptimal,
notification data often represent only a fraction of
the true incident cases. In addition, because case
definitions vary among countries (eg, when some
countries’ notification data include all cases, both
new and re-treatment cases), comparisons of case
notification data from different countries are difficult.
In industrialized countries, however, where tuber-
culosis incidence is generally low, where health ser-
vice coverage is generally universal, and where NTPs
are effective, notifications of cases often closely ap-
proximate to the true incidence of tuberculosis. In
any country, under stable program conditions, case
notifications may provide useful data on the trend of
incidence and a means for obtaining rates by age, sex,
and risk group.
Despite the limitations of tuberculosis case noti-
fications, WHO has since 1997 published worldwide
data provided by its member states, most recently
referring to the 4.1 million cases reported in 2002 [6].
chestmed.theclinics.com
168 maher
Box 1. The five elements of the directly
observed treatment, short-course strategy
for tuberculosis control
 Sustained government commitment
to tuberculosis control
 Diagnosis based on quality-assured
sputum-smear microscopy mainly
among symptomatic patients
presenting to health services
 Standardized short-course
chemotherapy for all cases of
tuberculosis, under proper case-
management conditions including
direct observation of treatment
 Uninterrupted supply of quality-
assured drugs
 A standard recording and reporting
system enabling program monitoring
by systematic assessment of
treatment outcomes of all
patients registered
Data from Refs. [2,3].
Table 1 shows tuberculosis case notifications and
rates by WHO region. Three regions dominate the
worldwide distribution of notified cases: the South-
East Asian Region (36% of cases), the African
Region (24% of cases), and the Western Pacific
Region (20% of cases). The three other regions have
much smaller proportions of the cases notified
worldwide: the Region of the Americas (9%), the
Eastern Mediterranean Region (6%), and the Euro-
pean Region (5%). Fig. 1 shows tuberculosis case
notification rates by country in 2002 [6].
In industrialized countries, case notifications gen-
erally approximate the true incidence of tuberculosis
more closely than in developing countries. Tuber-
culosis case notifications steadily declined through-
out most of the twentieth century in industrialized
countries, beginning before the introduction of anti-
tuberculosis chemotherapy, largely because of socio-
economic improvements and possibly also because of
the isolation of infectious cases in sanatoria. The
effective application of chemotherapy in the latter
half of the twentieth century further accelerated the
decline. From the mid-1980s onwards, however,
several countries saw a failure of the expected con-
tinued decline, and others saw the trend reversed,
with case notifications increasing for the first time in
many years. For example, in the United States, after
& raviglione
30 years of previous steady decline, tuberculosis
incidence increased regularly between 1985 and 1992
[7]. Factors responsible for the reversal of the
previous trend included increased poverty among
marginalized groups in inner city areas, immigration
from countries with high tuberculosis prevalence, the
impact of HIV, and, most importantly, the failure to
maintain the necessary public health infrastructure
under the mistaken belief that tuberculosis was a
problem of the past.
Many countries in Europe, including Denmark,
the Netherlands, Sweden, and the United Kingdom,
also reported a failure of the expected continued de-
cline or even a steady rise in tuberculosis cases [8].
The high proportion of cases in the foreign-born (eg,
24% in France, 51% in the Netherlands, 54% in
Sweden, 68% in Switzerland) indicated immigration
as the main cause of this change in trend [9]. Annual
case rates in foreign-born populations often exceed
50 per 100,000 and may even exceed 100 per
100,000 (eg, in the Netherlands), in contrast to
annual case rates usually below 15 per 100,000 in
indigenous populations [9]. In Western Europe, the
impact of HIV on tuberculosis has been largely
limited to certain countries (eg, Spain, Portugal) and
cities (eg, Paris, Amsterdam) [10]. In most countries
in Western Europe, the proportion of AIDS cases
diagnosed with tuberculosis is low; two notable
exceptions are Spain and Portugal [11], where the
overlap between the population infected with HIV
and the population infected with Mycobacterium
tuberculosis is greater than in the other countries of
Western Europe. Tuberculosis incidence rates in
Japan are still high, at about 40 per 100,000, but
Table 1
Tuberculosis case notifications and rates by World Health
Organization region in 2002
No. of Proportion Rate
cases notified of global (per 100,000
WHO region (all forms) total (%) population)
African 992,054 24 148
Americas 233,648 9 27
Eastern 188,458 6 37
Mediterranean
European 373,497 5 43
Southeast Asia 1,487,985 36 94
Western Pacific 806,112 20 47
Global 4,081,754 — 66
Data from World Health Organization. Global tuberculosis
control: surveillance, planning, financing. WHO report
2004. Document WHO/HTM/TB/2004.331. Geneva (Swit-
zerland): World Health Organization; 2004. p. 21.
 global epidemiology of tuberculosis 169

Fig. 1. Tuberculosis case notification rates by country in 2002. The designations employed and the presentation of material on
this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the
legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries.
White lines on maps represent approximate border lines for which there may not yet be full agreement. [From World Health
Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Document WHO/HTM/TB/
2004.331. Geneva (Switzerland): World Health Organization; 2004. p. 218, fig. 4; with permission.]

are declining [12]. In other industrialized countries,
including Australia, New Zealand, and Canada, rates
have leveled off during the past few years below
10 per 100,000. The proportion of cases in the
foreign-born is about 70% in Australia and about
50% in Canada [12]. The implication of the high
proportion of cases in the foreign-born in most indus-
trialized countries is that tuberculosis control in these
settings depends on tuberculosis control globally.
Tuberculosis case notification rates are still high
in the countries of the former Soviet Union [6]. In
many countries the previous continued decline in case
notifications stopped or reversed from the early 1990s
onwards. For example, annual notification rates
doubled in Russia from 1990 to 2002, with an in-
creased proportion of cases in young adults [6].
Dramatic social changes following the end of the
Soviet Union engendered a combination of factors
responsible for the reversal of the previous trend,
probably through increased susceptibility to infection
and increased breakdown to disease after infection.
These factors include increased poverty and poor
living conditions (resulting in malnutrition, crowding,
and stress) and in some cases civil conflicts and
wars, deteriorating health services, and lack of drugs,
resulting in decreased rates of cure of tuberculosis
patients and continued transmission in the commu-
nity. The spread of HIV in some countries, particu-
larly the Russian Federation and Ukraine, has the
potential, if unchecked, to fuel the tuberculosis epi-
demic further.
Data on tuberculosis deaths are reported through
national vital registration systems and through the
routine standard NTP recording and reporting system.
Few developing countries have comprehensive vital
registration systems for the accurate reporting of
deaths. Routine NTP data on tuberculosis deaths are
becoming more widely available in developing
countries [6]. NTPs report these tuberculosis-cohort
deaths (the number and proportion of tuberculosis
patients dying during treatment) without specifying
cause, because the cause of death can rarely be
determined in countries where income is low and the
prevalence of tuberculosis is high [13]. Inaccurate
170 maher & raviglione

routine NTP reporting of cohort deaths and incom-
plete NTP coverage of all incident cases in many
countries limit the extent to which tuberculosis cohort
deaths reflect tuberculosis mortality.
Estimated tuberculosis cases and deaths
Because of the limitations of tuberculosis notifi-
cations and the difficulties in directly measuring the
numbers of cases and deaths, the size of the tuber-
culosis disease burden must be estimated. WHO esti-
mates of tuberculosis incidence and deaths are based
on a variety of inputs, including surveys of preva-
lence of tuberculosis infection and disease, vital
registration data, and independent assessments of
quality of surveillance systems [14,15]. In 2002 there
were an estimated 8.8 million new cases of tuber-
culosis worldwide, with an incidence rate of 141 per
100,000 population [6]. The global incidence rate of
tuberculosis is growing at approximately 1.1% per
year, although this overall global trend is fueled by
and hides much faster increases in sub-Saharan
Africa and in countries of the former Soviet Union
[6]. Table 2 summarizes tuberculosis incidence and
mortality estimates in 2002 by WHO regions [6,14].
Fig. 2 shows estimated tuberculosis incidence by
country for 2002 [6]. The ranking of countries by
number of tuberculosis cases draws attention to the
22 countries that account for roughly 80% of the
world’s tuberculosis burden (Table 3). Developing
countries suffer the brunt of the tuberculosis epi-
demic. Overall, it is estimated that 95% of the world’s
tuberculosis cases and 98% of the tuberculosis deaths
occur in the developing world [12], and that tuber-
culosis causes more than 25% of avoidable adult
deaths in the developing world [16]. The importance
of the tuberculosis problem for individual countries is
expressed as the annual incidence (absolute number
of cases occurring yearly) and as the incidence rate
(cases per 100,000 population). Fig. 3 shows esti-
mated tuberculosis incidence rates by country in 2002
[6]. Tuberculosis incidence rates are generally much
lower in industrialized countries than in developing
countries. Among the 15 countries with the highest
estimated tuberculosis incidence rates, 13 are in sub-
Saharan Africa, and in most of these countries the

Table 2
Summary of tuberculosis estimates by World Health Organization region in 2002
WHO region
AFRa AMR EMR EUR SEAR WPR Global
Population (millions) 672 857 507 877 1591 1718 6222
New cases of TB (all forms)
No. of incident cases (thousands) 2354 370 622 472 2890 2090 8798
Incidence rate (per 100,000) 350 43 123 54 182 122 141
Change in incidence rate 1997 – 2000 (%/y) 5.9 3.6 0.7 1.9 2.1 0.2 1.1
HIV prevalence in new adult cases (%) 37.0 5.5 2.8 3.6 3.5 1.2 12.0
Attributable to HIV (thousands) 506.0 11.0 9.8 10.0 56.0 14.0 656.0
Attributable to HIV (% of adult cases) 31.0 5.0 2.5 3.3 2.9 1.1 11.0
New SS+ cases of TB
No. of incident cases (thousands) 1000 165 279 211 1294 939 3888
Prevalence rate of SS+ TB (per 100,000) 224 25 102 34 166 104 112
Prevalent SS+ cases HIV+ (%) 6.9 1.0 0.4 0.7 0.5 0.2 1.8
Deaths from TB
No. of deaths from TB (thousands) 556 53 143 73 625 373 1823
Deaths from TB (per 100,000) 83.0 6.2 28.0 8.3 39.0 22.0 29.0
Deaths from TB in HIV-positive adults (thousands) 208.0 3.7 4.8 3.0 26.0 5.5 251.0
Adult AIDS deaths caused by TB (%) 15.0 5.4 20.0 13.0 7.6 14.0 13.0
TB deaths attributable to HIV (%) 34.0 6.5 3.2 3.9 3.8 1.4 13.0
Abbreviations: adult, 15 – 49 years old; AFR, African; AMR, Americas; EMR, Eastern Mediterranean; EUR, European; SEAR,
Southeast Asia; SS+, sputum smear-positive; TB, tuberculosis; WPR, Western Pacific.
a
WHO African region comprises sub-Saharan Africa and Algeria. The remaining North African countries are included in
the WHO Eastern Mediterranean region.
Data from World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004.
Document WHO/HTM/TB/2004.331. Geneva (Switzerland): World Health Organization; 2004; and Corbett EL, Watt CJ,
Walker N, et al. The growing burden of tuberculosis: global trends and interactions with the HIV epidemic. Arch Intern Med
2003;163:1009 – 21.
 global epidemiology of tuberculosis 171

Fig. 2. Estimated tuberculosis incidence by country in 2002. The designations employed and the presentation of material on this
map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal
status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries.
White lines on maps represent approximate border lines for which there may not yet be full agreement. [From World Health
Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Document WHO/HTM/TB/
2004.331. Geneva (Switzerland): World Health Organization; 2004; with permission.]

prevalence of HIV infection among tuberculosis
patients is high [6].
In conclusion, worldwide notification data and
estimates suggest a steady decline in the tuberculosis
burden in many regions except in sub-Saharan Africa
and the former Soviet Union. The reasons for the
persisting global tuberculosis burden include (1) pov-
erty and the widening gap between rich and poor
in various populations (eg, developing countries,
inner city populations in developed countries);
(2) previous neglect of tuberculosis control (inad-
equate case detection, diagnosis, and cure); (3)
changing demography (increasing world population
and changing age structure); and (4) the impact of the
HIV pandemic [17].
HIV-related tuberculosis
Through potent immunocompromise of infected
hosts, HIV has emerged as the most important risk
factor for progression of dormant M. tuberculosis
infection to clinical tuberculosis disease [18]. A short
overview of HIV epidemiology is useful because HIV
is such an important force driving the tuberculosis
epidemic in sub-Saharan Africa and has the potential
to drive the tuberculosis epidemic in other regions
wherever HIV transmission spreads unchecked. HIV
surveillance systems in most countries with gener-
alized epidemics rely on tracking HIV prevalence
among pregnant women attending antenatal clinics.
These antenatal clinic data, supplemented by data
from other sources such as blood donors and sex
workers, are used to obtain national estimates of HIV
prevalence among men and women and to assess
trends. By the end of 2003, an estimated 38 million
adults and children worldwide had HIV infection or
AIDS [19]. Of these, 25 million (66%) were in sub-
Saharan Africa, and 6.5 million (17%) were in South
and South-East Asia. In 2003, 4.8 million adults and
children were newly infected with HIV. An estimated
2.9 million adults and children died from HIV/AIDS
172 maher & raviglione

Table 3
Ranking of countries by estimated number of tuberculosis cases
Number estimated
All cases Smear-positive cases
Rate Rate
Population No. (per 100,000 No. (per 100,000 Cumulative
Rank Country (thousands) (thousands) population) (thousands) population) incidence (%)
1 India 1,049,549 1761 168 787 75 20
2 China 1,294,867 1459 113 656 51 37
3 Indonesia 217,131 557 256 250 115 43
4 Nigeria 120,911 368 304 159 132 47
5 Bangladesh 143,809 318 221 143 99 51
6 Pakistan 149,911 272 181 122 81 54
7 Ethiopia 68,961 255 370 110 159 57
8 Philippines 78,580 251 320 113 144 60
9 South Africa 44,759 250 558 102 227 62
10 Democratic Republic 51,201 196 383 85 167 65
of the Congo
11 Russian Federation 144,082 182 126 81 56 67
12 Kenya 31,540 170 540 70 223 69
13 Vietnam 80,278 155 192 69 86 70
14 United Republic 36,276 132 363 56 155 72
of Tanzania
15 Brazil 176,257 110 62 49 28 73
16 Uganda 25,004 94 377 41 164 74
17 Zimbabwe 12,835 88 683 35 271 75
18 Mozambique 18,537 81 436 34 182 76
19 Thailand 62,193 80 128 35 57 77
20 Afghanistan 22,930 76 333 34 150 78
21 Cambodia 13,810 76 549 33 242 79
22 Myanmar 48,852 75 154 33 68 80
High-burden countries 3,892,274 7005 180 3100 80 80

Global total 6,219,011 8797 141 3887 63 100

The top 22 countries account for roughly 80% of the world’s tuberculosis burden.
Data from World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004.
Document WHO/HTM/TB/2004.331. Geneva (Switzerland): World Health Organization; 2004. p. 22.

during 2003. Roughly 2.2 million (76%) of these
deaths occurred in sub-Saharan Africa. Sub-Saharan
Africa is the region with the highest overall HIV
prevalence rate in the general adult (15 – 49 years)
population, 7.5% at the end of 2003.
Of 20 countries in the world with an adult HIV
prevalence rate in 2003 above 5%, 19 are in sub-
Saharan Africa (the other is Haiti). In seven countries
in southern Africa, adult HIV prevalence is 15% or
above. Although the countries that have the highest
rates of HIV infection are in Africa, certain countries
in South-East Asia and Latin America are also badly
affected, with an adult HIV prevalence of 1% to 5%.
Although the rise in HIV prevalence seems now to be
decelerating or even decreasing in parts of Eastern
and Southern Africa, it is still increasing rapidly in
some other large populations, for example in the
Russian Federation.
Tuberculosis cases
The HIV pandemic has dramatically fuelled
tuberculosis in populations where there is overlap
between those infected with M. tuberculosis and
those infected with HIV. Table 4 shows the number
of M. tuberculosis- and HIV-coinfected adults (15 –
49 years) in WHO regions and globally by the end of
2000 [14]. Of the 11.4 million adults coinfected with
M. tuberculosis and HIV worldwide by the end of
2000, 70% were in sub-Saharan Africa (Table 4) [14].
The estimated national HIV prevalence in tuber-
culosis patients reflects the extent of the overlap
 global epidemiology of tuberculosis 173

Fig. 3. Estimated tuberculosis incidence rates by country in 2002. The designations employed and the presentation of material on
this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the
legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers or boundaries.
White lines on maps represent approximate border lines for which there may not yet be full agreement. [From World Health
Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Document WHO/HTM/TB/
2004.331. Geneva (Switzerland): World Health Organization; 2004. p. 215, fig. 1; with permission.]

Table 4 between the population infected with M. tuberculosis

Number and global percentage of Mycobacterium tuber- and the population infected with HIV in that country.
culosis- and HIV-coinfected adults (15 – 49 years) in World
Fig. 4 shows the estimated HIV prevalence in
Health Organization regions by the end of 2000
tuberculosis patients by country in 2002. The esti-
No. of people mated HIV prevalence in tuberculosis patients is
coinfected with greater than 20% in nearly all of the countries of sub-
M. tuberculosis Proportion
Saharan Africa and is greater than 50% in most of the
and HIV of global
WHO region (thousands) total (%)
countries of the southern cone. Haiti is the only
country outside sub-Saharan Africa where the esti-
African 7979 70 mated HIV prevalence in tuberculosis patients is
Americas 468 4
greater than 20%. The largest share of the global
Eastern Mediterranean 163 1
European 133 1
burden of HIV-related tuberculosis falls on sub-
Southeast Asia 2269 20 Saharan Africa, where 31% of new cases of tuber-
Western Pacific 427 4 culosis (all forms) and 34% of tuberculosis deaths are
attributable to HIV, and where HIV is now the most
Total 11,440 100 important single predictor of tuberculosis incidence
Data from Corbett EL, Watt CJ, Walker N, et al. The grow- (Fig. 5) [14].
ing burden of tuberculosis: global trends and interac- The increasing spread of HIV, especially in
tions with the HIV epidemic. Arch Intern Med 2003;163: Eastern and Southern Africa, resulting in an increased
1009 – 21. population of M. tuberculosis- and HIV-coinfected
174 maher & raviglione

Fig. 4. Estimated HIV prevalence in tuberculosis cases by country in 2002. The designations employed and the presentation of
material on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization
concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation of its frontiers
or boundaries. White lines on maps represent approximate border lines for which there may not yet be full agreement. [From
World Health Organization. Global tuberculosis control: surveillance, planning, financing. WHO report 2004. Document WHO/
HTM/TB/2004.331. Geneva (Switzerland): World Health Organization; 2004. p. 216, fig. 2; with permission.]

people, has driven the incidence of tuberculosis

1000
upwards in sub-Saharan Africa [6]. From 1997 to
2002, the tuberculosis incidence rate in the WHO
(per 100,000 population)
Estimated TB incidence

800 African region grew at approximately 4% per year,

and at 6% per year in Eastern and Southern Africa,
600 faster than on any other continent and considerably
faster than the 1% per year global increase. In several
400
African countries, including those with well-organ-
200 ized control programs [20,21], annual tuberculosis
case notification rates have risen more than fivefold
0 since the mid 1980s, reaching more than 400 cases
0 10 20 30 40
per 100,000 population [6]. Because HIV infection
Estimated HIV prevalence, adults 15-49 yrs (%)
rates are higher in women than men, more tuber-
culosis cases are also being reported among women,
Fig. 5. Estimated tuberculosis incidence in relation to
estimated HIV prevalence for 42 countries in the WHO especially those aged 15 to 24 years. Although
African Region. (From Corbett EL, Watt CJ, Walker N, et al. tuberculosis case notifications typically show a male
The growing burden of tuberculosis: global trends and gender predominance, in several African countries
interactions with the HIV epidemic. Arch Intern Med 2003; with high rates of HIV infection, the majority of
163:1018; with permission.) notified tuberculosis cases are now women [6].
 global epidemiology of tuberculosis
Tuberculosis deaths
The aims of tuberculosis control are to reduce
tuberculosis mortality, morbidity, and disease trans-
mission while preventing the development of drug
resistance [13]. Tuberculosis deaths are not related to
the public health objective of cutting the cycle of
disease transmission, but, as an adverse outcome for
tuberculosis patients and their families, they are an
important indicator of NTP performance and of
progress toward reaching the global health targets
agreed as part of the United Nations Millennium
Development Goals (MDGs) [22]. These consider-
ations are particularly important in countries with
high HIV prevalence where the advent of the HIV
epidemic has dramatically increased both the inci-
dence of tuberculosis and tuberculosis deaths.
It is useful to consider briefly tuberculosis case
fatality (the proportion of tuberculosis cases that die
within a specified time) in the pre-HIV era (before
and after the introduction of effective antituberculosis
chemotherapy) before turning to the HIV era (ie, from
the 1980s onwards). Tuberculosis case fatality was
high before the introduction of effective antitubercu-
losis chemotherapy. For example, survival analysis of
confirmed pulmonary tuberculosis patients diagnosed
between 1925 and 1934 in a large town in Denmark
showed that the probability of dying ranged between
17% and 29%, 32% and 43%, and 42% and 55%
1 year, 3 years, and 5 years after tuberculosis diag-
nosis, respectively [23]. In an observational study
of sputum-positive tuberculosis patients diagnosed
between 1928 and 1938 in the United Kingdom, 40%
of patients died in the first year after they were
diagnosed with tuberculosis [24]. A reduction in
tuberculosis deaths usually quickly followed the
introduction of antituberculosis chemotherapy. Data
on tuberculosis case fatality in the prechemotherapy
era in sub-Saharan Africa are lacking, but data
from clinical trials of combination chemotherapy in
Eastern Africa in the 1970s showed a low case fatal-
ity [25].
HIV has dramatically increased tuberculosis case
fatality as measured in clinical trials and as reflected
by tuberculosis cohort deaths reported by NTPs. Risk
of death during and after tuberculosis treatment is
higher among HIV-positive than among HIV-negative
patients who have smear-positive pulmonary tuber-
culosis and is higher still among HIV-positive
patients who have smear-negative tuberculosis (prob-
ably reflecting their greater degree of immunosup-
pression) [26]. In sub-Saharan Africa, up to 30%
of HIV-infected tuberculosis patients die within
12 months of starting treatment [27]. Even with
treatment regimens that are highly effective in HIV-
175
negative pulmonary tuberculosis patients, cohort
deaths for HIV-positive pulmonary tuberculosis
patients in some sub-Saharan African countries are
now as high as 20% for sputum smear – positive cases
and 50% for sputum smear – negative cases [26].
Tuberculosis cohort deaths are linked closely to
HIV prevalence, both within countries (ie, in many
countries tuberculosis cohort deaths have increased as
adult HIV seroprevalence has increased) and in wider
areas (tuberculosis cohort deaths and national HIV
seroprevalence in sub-Saharan Africa are strongly
correlated) [26]. The increase in tuberculosis deaths
in populations with high HIV prevalence in sub-
Saharan Africa may change the popular perception of
tuberculosis as a curable disease and threaten the
reputation of NTPs. This experience may have an
adverse influence on the willingness of tuberculosis
suspects to come forward for diagnosis and on the
ability of the NTPs to ensure that tuberculosis pa-
tients complete treatment.
Measures to prevent tuberculosis deaths in coun-
tries with high HIV prevalence include [27]
1. Antiretroviral therapy (likely to have the great-
est impact)
2. Tuberculosis treatment regimens of proven ef-
fectiveness
3. Preventive therapy for HIV-related diseases
other than tuberculosis (eg, co-trimoxazole to
prevent common bacterial infections)
4. Improved tuberculosis and HIV control services
5. Improved general health services with better
diagnosis and treatment of HIV-related diseases
Implementing these measures will need increased
financial and human resources for the general health
services and for tuberculosis and HIV programs and
more effective collaboration between tuberculosis
and HIV/AIDS programs [4].
Drug-resistant tuberculosis
Drug resistance and eventually MDR (ie, resis-
tance to at least isoniazid and rifampicin) are ex-
pected to occur wherever there is inadequate
application of antituberculosis chemotherapy [28].
An assessment of the number and distribution of
drug-resistant tuberculosis cases is important for
planning tuberculosis control, because the treatment
of resistant cases is more costly and more complex
when second-line drugs are used, with more fre-
quent failures and deaths. The distinction between
resistance among new cases (previously known as
176 maher & raviglione

primary resistance) and resistance among previ-
ously treated cases (previously known as acquired
resistance) is important because of their different im-
plications for NTPs. Three rounds of surveys coor-
dinated by WHO and the International Union Against
Tuberculosis and Lung Disease (IUATLD) between
1996 and 2002 have yielded data on antituberculosis
drug resistance among new and previously treated
cases. The third round of surveys included new data
from 77 settings or countries collected between 1999
and 2002 and gave the following results for resistance
among new and previously treated cases [29].
New cases
Data on new cases were available for 75 settings.
In total, 55,779 patients were surveyed. The preva-
lence of resistance to at least one antituberculosis
drug (any resistance) ranged from 0% in some
Western European countries to 57.1% in Kazakhstan
(median, 10.2%). Median prevalences of resistance to
specific drugs were as follows: streptomycin, 6.3%;
isoniazid, 5.9%; rifampicin, 1.4%; and ethambutol,
0.8%. Prevalence of MDR ranged from 0% in eight
countries to 14.2% in Kazakhstan (51/359) and Israel
(36/253) (median, 1.1%). Fig. 6 shows by participat-
ing country the prevalence of MDR-tuberculosis
among new tuberculosis cases. Other high prevalen-
ces of MDR were observed in Tomsk Oblast (Russian
Federation) (13.7%), Karakalpakstan (Uzbekistan)
(13.2%), Estonia (12.2%), Liaoning Province (China)
(10.4%), Lithuania (9.4%), Latvia (9.3%), Henan
Province (China) (7.8%), and Ecuador (6.6% on
preliminary data).
Trends in drug resistance in new cases were
determined in 46 settings (20 with two data points
and 26 with at least three). Significant increases in
prevalence of any resistance were found in Peru,
Botswana, New Zealand, Poland, and Tomsk Oblast,
(Russian Federation). Cuba, Hong Kong SAR, and
Thailand reported significant decreases over time.
Tomsk Oblast (Russian Federation) and Poland
showed significantly increased prevalences of MDR.
Decreasing trends in MDR were observed in Hong
Kong SAR, Thailand, and the USA.

Fig. 6. Prevalence of MDR-tuberculosis among new tuberculosis cases, 1994 – 2002. The designations employed and the
presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the World Health
Organization concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the delimitation
of its frontiers or boundaries. Dashed lines represent approximate border lines for which there may not yet be full agreement.
[From World Health Organization. Anti-tuberculosis drug resistance in the world. Report no. 3. The WHO/IUATLD Global
Project on Anti-tuberculosis Drug Resistance Surveillance 1999 – 2002. Document WHO/HTM/TB/2004.343. Geneva
(Switzerland): World Health Organization; 2004. p. 47; with permission.]
 global epidemiology of tuberculosis 177

Previously treated cases
Data on previously treated cases were available
for 66 settings. In total, 8405 patients were surveyed.
The median prevalence of resistance to at least one
drug (any resistance) was 18.4%, with the highest
prevalence, 82.1%, in Kazakhstan (262/319). Median
prevalences of resistance to specific drugs were as
follows: isoniazid, 14.4%; streptomycin, 11.4%;
rifampicin, 8.7%; and ethambutol, 3.5%. The median
prevalence of MDR was 7.0%. Fig. 7 shows by par-
ticipating country the prevalence of MDR tuber-
culosis among previously treated tuberculosis cases.
The highest prevalences of MDR were reported in
Oman (58.3%; 7/12) and Kazakhstan (56.4%; 180/
319). Among countries of the former Soviet Union,
the median prevalence of resistance to the four drugs
was 30%, compared with a median of 1.3% in all
other settings. Given the small number of subjects
tested in some settings, prevalence of resistance
among previously treated cases should be interpreted
with caution.
Drug-resistance trends in previously treated cases
were determined in 43 settings (19 with two data
points and 24 with at least three data points). A
significant increase in the prevalence of any resis-
tance was observed in Botswana. Cuba, Switzerland,
and the United States showed significant decreases.
The prevalence of MDR significantly increased in
Estonia, Lithuania, and Tomsk Oblast (Russian
Federation). Decreasing trends were significant in
Slovakia and the United States. More representative
geographic coverage of global antituberculosis drug
resistance surveillance, with further data from longi-
tudinal studies, will enable more accurate and com-
prehensive monitoring of global trends in the spread
of MDR tuberculosis. Increases in prevalence of
resistance can be caused by poor or worsening tuber-
culosis control, immigration of patients from areas of
higher resistance, outbreaks of drug-resistant disease,
and variations in surveillance methodologies.
In conclusion, although drug-resistant tuberculosis
is present in all settings surveyed, the prevalence of
MDR is high only in certain settings. Because good
tuberculosis control practices are generally associ-
ated with lower or decreasing levels of resistance,
the findings of the WHO/IUATLD Global Project

Fig. 7. Prevalence of MDR-tuberculosis among previously treated tuberculosis cases, 1994 – 2002. The designations employed
and the presentation of material on this map do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area, or of its authorities, or concerning the
delimitation of its frontiers or boundaries. Dashed lines represent approximate border lines for which there may not yet be full
agreement. [From World Health Organization. Anti-tuberculosis drug resistance in the world. Report no. 3. The WHO/IUATLD
Global Project on Anti-tuberculosis Drug Resistance Surveillance 1999 – 2002. Document WHO/HTM/TB/2004.343. Geneva
(Switzerland): World Health Organization; 2004. p. 53; with permission.]
178 maher
emphasize the vital importance of strengthening
tuberculosis control worldwide, by expanding and
improving the quality of implementation of the
DOTS strategy, to prevent the emergence of further
drug resistance. National programs need to manage
MDR tuberculosis cases, regardless of prevalence,
through application of the DOTS-Plus strategy [30].
Status of global tuberculosis control
The scale of the tuberculosis epidemic, as de-
scribed previously, and the human rights approach
to tuberculosis demand effective and urgent action
[31]. WHO has promoted the DOTS strategy to
control tuberculosis primarily by the interruption of
transmission through the rapid identification and cure
of infectious cases. By 2002, the number of countries
and territories implementing the DOTS strategy was
180 (of 210), with an estimated 69% of the world’s
population living in administrative areas of countries
where the DOTS strategy was being implemented [6].
In practice, however, the proportion of the population
with access to the DOTS strategy is less than this
administrative figure because of several possible
barriers to access, including geographic, financial,
and cultural impediments, within the administrative
area. Relying on currently available methods of diag-
nosis and treatment, the DOTS strategy is effective,
affordable, and adaptable in different settings (eg, as
part of a strategy of expanded scope where HIV
prevalence is high [4], as DOTS-Plus in areas where
the prevalence of MDR tuberculosis is high [5], and
as public-private mix [PPM] DOTS where the ma-
jority of tuberculosis suspects consult private practi-
tioners) [32].
WHO coordinates a global tuberculosis monitor-
ing and evaluation project in which countries report
annual progress in implementation of the DOTS
strategy [33]. The World Health Assembly (WHA)
has set global targets for tuberculosis control through
the implementation of the DOTS strategy [34]. The
choice of these global targets reflected the need to
achieve a significant epidemiologic impact by reach-
ing targets that field experience had demonstrated
were feasible in countries with a high incidence of
tuberculosis. These targets are to detect at least 70%
of all new infectious cases and to cure at least 85% of
those detected by 2005 [35]. A 70% case detection
rate and an 85% cure rate eventually would reduce
both the prevalence of infectious tuberculosis cases
and the number of infected contacts by about 40%
[36] and would lead to an expected decline in annual
& raviglione
tuberculosis incidence rate of 6% to 7% per year [37].
The epidemiologic impact on the global tuberculosis
epidemic of sustained achievement of these targets is
expressed in the MDG relevant to tuberculosis (Goal
6, Target 8), ‘‘to have halted and begun to reverse
incidence by 2015’’ [22]. The epidemiologic inter-
pretation of this goal set by politicians is to decrease
tuberculosis prevalence and deaths by half by 2015.
The following section summarizes the most recent
assessment of progress in implementation of the
DOTS strategy toward achieving the cure rate and
case detection targets as set out in the 2004 WHO
Report, which reports on the cases detected in 2002
and the outcomes of treatment of patients detected in
2001 [6].
Cases detected and notified
Through the global tuberculosis monitoring and
evaluation project coordinated by WHO, countries
report annually the number and type of tuberculosis
cases detected, reported, and treated under DOTS and
non-DOTS programs [6]. In 2002, approximately
3 million patients who were newly diagnosed with
tuberculosis, 1.4 million of whom were smear-
positive, were reported in DOTS programs. A total
of 13.3 million tuberculosis patients and 6.8 million
smear-positive patients were treated in DOTS pro-
grams between 1995 and 2002. Regarding new cases
of sputum smear – positive pulmonary tuberculosis,
for the calculation of case detection rate in each
country, the numerator is the number of annual cases
detected and reported under the DOTS strategy, and
the denominator is the estimated annual incidence
of cases in that country. The numerator is derived
annually from country reports of registered cases (ie,
cases detected and reported under the DOTS strat-
egy). The denominator is an estimate based on a
variety of inputs, as outlined earlier. One of the
challenges in improving the accuracy of measurement
of the case detection rate is ensuring that all cases
detected by different care providers (eg, private
practitioners) and treated in line with the DOTS strat-
egy are reported through the NTP. The 1.4 million
smear-positive cases reported globally by DOTS
programs in 2002 represent 37% of the estimated
incidence, a little more than half of the 70% target.
Treatment success
The cure rate is reported by each country through
cohort analysis of standard treatment outcomes of
registered patients (Table 5) [13]. Because practice
varies considerably among countries in documenting
 global epidemiology of tuberculosis
Table 5
Standard treatment outcomes in patients who have sputum
smear-positive pulmonary tuberculosis
Outcome Patient characteristics
Cure Patient who is sputum smear-negative
in the last month of treatment and at
least on one previous occasion
Treatment Patient who has completed treatment
completeda but who does not meet the criteria to
be classified as a cure or a failure
Treatment Patient who is sputum smear-positive
failure at 5 months or later during treatmentb
Died Patient who dies for any reason during
the course of treatment
Default Patient whose treatment was interrupted
for 2 consecutive months or more
Transfer out Patient who has been transferred to
another recording and reporting unit
and for whom the treatment outcome
is not known
a
Treatment success is defined as the sum of patients
cured and those who have completed treatment.
b
Also a patient who was initially smear-negative before
starting treatment and became smear-positive after complet-
ing the initial phase of treatment.
Data from World Health Organization. Treatment of tuber-
culosis: guidelines for national programmes. 3rd edition.
Document WHO/CDS/TB/2003.313. Geneva (Switzerland):
World Health Organization; 2003. p. 55.
negative sputum smears on completion of treatment,
for practical purposes the treatment success rate (cure
plus treatment completion) is used as a proxy for cure
rate. Treatment success under DOTS for the 2001
cohort was 82% on average. As in previous years,
treatment success was substantially below average in
the WHO African Region (71%) and in the former
Soviet Union (70%). Low treatment success in these
two regions is attributable, in part, to NTPs failing to
cope with the increased caseload fuelled by HIV and
the problem of drug resistance, respectively. All in-
dicators of treatment outcome were much worse in
non-DOTS areas, although the true outcome of treat-
ment is unknown for a high proportion of patients
in non-DOTS areas because of the lack of use of
standardized definitions and lack of systematic
reporting when programs are weak. Fatal outcomes
were most common in Africa (7.2%), where a higher
percentage of cases is HIV-positive, and in Europe
(5.9%), where a higher percentage of cases occurs
among the elderly. Treatment interruption (default)
was most frequent in the WHO African Region
(10.3%), Eastern Mediterranean Region (7.2%), and
South-East Asia Region (6.7%). Transfer without
follow-up was also especially high in Africa (6.6%).
179
Treatment failure was conspicuously high in the Euro-
pean region (8.1%), mainly because of high failure
rates in the former Soviet Union, most likely resulting
from the high prevalence of MDR tuberculosis.
In summary, the global case detection rate for pa-
tients who had sputum smear – positive tuberculosis
was 37% in 2002, half of the 70% target, whereas
treatment success under the DOTS strategy for the
2001 cohort was 82% on average, close to the 85%
target. Although this progress toward the WHA 2005
targets of 70% case detection and 85% treatment
success represents a considerable gain, making an
impact on the global tuberculosis burden as expressed
in the 2015 MDGs will require speeding prog-
ress toward meeting and then sustaining the 2005
WHA targets.
Approaches needed to accelerate progress in
global tuberculosis control
A global alliance named the Stop TB Partnership
provides the means for international partners and the
governments of countries with high tuberculosis
incidence to intensify efforts to accelerate progress
in global tuberculosis control [38]. The development
of new tools for tuberculosis control (eg, a more
effective vaccine [39], better diagnostic tests [40], and
improved preventive [41] and therapeutic [42] ap-
proaches) holds out the prospect of rapid progress in
tuberculosis control in the future. In the meantime,
the challenge in maximizing the impact of currently
available methods of diagnosis and treatment lies in
implementing the DOTS strategy and its adaptations
as effectively and as widely as possible.
In coordination with a global network of partners
known as the DOTS Expansion Working Group
(DEWG), WHO is committed to implementing the
DOTS strategy as effectively and as widely as pos-
sible [43]. WHO published the Global DOTS
Expansion Plan (GDEP) in 2001 [44]. The GDEP is
based on two pillars: the preparation in each country
of a mid-term (at least 5-year) DOTS expansion plan,
and the establishment of a mechanism for interagency
coordination ensuring that all relevant partners
contribute to the implementation of the national plan.
Effective development and implementation of the
national plan depends on the engagement of the full
range of health providers under NTP stewardship:
government services, whether Ministry of Health
(nationally and locally administrated services) or not
(eg, social security schemes, prisons, military), and
nongovernment services (eg, NGOs, community
180 maher
groups [45], private practitioners [32], and employers
[46]). In practice, all health providers should refer
patients to public health facilities delivering tuber-
culosis care under the DOTS strategy or deliver
tuberculosis care consistent with the DOTS strategy
in collaboration with the NTP. The failure of
providers to deliver care consistent with the DOTS
strategy compromises the achievements of NTPs and
the chances of successful tuberculosis control. Gov-
ernments should consider reform of legislative and
regulatory frameworks to engage the full range of
health providers and will need to invest in developing
human resource capacity (for strengthened NTP
stewardship and service delivery) [47].
Three of the main adaptations of the DOTS
strategy are as part of a strategy of expanded scope
where HIV prevalence is high [4], as DOTS-Plus in
areas where the prevalence of MDR tuberculosis is
high [5], and as PPM DOTS where the majority of
tuberculosis suspects consult private practitioners
[32]. Until recently, the efforts to control tuberculosis
among HIV-infected people have focused mainly on
identifying and curing infectious tuberculosis cases
among patients presenting to general health services.
This approach targets the final step in the sequence of
events by which HIV fuels tuberculosis, namely the
transmission of M. tuberculosis infection by infec-
tious tuberculosis cases. The strategy of expanded
scope for tuberculosis control in populations with
high HIV prevalence comprises interventions against
tuberculosis (the DOTS strategy and tuberculosis
preventive treatment) and interventions against HIV
(and therefore indirectly against tuberculosis) (eg,
condoms, treatment of sexually transmitted infec-
tions, safe injecting drug use, and highly active
antiretroviral treatment) [4].
DOTS-Plus is the programmatic approach to the
diagnosis and treatment of MDR tuberculosis within
the context of DOTS programs. Management
involves the diagnosis of MDR tuberculosis through
quality-assured culture and drug-susceptibility testing
and treatment with second-line drugs under proper
case management conditions. In response to the
seriousness of MDR tuberculosis as a global public
health problem, the DOTS-Plus Working Group was
established in 1999 to promote improved manage-
ment of MDR tuberculosis in resource-limited
countries. The Working Group aims to assess the
feasibility and cost effectiveness of the use of second-
line antituberculosis drugs in DOTS-Plus projects.
Since 2000, the Working Group’s Green Light
Committee has successfully negotiated with the
pharmaceutical industry to obtain substantial conces-
sionary prices for second-line drugs that otherwise
& raviglione
were unaffordable in poor settings. As a result, prices
of the most expensive regimens have dropped
by 95%.
PPM-DOTS is the means of engaging private
practitioners in collaboration with the NTP in the
delivery of tuberculosis care consistent with the
DOTS strategy. This approach is necessary where
large numbers of tuberculosis suspects seek care from
private practitioners rather than from public health
services. Recent studies indicate the success of the
PPM approach in achieving high rates of case detec-
tion, notification, and cure [48]. A global subgroup of
the DEWG concerned with PPM-DOTS is promoting
the scaling up of this approach, accompanied by the
necessary strengthening of the NTP stewardship and
leadership roles. Lessons learned from PPM-DOTS
are applicable to engaging the contributions of a wide
range of public providers who in many countries are
providing tuberculosis care independently of the NTP
(eg, in prisons and social security programs).
Accelerating progress in global tuberculosis con-
trol depends on developments in the specific field of
tuberculosis control and on strengthening health
systems. In 2003, the Stop TB Partnership convened
a second ad hoc committee on the tuberculosis epi-
demic to seek solutions to the health system con-
straints to more rapid progress in global tuberculosis
control and to make recommendations to overcome
those constraints [49,50]. The committee made
recommendations under seven headings (many of
which cut across the different aspects of tuberculosis
control) [49]:
1. Consolidate, sustain, and advance achievements
2. Enhance political commitment (and its trans-
lation into policy and action)
3. Address the health workforce crisis
4. Strengthen health care systems, particularly
primary care delivery
5. Accelerate the response to the TB/HIV emergency
6. Mobilize communities and the corporate sector
7. Invest in research and development to shape
the future.
Implementation of these recommendations de-
pends on coordination between the health care sector
and other sectors to deliver effective tuberculosis
control covering all populations in need.
Summary
In 2002 there were an estimated 8.8 million new
cases of tuberculosis worldwide, and the global
 global epidemiology of tuberculosis
incidence rate was growing at approximately 1.1%
per year. The scale of the global tuberculosis epi-
demic indicates the huge challenge for tuberculosis
control, which is complicated by the impact of HIV
and drug-resistant tuberculosis. Global efforts to
implement the DOTS strategy widely and effectively
have resulted in a global case detection rate of 37%
in 2002, more than half of the target of 70%, and
treatment success for the 2001 cohort of 82%, on
average, close to the target of 85%. Faster progress
toward global targets depends on future development
of new drugs, diagnostics, and vaccines, meanwhile
overcoming health system constraints to intensified
implementation of the DOTS strategy and to its
adaptations in areas with high prevalence of HIV or
MDR tuberculosis or where not all care providers
deliver the internationally recommended standard
of care.
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 Clin Chest Med 26 (2005) 283 – 294

Issues in the Management of HIV-Related Tuberculosis

William J. Burman, MDa,b,*
a
Division of Infectious Diseases, University of Colorado Health Sciences Center, 4200 East Ninth Avenue,
Denver, CO 80262, USA
b
Infectious Diseases Clinic, Denver Department of Public Health, 605 Bannock Street, Denver, CO 80204, USA

The HIV pandemic poses major problems for the
tuberculosis control program and for the individual
clinician treating HIV-related tuberculosis. HIV-
related immunosuppression is the single most potent
risk factor for progression from latent tuberculosis
infection to active tuberculosis [1]. As a result, HIV is
major factor driving the global resurgence of tuber-
culosis; incidence rates of tuberculosis in countries
with high prevalence of HIV infection have increased
up to fivefold [2]. Severe immunosuppression also
results in marked changes in the clinical, radiographic,
and histopathologic presentation of tuberculosis [3].
This article does not review all aspects of HIV-related
tuberculosis; the dramatic effects of HIV on the
epidemiology, presentation, and diagnosis of tuber-
culosis have been reviewed elsewhere recently [2,3].
This article focuses on the ways in which HIV infec-
tion and the associated immunodeficiency affect the
management of active tuberculosis. Controversial
topics are highlighted, followed by a suggested strat-
egy for management while awaiting additional data.
There are a number of unique challenges in the
treatment of HIV-related tuberculosis, but the basic
principles of tuberculosis treatment developed over
the past 50 years are applicable to HIV-related
tuberculosis. Drug-susceptible tuberculosis is treated
most efficiently with regimens including an initial
intensive phase—2 months of isoniazid, rifampin or
This work was supported in part by the Tuberculosis
Trials Consortium, Centers for Disease Control and Pre-
vention, Atlanta, GA. The author has had research contracts
with Roche Laboratories, Merck, Glaxo-Smith Kline, and
Bristol Myers-Squibb.
* 605 Bannock Street, Denver, CO 80204.
E-mail address: bburman@dhha.org
rifabutin, pyrazinamide, and ethambutol—followed
by a 4-month continuation phase of isoniazid and
rifampin or rifabutin. A remaining challenge for the
treatment of active tuberculosis among HIV-infected
and uninfected persons is finding efficient and pro-
grammatically relevant ways to identify patients at
increased risk for relapse and targeting them for pro-
longed or otherwise altered treatment [4,5]. Ad-
herence to multidrug therapy is difficult, particularly
when it must be sustained for at least 6 months.
Directly observed therapy, the most effective way of
promoting adherence to tuberculosis treatment [6], is
all the more important in the management of HIV-
related tuberculosis [7]. There is little margin for er-
ror in the treatment of tuberculosis in a severely
immunocompromised person.
Issues in the treatment of HIV-related tuberculosis
When these basic principles are observed, the
outcomes of treatment of active tuberculosis among
persons with HIV infection are similar to those of
HIV-negative patients with tuberculosis [5,8 – 14].
The rates of treatment failure (a positive culture at or
beyond 4 months of treatment) and relapse are low.
Whether the rates of treatment failure and relapse are
somewhat higher among patients with HIV coinfec-
tion and how the rate of treatment failure should
affect the management of HIV-related tuberculosis
remain subjects of controversy. One key difference is
that the risk of death during tuberculosis treatment is
much higher among persons with HIV-related tuber-
culosis. For example, in a study from South Africa
the risk of death during tuberculosis treatment was
13.7% among HIV-infected miners versus 0.5%

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.002 chestmed.theclinics.com
284
among HIV-negative miners [11]. After the first few
weeks of tuberculosis treatment, nearly all the excess
mortality is related to complications of AIDS other
than tuberculosis [10,15]. Combination antiretrovi-
ral therapy markedly reduces new opportunistic in-
fections and death among persons with AIDS [16]
and seems to do so among persons with HIV-related
tuberculosis [17 – 19]. The use of combination anti-
retroviral therapy in persons being treated with tuber-
culosis poses a number of challenges for the patient
and clinician, however.
To summarize, the controversies in the manage-
ment of HIV-related tuberculosis can be grouped into
issues about tuberculosis treatment itself and issues
posed by the use of combination antiretroviral ther-
apy. The issues related to tuberculosis treatment are
the uncertainties about the optimal duration of
therapy and the adequacy of intermittent dosing of
tuberculosis therapy (dosing less frequently than
daily). Use of combination antiretroviral therapy dur-
ing tuberculosis treatment is complicated by (1) the
adherence challenge of polypharmacy, (2) overlapping
side-effect profiles of the antituberculosis drugs,
antiretroviral therapy, and drugs used to prevent or
treat other opportunistic infections, (3) drug – drug
interactions, and (4) the occurrence of immune
reconstitution inflammatory syndromes following
the institution of effective antiretroviral therapy.
These four issues lead to uncertainties about the op-
timal timing of antiretroviral therapy during tuber-
culosis treatment.
Issues related to tuberculosis treatment
Optimal duration of therapy
Early in the HIV pandemic, it became clear that
some opportunistic infections required prolonged,
if not lifelong, treatment in persons with advanced
HIV disease. For example, cryptococcal meningitis
can be cured in a high percentage of immunocompe-
tent patients with 6 weeks of treatment [20], but
Table 1
Comparison of the outcomes of tuberculosis treatment by HIV serostatus in cohort studies using directly-observed, 6-month,
rifampin-containing regimens
HIV positive
Study [reference] Treatment failure (%)
Haiti (n = 427) [14] 2.0
South Africa (n = 403) [13] 3.0
Baltimore (n = 407) [5] 0 8.3
South Africa (n = 385) [23] 5.3
burman
patients with advanced HIV disease (in the era before
combination antiretroviral therapy) required lifelong
therapy to prevent recurrent meningitis [21]. Such
experience suggested that treatment of tuberculosis
might also have to be longer among patients with
advanced HIV disease.
Despite the importance of the question, there have
been no definitive studies of the optimal duration of
treatment for HIV-related tuberculosis. A large study
performed in Zaire randomly assigned patients to 6 or
12 months of therapy and found a higher rate of
recurrent tuberculosis among patients treated with
6 months of therapy [22]. High losses to follow-up
and the inability to distinguish infection with a new
strain of Mycobacterium tuberculosis (re-infection)
from relapse of the initial infecting strain make
this study difficult to interpret. In an area with high
tuberculosis case rates, re-infection can be a com-
mon cause of recurrent tuberculosis, particularly
among HIV-infected persons [23,24]. A trial in the
United States comparing 6 versus 9 months of ther-
apy showed low relapse rates in both arms (<3%),
but the study was inadequately powered to be defini-
tive [25].
The results of published observational cohort
studies of standard 6-month regimens (isoniazid,
rifampin, pyrazinamide, and ethambutol for 2 months,
followed by isoniazid and rifampin for 4 months)
given by directly observed therapy to patients with
and without HIV coinfection are shown in Table 1.
Most studies have shown similar rates of treatment
failure and relapse among HIV-positive and HIV-
negative persons [5,13,14,23]. The one study that
found a much higher risk of recurrent tuberculosis
among HIV-infected patients was done in a setting of
high rates of tuberculosis (gold mines in South
Africa) [23]. Notably, this study used DNA finger-
printing of initial and relapse isolates and showed that
the higher rate of recurrent tuberculosis in HIV-
infected patients resulted entirely from an increased
risk of re-infection.
These cohort studies do not offer a definitive
answer to the question whether patients with HIV-
HIV negative
Relapse (%) Treatment failure (%) Relapse (%)
5.4 3.0 2.8
5.0 7.0 5.0
0 1.7
21.5 8.1 13.0
 management of hiv-related tuberculosis 285

related tuberculosis might require longer or more in-
tensive therapy. The size of the cohorts evaluated
(approximately 400) is not been adequate to eval-
uate the optimal duration of therapy, particularly in
key subgroups, such as patients with advanced HIV
disease (CD4 cell count <200/mm3). Cohort studies
and clinical trials suggest that patients with advanced
HIV disease are at increased risk of treatment failure
and relapse [5,18,25,26]. These studies also demon-
strated that a surprisingly high percentage of M. tu-
berculosis isolates from cases of treatment failure
and relapse among patients with advanced HIV
disease and tuberculosis had acquired rifamycin
resistance. Before making provisional recommenda-
tions about duration of treatment for HIV-related
tuberculosis, it is important to review the factors
associated with acquired rifamycin resistance.
One of the key advantages of directly observed
therapy is that it prevents selective drug taking (ie, a
patient takes some, but not all, medications in a
multidrug regimen). Among HIV-negative patients,
this feature of directly observed therapy almost
completely prevents acquired drug resistance among
the 2% to 5% of patients whose tuberculosis relapses
[27 – 29]. There is, however, increasing evidence that
directly observed therapy does not prevent acquired
drug resistance among patients with advanced HIV
disease. The clearest demonstration of the association
between HIV infection and acquired drug resis-
tance despite use of directly observed therapy comes
from a clinical trial evaluating once-weekly rifapen-
tine and isoniazid during the last 4 months of therapy
for drug-susceptible tuberculosis. Among 30 HIV-
infected patients treated with this regimen, 5 relapsed,
4 of whom had isolates with acquired drug resistance
[30], whereas there were no cases of acquired drug
resistance among the 502 HIV-negative patients
treated with the same regimen [4]. In all cases, the
drug class to which resistance was acquired was the
rifamycin class, and all patients with acquired rifa-
mycin resistance had advanced HIV disease (CD4
cell counts <200/mm3) [30].
Subsequent clinical trials and observational cohort
studies have confirmed and extended the findings from
the trial evaluating once-weekly rifapentine-based
therapy (Table 2). Acquired rifamycin resistance is
clearly associated with HIV coinfection. Among
patients with HIV-related tuberculosis, the consistent
associations are advanced HIV disease (CD4 counts
in cases of acquired rifamycin resistance have

Table 2
Summary of studies of acquired rifamycin resistance in studies using directly observed therapy treatment of HIV-related
tuberculosis
Rate of Rate of CD4 cell
Dosing frequency
treatment acquired counts of
Study Rifamycin Intensive phase Continuation failure/ rifamycin cases of acquired
[reference] used (first 8 weeks) phase relapse resistance rifamycin resistance
TBTC 23 [18] Rifabutin Daily for 2 weeks, Twice weekly 5.3% (9/169) 4.7% (8/169) 4 – 55
then daily or
intermittent
TBTC 22 [30] Rifapentine Daily for 2 weeks, Once weekly 16.7% (5/30) 13.3% (4/30) 8, 8, 23, 188
then daily or
intermittent
Rifampin Daily for 2 weeks, Twice weekly 10.0% (3/30) 0% Not applicable
then daily or
intermittent
CPCRA/ Rifampin Daily for 2 weeks, Twice weekly 3.0% (3/101) 2.0% (2/101)a 17, 26
ACTG [25] then thrice weekly
Baltimore [5] Rifampin 5 d/wk for 3 weeks, Twice weekly 11.1% (9/81) 3.7% (3/81) Median, 61
then twice weekly
Rifabutin 5 d/wk for 3 weeks, Twice weekly 0% (0/27) 0% Not applicable
then twice weekly
South Rifampin 5 d/wk 5 d/wk 0% (0/151)b Not applicable
Africa [23]
Abbreviations: CPCRA/ACTG, Community Programs for Clinical Research on AIDS/AIDS Clinical Trials Group; TBTC,
Tuberculosis Trials Consortium.
a
One patient was thought to have re-infection with rifamycin-monoresistant tuberculosis, based on DNA fingerprinting
of the relapse isolate.
b
Cases of treatment failure and relapse occurred in the cohort study, but none had acquired rifamycin resistance.
286 burman
all been <200 cells/mm3 and usually <50 cells/mm3)
and the use of highly intermittent therapy (once or
twice weekly) [5,18,23,25,26,30]. The timing of the
use of intermittent therapy may also be important.
The greatest risk of acquired rifamycin resistance
seems to be among patients who received twice-
weekly therapy during the intensive phase (the first
2 months of treatment) [18,26]. Despite the appeal of
the hypothesis that acquired rifamycin resistance
might be caused by the pharmacokinetic mismatch
between isoniazid (half-life of 1 – 3 hours) and the
long-acting rifamycins, rifabutin and rifapentine
(half-lives of 33 and 15 hours, respectively) [31,32],
it is clear that acquired rifamycin resistance can occur
with twice-weekly rifampin-based therapy (half-life
of rifamycin, 2 – 3 hours) [5,25,26].
Recommendations for tuberculosis treatment
The current recommendation for the duration of
therapy for HIV-related tuberculosis is to use stan-
dard 6-month regimens with extension of therapy to
9 months for patients with a delayed clinical or mi-
crobiologic response (continued symptoms or sputum
culture-positive at 2 months) [33]. Given the lack of
data that patients with HIV-related tuberculosis re-
quire longer durations of treatment, the recommen-
dation for 6-month regimens is reasonable and has the
programmatic advantage of having consistent recom-
mendations for HIV-infected and HIV-uninfected
patients. If a subgroup is to be targeted for longer
therapy, it seems that criteria derived from studies of
HIV-uninfected patients, such as 2-month sputum
culture positivity and pulmonary cavitation [4], may
not be appropriate for HIV-related tuberculosis. The
key patient-related risk factor for treatment failure
and relapse among patients with HIV coinfection is
advanced immunodeficiency, not 2-month sputum
culture results [5,18,25,30].
A high percentage of cases of treatment failure
and relapse among patients with HIV-related tuber-
culosis are cases of acquired rifamycin resistance
(Table 2). Therefore, the question whether to treat
HIV-related tuberculosis differently from tuberculosis
among immunocompetent patients devolves to con-
siderations of how to avoid acquired rifamycin
resistance. There have been no randomized trials of
different dosing frequencies of tuberculosis therapy
among HIV-coinfected patients, so all recommenda-
tions for avoiding or reducing acquired rifamycin
resistance are derived from comparisons of cohort
studies and expert opinion. Given the consistency of
the association between acquired rifamycin resistance
and highly intermittent dosing, it is prudent to follow
the current recommendation that patients with
advanced HIV disease (CD4 cell count <200/mm3)
should receive daily (5 days/week) tuberculosis treat-
ment, at least for the first 2 months of treatment. The
choice of rifamycin (rifampin or rifabutin) should be
based on the drug interactions with the planned
antiretroviral treatment regimen. The available data
suggest that rifampin and rifabutin are equally effec-
tive for tuberculosis treatment [34 – 36].
Whether caused by re-infection or relapse, the
high rates of recurrent tuberculosis among HIV-
coinfected patients in areas of the world with endemic
tuberculosis are worrisome. Possible interventions to
decrease the risk of recurrent tuberculosis in these
areas include changes in tuberculosis treatment and
the use of combination antiretroviral therapy. A
longer duration of multidrug tuberculosis treatment
[22] or the use of isoniazid after completion of the
standard 6-month multidrug regimen may decrease
the risk of recurrent tuberculosis [37,38], probably
by decreasing rates of re-infection. Use of potent
antiretroviral therapy seems to decrease the rate of
initial progression to active tuberculosis [39,40] and
may decrease the risk of recurrent tuberculosis
after completion of tuberculosis treatment. Random-
ized trials are underway to evaluate some of these
possibilities. If available, the most promising inter-
vention seems to be use of potent antiretroviral ther-
apy, because it should protect against the many
complications of AIDS, not only prevent recur-
rent tuberculosis.
Challenges of using antiretroviral therapy during
tuberculosis therapy
Combination antiretroviral therapy has revolution-
ized the treatment of advanced HIV disease, dramati-
cally decreasing rates of death and opportunistic
infection. Because patients with HIV-related tuber-
culosis have relatively high rates of HIV disease pro-
gression (death or a new opportunistic illness) during
the 6-month period of tuberculosis treatment [15,25],
antiretroviral therapy should markedly improve the
outcome of patients with HIV-related tuberculosis.
Despite its promise, the use of antiretroviral ther-
apy during tuberculosis treatment is complex for
both patient and clinician. Therefore, it is important
that use of antiretroviral therapy be targeted to those
at substantial risk of HIV disease progression during
tuberculosis treatment. As is true for all persons
with HIV infection, the short-term (6 – 12 month) risk
of HIV disease progression among persons with
HIV-related tuberculosis is related closely to the de-
 management of hiv-related tuberculosis
gree of immunodeficiency at the time of tuberculosis
diagnosis (as measured by CD4 cell count or CD4
cell percentage) [10,11,25]. Therefore, it is reason-
able to use the standards for initiating combination
antiretroviral therapy among patients with concomi-
tant tuberculosis that are used for all patients with
HIV disease: start combination antiretroviral therapy
for those with clinical or laboratory evidence of ad-
vanced HIV disease (presence of an opportunistic
illnesses or a CD4 cell count <200/mm3) [41].
Given the lack of clear evidence that, in general,
patients having CD4 cell counts higher than 200 to
250/mm3 benefit from earlier initiation of antiretro-
viral therapy, it seems prudent to avoid the sub-
stantial difficulties of using antiretroviral therapy
during tuberculosis treatment for the subset with
concomitant active tuberculosis. Those with higher
CD4 cell counts can be re-evaluated during and
after tuberculosis treatment. It is also noteworthy
that tuberculosis treatment itself results in substan-
tial increases in CD4 cell counts among coinfected
patients [42].
Adherence to treatment of HIV and tuberculosis
Combination antiretroviral treatment regimens
have become simpler during the past few years. Most
regimens can now be given twice daily with food,
and a number of potent combinations can be given
once daily without regard to food. Even so, adherence
to any long-term therapy is a tremendous challenge,
and adherence remains one of the most important
determinants of survival among patients with ad-
vanced AIDS [43]. Therefore, it is important to
consider how the adherence challenge of concomitant
multidrug therapy for tuberculosis treatment might
affect the success of antiretroviral therapy.
Adherence to antiretroviral therapy seems to
decrease with increasing number of pills per day
and increasing overall complexity of the regimen
(number of different medications, number of different
doses per day) [44]. The patient’s readiness to start
combination antiretroviral therapy is also a determi-
nant of outcomes [45]. There are no published studies
of how tuberculosis treatment affects adherence to
antiretroviral therapy, but studies of adherence in
the general HIV-infected population suggest that,
to promote readiness to begin antiretroviral treat-
ment, it is important to take the time to deal with the
psychologic reactions to the diagnoses of tubercu-
losis and advanced HIV disease, as well as the social
issues—poverty, homelessness, substance abuse—
that are commonly present among patients with
HIV-related tuberculosis. Programs focusing on the
287
importance of adherence and behavioral techniques
to promote adherence are associated with better
response to antiretroviral therapy [46]. Finally, it
may be possible to use the team that provides directly
observed treatment for tuberculosis to promote
adherence to antiretroviral therapy [47]. This coop-
eration is one of many benefits that can come from
close collaboration between HIV and tuberculosis
care providers.
Overlapping adverse event profiles
Adverse clinical events are common among
patients with HIV-related tuberculosis [18,48], and
it may be difficult to ascribe a specific cause to many
adverse events (Table 3). The severe immunosup-
pression of advanced HIV disease may lead to
additional opportunistic illnesses or direct complica-
tions of HIV itself (eg, HIV-related thrombocytope-
nia). Although tuberculosis treatment is generally
well tolerated, there are a host of common bother-
some side effects (eg, nausea from pyrazinamide) and
occasional serious side effects (eg, hepatitis from
isoniazid or pyrazinamide). Antiretroviral drugs have
many of the same side effects as drugs used to treat
tuberculosis or other opportunistic infections (eg,
efavirenz, pyrazinamide, and cotrimoxacole all com-
monly cause skin rash). Finally, the immune recon-
stitution following successful antiretroviral therapy
may cause clinical events that may mimic drug side
effects (eg, rising hepatic transaminases in a patient
with chronic viral hepatitis).
Even an experienced clinician may have great
difficulty determining the cause of a specific clinical
event, such as skin rash in a patients with HIV-related
tuberculosis who has recently started multidrug tu-
berculosis treatment, cotrimoxazole, and efavirenz-
based antiretroviral therapy. Laboratory testing is
seldom helpful in these situations; the temporal
sequence of events is often the best clinical tool for
ascribing a cause to the many clinical events in
patients with HIV-related tuberculosis. Therefore, the
implication of overlapping adverse event profiles is
that, as much as possible, the clinician should initiate
one intervention at a time, allowing time to gauge the
success and tolerability of that intervention. The
attempt to start tuberculosis treatment, opportunistic
infection prophylaxis, and antiretroviral therapy in a
short period may result in adverse events that lead to
the discontinuation of all drug therapy while awaiting
resolution or stabilization of the adverse event. The
first-line tuberculosis drugs should not be discon-
tinued permanently without clear evidence that they
are causing a serious side effect. Despite the fre-
288 burman

Table 3
The challenge of attributing adverse events to a specific cause among patients with HIV-related tuberculosis
Possible causes
Medications other
Antituberculosis than antiretroviral Antiretroviral Immune reconstitution
Adverse event drugs HIV disease drugs drugs inflammatory syndrome
Skin rash Pyrazinamide, rifampin, Folliculitis, Cotrimoxazole Nevirapine,
rifabutin, isoniazid severe delavirdine,
asteatosis efavirenz,
abacavir
Nausea, Pyrazinamide, rifampin, Other Cotrimoxazole Zidovudine, Immune reconstitution
vomiting rifabutin, isoniazid opportunistic ritonavir, intraabdominal adenitis
infections amprenavir, or pancreatitis
indinavir
Hepatitis Pyrazinamide, rifampin, Cotrimoxazole Nevirapine, Immune reconstitution
rifabutin, isoniazid HIV-1 in patients with chronic
protease viral hepatitis
inhibitors
Leukopenia, Rifabutin, rifampin HIV-related Cotrimoxazole, Zidovudine
anemia, bone marrow valganciclovir
thrombocytopenia dysplasia

quency of adverse events, experienced clinicians can
complete tuberculosis treatment with the first-line
drugs in a high percentage of cases [18,49].
Drug – drug interactions
Clinically significant interactions are common
between drugs for tuberculosis and HIV treatment
[50]. Absorption interactions have been described,
such as the marked decrease in fluoroquinolone
exposure if given with the buffered formulation of
didanosine [51], but these interactions are uncommon
and are easily managed by spacing the ingestion of
these two medications several hours apart. The more
common and problematic interactions between drugs
used to treat tuberculosis and HIV disease occur in
the process of hepatic and gut-wall metabolism.
The rifamycins increase the synthesis of a number
of hepatic enzyme systems involved in drug metabo-
lism. Particularly important in drug interactions
with the antiretroviral drugs is the effect of the rifa-
mycins on the cytochrome P450 3A (CYP3A) enzyme
system. Rifampin administration results in marked
decreases in the concentrations of antiretroviral
drugs predominantly metabolized by CYP3A. The
magnitude of this interaction is such that rifampin
cannot be used with the HIV-1 protease inhibitors
other than relatively high-dose ritonavir (400 – 600 mg
twice daily) [50]. Rifabutin also increases the expres-
sion of CYP3A, but the effect is much less marked,
so rifabutin can be given with the protease inhibitors
(other than unboosted saquinavir). Both rifamycins
can be given with the non-nucleoside reverse-
transcriptase inhibitor efavirenz and probably with
nevirapine, as well.
Antiretroviral drugs can also affect the concen-
trations of the rifamycins, particularly rifabutin. Con-
centrations of rifabutin and its metabolites are
markedly increased by the protease inhibitors [52],
and this increased concentration can lead to increased
rifabutin toxicity [53]. Conversely, concentrations of
rifabutin are substantially decreased by efavirenz
[54]. Therefore, the clinician caring for the patient
with HIV-related tuberculosis must be aware of both
sides of the possible interactions between HIV and
tuberculosis drugs: the effect of the rifamycins on
antiretroviral drugs and the effect of antiretroviral
drugs on rifabutin.
Recommendations for dosing of the rifamycins
and antiretroviral therapy are provided in Tables 4
and 5 [55]. Because this field is rapidly changing, the
clinician should use a regularly updated source of
information on the interactions between tuberculosis
drugs and antiretroviral drugs, such as the website
sponsored by the Centers for Disease Control and
Prevention (http://www.cdc.gov/nchstp/tb/TB_HIV_
Drugs/TOC.htm). Other ways to avoid major drug –
drug interactions (Box 1) include ongoing communi-
cation between HIV and tuberculosis care providers
and awareness of the need to readjust doses of
drugs that have been altered because of an interaction
when the use of an interacting drug has been stopped
(eg, decreasing the dose of methadone back to
baseline when rifampin is discontinued).
 management of hiv-related tuberculosis 289

Table 4
Recommendations for coadministering protease inhibitors and non-nucleoside reverse transcriptase inhibitors with rifabutin –
United States, 2003
Antiretroviral
Drug dose change Rifabutin dose change Comments
Non-nucleoside reverse-transcriptase inhibitors
Efavirenz None " to 450 – 600 mg/d or Rifabutin AUC # by 38%; effect of efavirenz +
600 mg 2 – 3 /wk protease inhibitor(s) on rifabutin concentration
has not been studied
Nevirapine None 300 mg/d or 3 /wk Rifabutin and nevirapine AUC not
significantly changed
Delavirdine Rifabutin and delavirdine should not be Delavirdine AUC # by 80%;
used together rifabutin AUC " by 100%
Single protease inhibitors
Amprenavir None # to 150 mg/d or Rifabutin AUC " by 193%; no change in
300 mg 3 /wk amprenavir concentration
fos-Amprenavir None # to 150 mg/d or
300 mg 3 /wk
Atazanavir None # to 150 mg every Rifabutin AUC " by 250%
other day or 3 /wk
Indinavir " to 1000 every # to 150 mg/d or Rifabutin AUC " by 204%; indinavir AUC
mg q 8 h 300 mg 3 /wk # by 32%
Nelfinavir None # to 150 mg/d or Rifabutin AUC " by 207%; insignificant
300 mg 3 /wk change in nelfinavir concentration
Saquinavir Rifabutin and saquinavir should not be Saquinavir AUC # by 43%
used together
Dual-protease inhibitor combinations
Lopinavir/ritonavir (Kaletra) None # to 150 mg every Rifabutin AUC " by 303%; 25-O-des-acetyl
other day or 3 /wk rifabutin AUC " by 47.5 fold
Ritonavir (any dose) None # to 150 mg every
with saquinavir, indinavir, other day or 3 /wk
amprenavir, fos-amprenavir,
or atazanavir
Abbreviation: AUC, area under the curve.

Immune reconstitution inflammatory events [57,59,60]. Less common manifestations include

The improvement in immune function following
antiretroviral therapy clearly has tremendous benefits.
Restoration of immunity, however, can also cause
markedly increased inflammation in tuberculosis
lesions and result in a significant worsening of clini-
cal symptoms and signs [56]. The clinical spectrum
of these immune reconstitution inflammatory events
ranges from fevers and mild increased adenopathy
[57] to life-threatening complications such as the
expansion of intracranial tuberculomas [58]. The oc-
currence of severe immune reconstitution inflamma-
tory events needs to be considered in decisions about
use of antiretroviral therapy in patients being treated
for tuberculosis.
Common clinical manifestations of immune re-
constitution inflammatory events include fever,
adenopathy, increased pulmonary infiltrates, and
serositis (pleural or pericardial effusions, ascites)
worsening meningitis, enlargement of central nervous
system tuberculomas, soft tissue and bone abscesses,
and diffuse skin lesions [60]. These manifestations
are often at sites of previously evident tuberculosis
but can also occur at sites that were not previously
known to be involved. The diagnosis of an immune
reconstitution inflammatory event may be difficult
in that its clinical manifestation may be similar to
those of other infections, drug side effects, or failure
of tuberculosis treatment.
There is much to be learned about immune
reconstitution inflammatory events following antire-
troviral therapy, but early studies have shown a
number of consistent features to this syndrome. The
time of onset is often within days of starting anti-
retroviral therapy, earlier than one might expect
significant restoration of immune function. The
median time from starting antiretroviral therapy to
the onset of the immune reconstitution inflammatory
290 burman

Table 5
Recommendations for coadministering protease inhibitors and non-nucleoside reverse transcriptase inhibitors with rifampin –
United States, 2003
Rifampin
Drug Antiretroviral dose change dose change Comments
Single protease inhibitors
Ritonavir None None (600 mg/d) Use with caution. Ritonavir
AUC # by 35%; no change
in rifampin concentration.
Monitor for antiretroviral
activity of ritonavir
Amprenavir Rifampin and amprenavir should not be used together Amprenavir AUC # by 82%,
Cmin # by 92%
fos-Amprenavir Rifampin and fos-amprenavir should not be used together See amprenavir
Atazanavir Rifampin and atazanavir should not be used together Interaction studies not
performed, but marked
decrease in atazanavir
concentrations predicted
Indinavir Rifampin and indinavir should not be used together Indinavir AUC # by 89%
Nelfinavir Rifampin and nelfinavir should not be used together Nelfinavir AUC # 82%
Saquinavir Rifampin and saquinavir should not be used together Saquinavir AUC # by 84%
Dual protease-inhibitor combinations
Saquinavir/ritonavira Saquinavir 400 mg + None (600 mg/d) Limited clinical experience
ritonavir 400 mg twice daily
Boosted lopinavir/ Lopinavir/ritonavir (Kaletra) 3 capsules + None (600 mg/d) Limited clinical experience
ritonavir (Kaletra) 300 mg ritonavir twice daily
Lopinavir/ritonavir Rifampin and unboosted lopinavir/ritonavir (Kaletra) should not Lopinavir AUC # by 75%
(Kaletra) be used together and Cmin # by 99%
Non-nucleoside reverse transcriptase inhibitors
Efavirenz None or " to 800 mg/d None (600 mg/d) Efavirenz AUC # by 22%;
no change in rifampin
concentration
Nevirapine Consider " to 300 mg twice dailyb None (600 mg/d) Nevirapine AUC #
37% – 58% and Cmin # 68%
with 200 mg 2 /d dose
Delavirdine Rifampin and delavirdine should not be used together Delavirdine AUC # by 95%
Abbreviation: AUC, area under the curve.
a
In a recent drug interaction study among healthy volunteers, there was a high and unacceptable rate of hepatoxicity during
treatment with saquinavir, ritonavir, and rifampin. The FDA and Roche Laboratories advise that this combination not be used.
b
No safety data available; limited data on antiretroviral efficacy.

event in a large series of patients with HIV-related
tuberculosis was 11 days [61], with some events
beginning within 2 days [57]. On the other hand,
other patients can have the onset of an immune
reconstitution event months after starting antiretrovi-
ral therapy [62]. The most consistent risk factor for
immune reconstitution inflammatory events seems
to be severity of immunosuppression; patients with
very low CD4 cell counts, and hence those in greatest
need of effective antiretroviral therapy, seem to be at
highest risk of an immune reconstitution inflamma-
tory event [57,58,63,64]. The potency of the anti-
retroviral regimen seems to be related to the risk of
an immune reconstitution inflammatory event; such
events were infrequently reported in the era of single-
drug therapy but are common in the era of potent
combination antiretroviral therapy (being reported in
11% to 35% of patients starting potent antiretroviral
therapy) [18,57,61,63]. Finally, the timing of anti-
retroviral therapy may also be important; earlier
initiation of antiretroviral therapy may increase the
risk and severity of immune reconstitution inflam-
matory event [61,64].
Summary of issues involved in the use of combination
antiretroviral therapy
The use of antiretroviral therapy during tuber-
culosis treatment seems to reduce markedly the risk
of death and opportunistic infections among patients
 management of hiv-related tuberculosis 291

with advanced HIV disease [17 – 19]. For example,

Box 1. Principles for anticipating and
the rate of death within the 12 months of tuberculosis
managing drug – drug interactions in the
diagnosis among patients in a recent study in which
treatment of HIV-related tuberculosis
most patients received combination antiretroviral
therapy was 5%, compared with 20% among patients
1. Frequent communication between
with similar baseline characteristics in a study
the tuberculosis control program
conducted before the availability of potent antiretro-
and the HIV primary care provider
viral therapy [18,25]. Other studies have shown
is necessary.
comparable early outcomes of antiretroviral therapy
2. Avoid the use of delavirdine,
among patients who did and did not have concomi-
ketoconazole, and itraconazole
tant tuberculosis [19].
when using rifabutin.
The optimal timing of antiretroviral therapy dur-
3. Rifampin probably causes more
ing tuberculosis treatment remains controversial.
clinically significant interactions
Some experts [48] recommend that antiretroviral
than any other drug. Have a
therapy be started within 2 weeks of the initiation
regularly updated reference for drug
of tuberculosis treatment for patients with severe im-
interactions and look for possible as
munosuppression (CD4 cell count <100 cells/mm3).
well as documented interactions
Others recommend that antiretroviral therapy be
every time rifamycin-containing
delayed until after 2 months of tuberculosis treat-
tuberculosis treatment is started.
ment [65]. The issues are complex, and a randomized
4. When using a fluoroquinolone,
trial is needed to clarify how the timing of anti-
avoid the use of the buffered
retroviral therapy affects the competing risks of
tablet formulations of didanosine.
HIV disease progression versus those of drug side
Antacids, iron, zinc, or vitamins
effects or a severe immune reconstitution event. For
containing these substances should
now, decisions about the timing of antiretroviral
not be given within 2 hours of the
therapy should be individualized using the consid-
dose of directly observed
erations outlined in Table 6 [33]: adherence demands
tuberculosis treatment.
and the patient’s readiness for antiretroviral therapy,
5. If a drug dose is increased to com-
overlapping adverse event profiles, severe immune
pensate for the effect of a rifamycin,
reconstitution events, and the risk of HIV disease
it must be decreased when the
progression. The author’s practice is to wait until the
rifamycin is discontinued.
first 2 months of tuberculosis treatment have been
completed. At this point, tuberculosis treatment can

Table 6
Possible advantages and disadvantages of early versus delayed initiation of antiretroviral therapy during tuberculosis treatment
Adherence demands
Ability to determine the cause
of adverse events
Drug – drug interactions
Severe immune reconstitution
inflammatory events
HIV disease progression
(new opportunistic infection
or death)
Abbreviation: TB, tuberculosis.
Early antiretroviral therapy
(before 8 weeks of tuberculosis treatment)
Problematic with use of four-drug therapy
for TB and multidrug therapy for HIV
Complex because of the large number
of medications started in a short time
period and overlapping side effect profiles
Problematic
Risk may be increased
Risk may be decreased
Delayed antiretroviral therapy
(after 8 weeks of tuberculosis treatment)
Less problematic because fewer drugs
necessary for TB treatment
Simpler because the number of drugs
for TB treatment is less and there has
been more time to evaluate response to
tuberculosis treatment
Problematic
Risk may be decreased
Risk may be increased
292 burman
usually be simplified (to a rifamycin plus isoniazid),
the patient has had sufficient time to prepare for
antiretroviral therapy, and the risk of a severe immune
reconstitution inflammatory event may be lower.
Summary of recommendations
HIV-related tuberculosis in patients with relatively
high CD4 cell counts (>200/mm3) can be managed
much like tuberculosis in HIV-negative patients.
Standard 6-month regimens given as directly ob-
served therapy are effective. The risk of acquired
rifamycin resistance seems to be low, so intermittent
therapy can be used. The risk of HIV disease pro-
gression during tuberculosis treatment is low, so the
author recommends observation of antiretroviral ther-
apy. HIV disease should be appropriately monitored
using CD4 cell count and HIV-RNA level, and
treatment of tuberculosis alone will probably result
in an increase in immune function, as judged by CD4
cell count [42,66].
Patients with lower CD4 cell counts do well with
standard 6-month regimens, but the risk of acquired
rifamycin resistance becomes significant. Therefore,
patients should be treated with daily tuberculosis
treatment, at least for the first 2 months of therapy.
Patients with baseline CD4 cell counts lower than
200/mm3 seem to benefit from antiretroviral therapy
during tuberculosis treatment, but the initiation of
antiretroviral therapy should be approached methodi-
cally and not considered an emergency. Even in the
presence of advanced HIV disease (CD4 cell count
<50/mm3), the clinician should do one intervention
at a time. The first priority is the initiation of four-
drug tuberculosis treatment and the assessment of its
tolerability and its success in decreasing the clinical
manifestations of tuberculosis. Prevention of pneu-
mocystosis is often the next priority, because these
patients have advanced immunodeficiency. Many
patients are diagnosed with tuberculosis and ad-
vanced HIV disease at the same time, and it is im-
portant to take the time to help them adjust to these
two life-changing diagnoses. Successful antiretroviral
therapy requires a high level of adherence (>95%),
and it is critical to allow sufficient time to manage
psychosocial issues and help the patient prepare for
long-term adherence. Immune reconstitution inflam-
matory events are common, and patients should be
counseled about the frequency and management of
such an event. After these critical initial steps have
been completed, it is appropriate to start combination
antiretroviral therapy.
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 Clin Chest Med 26 (2005) 217 – 231
Molecular Epidemiology: A Tool for Understanding Control
of Tuberculosis Transmission
Charles L. Daley, MD
Division of Mycobacterial and Respiratory Infections, National Jewish Medical and Research Center, 1400 Jackson Street,
Denver, CO 80206, USA
One of the primary goals of tuberculosis control
programs is to interrupt the transmission of Myco-
bacterium tuberculosis. The most effective way to
accomplish this goal is to identify and treat individu-
als who have active tuberculosis. Even in effective
tuberculosis control programs, however, M. tuber-
culosis continues to be transmitted to others, largely
because most transmission occurs before diagnosis
and initiation of therapy. The ability to track specific
strains of M. tuberculosis as they spread through a
community would greatly increase the understanding
of the transmission and pathogenesis of tuberculosis,
but, until recently, the only means of distinguishing
different strains of M. tuberculosis were drug-
resistance patterns and mycobacterial phage typing,
both of which have significant limitations. Fortu-
nately, several molecular genotyping techniques
available now allow differentiation of isolates of
M. tuberculosis for tracking strains in the community.
Epidemiologic investigations that incorporate geno-
typing of M. tuberculosis have provided important
information about the spread of tubercle bacilli by
identifying factors related to transmission and rapid
progression to disease. This article reviews how these
genotyping tools have increased the understanding of
the transmission and pathogenesis of M. tuberculosis.
E-mail address: daleyc@njc.org
0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.005
Genotyping methods and methodologic
considerations
Several nucleic acid – based genotyping methods
have been developed that allow different strains of
M. tuberculosis to be distinguished. The most widely
used method of genotyping, referred to as restriction
fragment-length polymorphism (RFLP) analysis, uses
restriction endonucleases to cleave the mycobacterial
DNA at the sites of specific repetitive sequences,
producing DNA restriction fragments of different
lengths that can be separated by gel electrophoresis
(Fig. 1) [1]. Only the genomic DNA restriction
fragments that are complementary to and hybridize
with specific probes are visible, resulting in an eas-
ily readable band pattern. Most laboratories use a
standardized protocol for RFLP genotyping of the
M. tuberculosis complex that takes advantage of a
specific, well-characterized, repetitive element, inser-
tion sequence 6110 (IS6110) [1].
Despite its widespread use, there are several
disadvantages with IS6110-based RFLP genotyping.
First, it can be done only on cultures of M. tuber-
culosis. Second, it is a slow, labor-intensive, and
technically demanding technique. Finally, it has rela-
tively poor discriminatory power for isolates that
have six or fewer copies of IS6110 and should be
supplemented with other methods such as polymor-
phic guanine-cytosine – rich genotyping or spoligo-
typing [2].
Spoligotyping is a polymerase chain reaction
(PCR)-based method that interrogates a direct repeat
sequence comprising a repetitive 36 – base-pair ele-
ment separated by short, unique, nonrepetitive se-
chestmed.theclinics.com
218 daley

M. tuberculosis Chromosomal DNA Digested DNA

1
1 2

Extract Digest
2 DNA DNA

IS6110 site Separate by gel 3

electrophoresis
1 2 1 2

Hybridization performed
with labeled IS6110

Fig. 1. IS6110-based restriction fragment length polymorphisms analysis. Depicted are two strains of Mycobacterium
tuberculosis, labeled 1 and 2. The location and number of the insertion sequence IS6110 is noted by the small black rectangles.
Step 1: Chromosomal DNA is extracted. Step 2: Extracted DNA is cleaved with a restriction endonuclease (Pvu-II). (In reality,
thousands of fragments are created.) Step 3: After digestion, the DNA fragments are separated according to molecular weight by
gel electrophoresis. (In reality, this process results in thousands of bands that are nearly confluent on the gel.) Step 4:
Hybridization with probe for IS6110 results in a gel with bands containing only the IS6110 element. The two strains can be seen
to differ in the number of bands (ie, the number of IS6110 copies in the genome) and the location of the bands.

quences [3]. By using one set of primers, all the
unique, nonrepetitive sequences, or spacers, between
the direct repeats can be amplified simultaneously.
Individual strains are differentiated by the number
and position of the spacers that are missing from
the complete spacer set. Spoligotyping has at least
two advantages over IS6110-based genotyping: (1)
smaller amounts of DNA are needed so the procedure
can be performed on clinical samples or on strains
of M. tuberculosis shortly after inoculation into liq-
uid culture, and (2) the spoligotyping results can be
expressed in a digital format [4]. Spoligotyping can
be used as either a secondary genotyping method or
as a primary genotyping method followed by another
genotyping method that has greater discriminatory
power [5,6].
A promising PCR-based method is a high-
resolution genotyping technique that characterizes
the number and size of the variable number tandem
repeats (VNTR) in each of 12 independent myco-
bacterial interspersed repetitive units (MIRUs) [7,8].
MIRU-VNTR profiling is appropriate for strains re-
gardless of their IS6110 RFLP copy number, can be
automated for large-scale genotyping, and permits
rapid comparison of results from independent labo-
ratories using a 12-digit classification system [9,10].
The Centers for Disease Control and Prevention
(CDC) will use this methodology, along with spoligo-
typing, for all initial isolates of M. tuberculosis in
the United States as part of a national genotyping
program. More studies are needed, however, to un-
derstand better the role of MIRU typing in the
molecular epidemiology of tuberculosis. In a recent
study from Quebec, Canada, 302 clinical isolates
were evaluated with three different genotyping meth-
ods: IS6110-based genotyping noted that 27% of the
isolates were clustered, MIRU noted clustering in
61%, and spoligotyping noted clustering in 77% [11].
When all three methods were used, only 14% were
clustered, closer to the percentage that would have
been expected in the population. This study provided
some insight into the evolution of genotypes in en-
demic areas and the potential for false clustering
when the wrong genotyping methodologies are used.
The genotyping method used depends on several
factors including technical capacity and the speed
with which results are needed. The genotyping
methods vary in the reproducibility of the tests and
in their ability to differentiate individual strains of
M. tuberculosis. An interlaboratory comparative
study compared several genotyping techniques [12].
Of the seven PCR-based assays, only mixed linker
 molecular epidemiology
Table 1
Reproducibility and differentiating capabilities of common
genotyping methods
No. of different
Method Reproducibility (%) genotypes (%)
IS6110 RFLP 100 84
IS6110 mixed 100 81
linker PCR
PGRS RFLP 100 70
Spoligotyping 94 61
Variable number 97 56
tandem repeats
Study analyzed 90 strains of Mycobacterium tuberculosis
and 10 nontuberculous strains.
Abbreviations: IS6110, insertion sequence 6110; PCR, poly-
merase chain reaction; PGRS, polymorphic guanine–cytosine-
rich sequence; RFLP, restriction fragment length polymorphisms.
Data from Kremer K, van Soolingen D, Frothingham R,
et al. Comparison of methods based on different molecular
epidemiological markers for typing of Mycobacterium
tuberculosis complex strains: interlaboratory study of dis-
criminatory power and reproducibility. J Clin Microbiol
1999;37:2607 – 18.
PCR and VNTR typing were highly reproducible
(Table 1). Only mixed linker PCR had discriminatory
power similar to IS6110-based RFLP analysis. Other
studies [10] showed VNTR-MIRU typing to be
slightly more discriminatory than spoligotyping.
The combination of MIRU-VNTR, IS6110 RFLP,
and spoligotyping has demonstrated the highest
specificity [9].
Regardless of the genotyping method used, in-
terpretation of the results is based on the assumption
that epidemiologically related strains will have the
same genotype pattern and epidemiologically unre-
lated strains will have different patterns. Clustering
has often been equated with recent or ongoing trans-
mission, and the factors associated with clustering
have been sought as a means to identify and target
subpopulations that have substantial ongoing trans-
mission [13]. In contrast, patients whose isolates of
M. tuberculosis have genotype patterns that do not
match any other isolates in the community are con-
sidered to be unique and likely represent disease
caused by reactivation of a latent tuberculosis infec-
tion (LTBI). Thus, genotyping allows tuberculosis
resulting from recent or ongoing infection to be dis-
tinguished from reactivation of LTBI and makes it
possible to estimate the proportion of ongoing tuber-
culosis transmission in a community.
There is not always an epidemiologic link be-
tween patients whose isolates have identical genotype
patterns. Some studies have demonstrated that clus-
219
tered cases often have no discernible contact or other
epidemiologic links among themselves, even in rela-
tively stable populations [14,15], whereas other
studies have shown that most patients do have epi-
demiologic links [16]. The amount of transmission
represented by genotypic clustering depends on the
sampling strategy and the duration of the study
[17,18]. Undersampling can bias the estimates of
the proportion of tuberculosis cases that were likely
caused by recent or ongoing transmission, and it can
bias the estimates of the risk factors associated with
clustering. Two population-based cohort studies in
San Francisco, California [19], and the Netherlands
[20] reported that the percentage of clustered strains
was high during the first 2 years and declined
thereafter. Thus, clustering based on less than 2 years
of sampling will probably underestimate the amount
of ongoing transmission. Despite its limitations, geno-
typing has provided investigators and tuberculosis
control programs new tools in which to uncover the
transmission of M. tuberculosis in our communities.
Lessons learned regarding the transmission and
pathogenesis of tuberculosis
Molecular genotyping has revolutionized the abil-
ity to track strains of M. tuberculosis as they spread
through a community. Studies using genotyping tech-
niques in combination with standard epidemiologic
investigations have provided insights into the trans-
mission and pathogenesis of M. tuberculosis and
in the process have provided important lessons for
tuberculosis control.
Infectiousness of patients
Several studies that have assessed tuberculin skin
test reactivity among contacts to cases of pulmonary
tuberculosis have documented the variation in infec-
tivity among source cases based on the bacteriologic
status of the source, the extent of disease, and the
frequency of cough [21]. These studies have docu-
mented that patients who have more extensive pulmo-
nary tuberculosis, as evidenced by cavitary changes
on the chest radiograph or the identification of
acid-fast bacilli on sputum smear examination, are
more likely to transmit M. tuberculosis to contacts.
Molecular epidemiology studies have confirmed the
variation in infectivity that exists among patients
who have tuberculosis and highlighted the infectivity
of patients who have smear-positive pulmonary
tuberculosis. For example, a single patient who had
smear-positive pulmonary tuberculosis was directly
220 daley
or indirectly responsible for 6% of the tuberculosis
cases in San Francisco during a 2-year period [22]. In
another report, investigators showed that a single
homeless tuberculosis patient who had highly infec-
tious pulmonary tuberculosis and was a regular pa-
tron of a neighborhood bar probably infected 42%
(41/97) of the contacts who were regular customers
and employees of the bar and caused disease in 14
(34%) of them. All 12 patients whose isolates of
M. tuberculosis were available had identical IS6110
RFLP band patterns [23].
Most infection-control policies and recommenda-
tions prioritize smear-positive pulmonary tuberculo-
sis over smear-negative cases, leading to the false
assumption that smear-negative cases are not infec-
tious. Several studies have demonstrated that patients
who have sputum smears that are negative for acid-
fast bacilli but culture-positive for M. tuberculosis
can transmit infection to others in the community.
Behr and colleagues [24] reported that patients who
have smear-negative culture-positive pulmonary
tuberculosis were probably responsible for 17% of
cases in San Francisco. In a recent study from Van-
couver, British Columbia [25], investigators reported
that a similar proportion of cases resulted from smear-
negative source cases. In this study, the authors also
included extrapulmonary cases of tuberculosis and
noted that the proportion of episodes of transmission
from smear-negative clustered cases increased to at
least 25%, suggesting that some transmission was
occurring from extrapulmonary cases. Pulmonary tu-
berculosis apparently was not ruled out in all of these
cases, so transmission probably occurred through
more traditional means of spread. As an illustration
of this point, investigators in San Francisco reported
that patients who have pleural tuberculosis combined
with negative sputum cultures were unlikely to gen-
erate secondary cases of tuberculosis [26].
Although the frequency of cough has been shown
to correlate with skin test reactivity among contacts
[21], genotyping has provided conflicting results
regarding the importance of symptoms in transmis-
sion. Investigators in Harris County, Texas, reported
no association between the duration of symptoms and
the size of molecularly defined clusters [27]. Cronin
and colleagues [28], however, reported that the time
from symptom onset to diagnosis was twice as long
for patients who were considered to be transmitters
than for nontransmitters. These latter data support the
belief that reducing diagnostic delays can prevent
transmission of M. tubeculosis.
The studies reviewed here have demonstrated that
the potential for transmitting tuberculosis should be
considered in all pulmonary tuberculosis patients/
suspects, particularly in settings and environments
that facilitate transmission, such as shelters, hospices,
health care facilities, prisons, and other institutional
or crowded settings [13]. It would be prudent to treat
smear-negative pulmonary tuberculosis suspects for
some period before removing them from isolation or
sending them into high-risk settings such as jails and
prisons. In addition, pulmonary tuberculosis should
be carefully ruled out in patients who have extra-
pulmonary diseases. Although international guide-
lines for the diagnosis and treatment of tuberculosis
prioritize the detection and treatment of infectious
sputum smear – positive patients [29], timely diag-
nosis and treatment of sputum smear – negative cases
should be considered when resources permit.
Exogenous reinfection and mixed infection
Molecular genotyping can determine whether a
patient who has a recurrent episode of tuberculosis
has a relapse with the previous strain of M. tuber-
culosis or exogenous reinfection with a new strain.
Although exogenous reinfection was reported before
the availability of genotyping [30], these techniques
have made the identification of reinfection easier and
more specific. Exogenous reinfection has been re-
ported in both immunocompromised and immuno-
competent persons (Table 2) [31 – 34]. In Cape Town,
South Africa, where there is a high incidence of
tuberculosis and ongoing transmission, 16 of 698 pa-
tients had more than one episode of tuberculosis.
Twelve of these 16 (75%) had pairs of isolates of
M. tuberculosis with different genotyping patterns
[34]. Exogenous reinfection is relatively uncommon
in areas that have a low incidence of tuberculosis,
such as Switzerland [35] and the Netherlands [36],
compared with high- to moderate-incidence regions
[37 – 45]. In Houston, Texas, among 100 patients
who have recurrent tuberculosis and have completed
therapy for a first episode of tuberculosis, exogenous
reinfection was reported to cause a surprisingly high
24% to 31% of the second episodes of tuberculo-
sis [46].
Some cases of suspected exogenous reinfection
might be caused by initial infections that include
more than one strain. These instances would repre-
sent repeated infections over time that lead to a mixed
infection with different strains of M. tuberculosis.
Multiple infections were demonstrated in a patient in
San Francisco [47], in two patients who worked in a
medical-waste processing plant in Washington State
[48], and among prisoners in Spain [49]. In South
Africa, a country that has a reportedly high frequency
of exogenous reinfection [34], mixed infections are
Table 2
The frequency of exogenous reinfection in selected studies by tuberculosis incidence rates
No. of patients who
have two episodes No. of patients who No. of patients who
First author/date [reference] Study location Study population TB or two isolates have genotyping have reinfection (%)
Low and moderate incidence areas (<100 per 100,000 population)
Small, 1993 [31] King’s County Hospital, AIDS patients with positive culture for 17 6 0 (0)
New York City, NY >1 y or increasing drug resistance 31 11 4 (36)

molecular epidemiology
Sudre, 1999 [32] Switzerland HIV cohort with two isolates 20 20 2 (10)
Chaves, 1999 [49] Madrid, Spain HIV-infected Spanish inmates who 11 9 2 (22)
remained culture positive for >4 mo
Bandera, 2001 [45] Lombardy, Italy TB recurrences separated >6 mo NA 32 5 (16)
Caminero, 2001 [38] Gran Canaria Island, Spain Two positive cultures >12 mo apart 23 18 8 (44)
Krüüner, 2002 [41] Tartu, Estonia Treatment failures 35 11 11 (100)
Garcia de Viedma, 2002 [40] Madrid, Spain HIV+ and HIV cases with two 172 43 14 (33)
isolates >100 d apart
El Sahly, 2004 [46] Houston, TX TB recurrences 100 100 . . . (24 – 31)
High incidence areas (100 per 100,000 population)
Godfrey-Faussett, 1994 [42] Nairobi, Kenya TB recurrences NA 4 1 (20)
Das, 1995 [37] Madras, India Recurrence or isolated positive culture 30 30 11 (37)
32 32 29 (91)
Van Rie, 1999 [34] Cape Town, South Africa Recurrent TB 48 16 12 (75)
Sonnenberg, 2000 [43] Gauteng Province, South Africa HIV+ and HIV gold miners 57 48 2 (4)
Lourenco, 2000 [39] Rio de Janeiro, Brazil HIV+ patients with multiple isolates 12 12 3 (25)
Fitzpatrick, 2002 [44] Kampala, Uganda HIV+ and HIV TB recurrences NA 40 9 (23)
Abbreviations: HIV , sero-negative for HIV; HIV+, seropositive for HIV; NA, not available; TB, tuberculosis.

221
222
common. Warren and colleagues [50], using a PCR-
based method of strain classification reported that
19% of all patients were simultaneously infected with
Beijing and non-Beijing strains and that 57% of
patients infected with Beijing strains also were in-
fected with a non-Beijing strain. These observations
indicate that simultaneous infections with multiple
strains of M. tuberculosis occur and may be re-
sponsible for conflicting drug-susceptibility results
[51] or episodes of recurrence caused by exoge-
nous reinfection.
Impact of drug resistance on transmission and
pathogenesis
Before the advent of genotyping, studies sug-
gested that isoniazid-resistant strains of M. tuber-
culosis were less likely to result in disease in animals
[52 – 54]. Mutations or deletions within the katG gene
of isoniazid-resistant strains of M. tuberculosis have
been associated with a decrease in the pathogenicity
in animal models [55]. Several molecular epidemio-
logic studies have reported that patients who have
drug-resistant strains were less likely to be in clusters,
suggesting that drug-resistant strains might be less
predisposed to being transmitted or to cause active
tuberculosis [20,56,57]. The spread of tuberculosis
involves a three-step process: transmission of bac-
teria, establishment of infection, and progression to
disease. Because genotyping studies require the de-
velopment of active tuberculosis, they cannot deter-
mine whether drug resistance influences only one,
two, or all three of the processes. Burgos and col-
leagues [58] recently reported that the number of
secondary cases generated by isoniazid-resistant
cases of tuberculosis was significantly less than the
drug-susceptible cases. This difference in the gen-
eration of secondary cases was noted regardless of
HIV status and place of birth.
These findings support the hypothesis that drug-
resistant strains are less likely than drug-susceptible
strains to result in disease. There are, however,
populations in which drug resistance is neither de-
tected nor treated effectively and where the longer
duration of infectiousness for patients who have drug-
resistant organisms treated with standard regimens
might offset the bacterium’s diminished capacity to
cause secondary cases [58]. In areas that have high
prevalence rates of HIV, the increased host suscep-
tibility, even to strains that have diminished viru-
lence, may offset bacterial differences. For example,
one multidrug-resistant strain of M. tuberculosis,
strain W, caused several nosocomial outbreaks in
New York City in the early 1990s [59]. Over the next
daley
few years, this strain was documented to have dis-
seminated widely in the community. Because poor
tuberculosis control and underlying HIV infection are
common in many areas, drug resistance may dissemi-
nate locally despite the diminished propensity of
drug-resistant strains to cause disease. In addition, it
is possible that some organisms could experience a
subsequent mutation that increases its virulence back
to its pre – drug-resistant state [60].
Contact and outbreak investigations
Conventional tuberculosis contact investigations
use the stone-in-the-pond or concentric circle ap-
proach to collect information and to screen household
contacts, coworkers, and increasingly distant contacts
for tuberculosis infection and disease [61]. Studies in
low-incidence areas such as San Francisco [22] and
Amsterdam [62] demonstrated that a relatively small
proportion (5% – 10%) of tuberculosis cases that had
identical IS6110 -based genotyping patterns were
named as a contact by the source case. One expla-
nation for these findings is that unsuspected trans-
mission of M. tuberculosis occurred and was not
easily detected by conventional contact tracing in-
vestigations. In a 5-year, population-based study in
the Netherlands, contact investigations of persons in
five of the largest clusters identified epidemiologic
links among them based on time, place, and risk
factors [20]. Tuberculosis transmission also occurred
through only short-term, casual contact that was not
easily identified in routine contact investigations.
In a more recent study [16] from the Netherlands,
patients were divided into one of five transmission
groups based on the results of contact investigations,
genotyping, and, in some cases, a second interview:
1. Clear epidemiologic links, confirmed by geno-
typing and contact tracing (24%)
2. Clear epidemiologic links, confirmed by geno-
typing and second interview but not by contact
tracing (6%)
3. Initially unclear epidemiologic links that be-
came likely after genotyping and second inter-
view (55%)
4. No epidemiologic links but genotyping indi-
cated clustering
5. Patients who were part of a different cluster
other than expected (1%)
Combining groups 1 and 2 would suggest that
at best contact investigations could identify about
30% of the clustered cases. Fifty-five percent of
 molecular epidemiology
the clustered cases had an epidemiologic link iden-
tified after the genotyping results became available
and a second interview was performed. These data
suggest that as newer, more rapid amplification-
based genotyping methods become available, this
approach might be able to improve contact inves-
tigations [63].
Genotyping has also demonstrated that even when
another case is identified through a contact inves-
tigation, the contact case may be unrelated to the
index case. For example, Marcel Behr and colleagues
[64] in San Francisco reported that 30% of case –
contact pairs had different strains of M. tuberculosis.
Unrelated strains were more common among foreign-
born, particularly Asian, contacts. Of 538 similar case
pairs in a study [65] involving seven sites in the
United States, 29% did not have matching genotype
patterns, similar to the finding in San Francisco. Case
pairs from the same household were no more likely to
have confirmed transmission than those linked else-
where. Among patients younger than 5 years of age,
15% of culture-confirmed cases and their suspected
source patient had different genotype patterns [66]. In
a recent study from South Africa, investigators
evaluated 129 households in which genotyping data
were available for more than one patient [67]. They
identified 313 patients of whom 145 (46%) had a
genotype pattern matching that of another member of
the household. These studies suggest that contact
investigations should not focus solely on the house-
hold but all settings frequented by the index case.
Even when the essential elements of tuberculosis
control are in place, ongoing transmission of
M. tuberculosis will continue until tuberculosis is
diagnosed and therapy is initiated. In a population-
based molecular epidemiologic study in an urban
community in the San Francisco Bay area, 75 (33%)
of 221 cases had the same strain of M. tuberculosis
[68]. Thirty-nine (53%) of the 73 patients developed
tuberculosis because they were not identified as con-
tacts of source-case patients; 20 case patients (27%)
developed tuberculosis because of delayed diagnosis
of their sources; 13 case patients (18%) developed
tuberculosis because of problems associated with the
evaluation or treatment of contacts; and one case
patient (1%) developed tuberculosis because of de-
lays identifying the person as a contact.
Contact tracing in the community can be ineffec-
tive in tuberculosis outbreaks if patients do not live in
stable settings and either do not know or are un-
willing to reveal the names and locations of contacts.
Fortunately, studies that incorporate genotyping are
able to provide information about the chains of
transmission in these groups [69 – 71]. A prospective
223
study of tuberculosis transmission in Los Angeles,
California, identified 162 patients who had culture-
positive tuberculosis and interviewed the patients to
identify their contacts and whereabouts [72]. Tradi-
tional contact investigations did not reliably identify
patients infected with the same strain of M. tuber-
culosis: only 2 of the 96 clustered cases named others
in the cluster as contacts. The degree of homelessness
and the use of daytime services at three shelters were
independently associated with clustering, however.
This study demonstrated that locations where the
homeless congregate are important sites of tuber-
culosis transmission.
Several studies support the idea that specific
locations can be associated with recent or ongoing
transmission of M. tuberculosis. In a 30-month
prospective, city-wide study of all tuberculosis cases
in Baltimore, Maryland, using traditional contact
investigations and IS6110-based genotyping, 46%
(84/182) of initial isolates were clustered, and 32%
(58/182) of the cases were considered to have
tuberculosis that was recently transmitted [73]. Only
24% (20/84) of clustered cases had an identifiable
epidemiologic link of recent contact with an infec-
tious tuberculosis patient. Using geographic informa-
tion system data, the 20 clustered cases, which have
epidemiologic links in geographic areas of the city
that have low socioeconomic status and high drug
use, were spatially aggregated. Therefore, in some
populations, location-based control efforts may be
more effective than traditional concentric circle –
based contact tracing for early identification of cases.
Genotyping has been particularly useful in
identifying otherwise unsuspected and undetected
transmission in the community [13]. Molecular epi-
demiologic studies have confirmed suspected and un-
suspected transmission of tuberculosis in places such
as residential care facilities [74], bars [23,75 – 77],
crack houses [78], sites of illegal floating card
games [79], schools [80,81], hospitals [82,83], and
jails and prisons [84 – 87]. Tuberculosis transmission
also has been demonstrated among groups such as
church choirs [88], interstate transgender social net-
works [89], renal transplant patients [90], from
patient to health care providers [91], and from health
care provider to patients [92,93]. Processing con-
taminated medical waste resulted in transmission of
M. tuberculosis to at least one worker in a medical
waste treatment facility [94]. Genotyping was also
used to document unsuspected bronchoscopy-related
transmission and the cross-contamination of patients
[95,96]. Without the availability of genotyping, it
would have been difficult to confirm that trans-
mission had occurred in such settings.
224
Community epidemiology and risk factors for
clustering
Tuberculosis develops by rapid progression from
a recently acquired infection, from LTBI, or from
exogenous reinfection. Most molecular epidemiology
studies have assumed that the proportion of clustered
isolates in a population estimates the amount of
recent or ongoing transmission of M. tuberculosis.
The frequency of clustering has ranged from 7%
to 32% in low-incidence areas such as Canada
[97 – 100] to 34% to 46% in urban areas in the
United States [22,28,73,101] and Europe [20,102 –
104]. Among gold miners in South Africa, 50% of
tuberculosis patients were in clusters [15], and in
Botswana 42% of the cases were clustered [105].
Whether or not clustered cases represent tuberculosis
caused by recent transmission has remained a con-
troversial point. A recent study from the Netherlands
suggests that clustered cases do, in fact, repre-
sent recent transmission and rapid progression. Of
481 patients who had tuberculosis, 29% were clus-
tered, suggesting recent transmission in 20% (using
the n-1 approach to calculate recent transmission).
The authors reported that 86% of the cases had
epidemiologic links consistent with recent trans-
mission [16]. In high-incidence areas, the frequency
of clustering has ranged from 25% in Hong Kong
[106], to 38% in India [107], to 42% to 72% in
various African populations [57,67,105].
Conventional epidemiologic methods can be used
in combination with molecular genotyping techniques
to identify the risk factors associated with recent
infection and rapid progression to disease (Table 3).
In studies in low-incidence areas, young age, being in
an ethnic minority group, homelessness, and sub-
stance abuse have been associated with recent
infection and rapid progression to disease [22,62,
73,101]. In New York City, birth outside the United
States, age of 60 years or older, and diagnosis after
1993 were factors independently associated with
having a unique strain; homelessness was associated
with clustering or recent transmission [108]. Tuber-
culosis among foreign-born persons was more likely
to result from recent transmission among those who
were HIV-infected and more likely to result from
LTBI among those who were not infected with HIV.
These data suggest that tuberculosis prevention and
control strategies need to be targeted to the large
number of foreign-born persons in New York City
who have latent tuberculosis infection. Among
foreign-born patients who have tuberculosis in Ham-
burg, Germany, risk factors for recent infection
included a history of contact tracing, intravenous
daley
drug use, alcohol dependence, asylum stay, and
unemployment [109]. Thus, the risk factors associ-
ated with recent infection and rapid progression to
disease have varied from study to study, partly
because of differences in populations, methodologies,
and definitions.
Unfortunately, there are few population-based
studies from high-incidence areas. In a study of
South African gold miners, tuberculosis patients who
had not responded to treatment at entry to the study
were more likely to be in clusters (adjusted odds ratio
[OR] = 3.41). Patients who have multidrug-resistant
tuberculosis were more likely not to have responded
to tuberculosis treatment but were less likely to be
clustered than those who have a drug-susceptible
strain (OR = 0.27) [15]. HIV infection, although
common (53.6%), was not associated with clustering.
Apparently, persistently infectious individuals who
had previously not responded to treatment were
responsible for one third of the tuberculosis cases in
this population. In a study from Cape Town, 72% of
cases were clustered, suggesting high rates of trans-
mission in the community [110].
Measuring the performance of a tuberculosis control
program
As noted previously, tuberculosis can develop
through three mechanisms: recent transmission and
rapid progression to disease, reactivation of latent
infection, or exogenous reinfection. Because cluster-
ing is considered a measure of recent transmission, a
decline in the rate of clustering could be used to
evaluate interventions aimed at reducing recent trans-
mission [111]. In an evaluation of tuberculosis trans-
mission over a seven-year period in San Francisco,
the number and proportion of clustered tuberculosis
cases declined, particularly among the native-born
population [19]. This decline was attributed to the
implementation of targeted tuberculosis prevention
and control programs such as screening high-risk
populations and implementing directly observed
therapy to ensure high cure rates. A recent study
in New York City showed that as tuberculosis case
rates fell from recent high levels, the proportion of
tuberculosis cases caused by recent transmission
dropped from 63.2% in 1993 to 31.4% in 1999
[108]. Tuberculosis was unlikely to result from recent
transmission in persons born outside the United
States. Investigators in Denver, Colorado [112], used
clustering to measure the impact of a skin testing
program among homeless persons and showed that
clustering decreased from 49% during the implemen-
 molecular epidemiology 225

Table 3
Frequency of clustering and risk factors for clustering in selected studies by tuberculosis incidence rate
First author/date N ever
[reference] Study location Study population clustered (%) Risk factors for clustering
Low and moderate incidence areas (<100 per 100,000 population)
Alland, 1994 [101] New York, NY Hospital-based 104 (38) HIV seropositive
Hispanic ethnicity
Younger age
Drug-resistant disease
Low income
Small, 1994 [22] San Francisco, CA Community-based 473 (40) AIDS
Born in the United States
Bishai, 1998 [73] Baltimore, MD Community-based 182 (46) Intravenous drug use
van Soolingen, 1999 [20] The Netherlands Country-based 4266 (46) Male gender
Urban residence
Dutch and Surinamese nationality
Long-term residence in
The Netherlands
Hernandez-Garduño, Vancouver, BC, Community-based 793 (17) Canadian-born aboriginals
2002 [97] Canada Canadian-born nonaboriginals
Injection drug users
Kulaga, 2002 [98] Montreal, QC, Community-based 243 (25) Haitian birth
Canada
Diel, 2002 [102] Hamburg, Community-based 423 (34) Alcohol abuse
Germany History of contact tracing
Unemployment
Fitzgerald, 2003 [99] Western Canada Regionally-based 944 (32) Younger age
Male gender
Pulmonary disease
Living in shelter
Drug-susceptible disease
Predisposing factors
Prior contact
Prior skin test
Blackwood, 2003 [100] MB, Canada Province-based 629 (7) Male gender
Younger age
Treaty aboriginals
Living on reserve land
Vokovic, 2003 [103] Belgrade, Random sample 176 (31) Multidrug-resistant disease
Central Serbia
Zolnir-Dove, 2003 [104] Slovenia Country-based 306 (38) Younger age
Alcohol abuse
Homelessness
High incidence areas (100 per 100,000 population)
Godfrey-Faussett, South Africa Gold miners 419 (50) Treatment failure
2000 [57] Time spent working in mines
Lockman, 2001 [105] Botswana Community-based 301 (42) Imprisonment
Narayanan, 2002 [107] Tiruvallur District, Community-based 378 (38) Identified by house-to-house
India survey
Chan-Yeung, 2003 [106] Hong Kong, China Community-based 702 (25) Permanent residents
Recent travel to mainland China
Verver, 2004 [110] Capetown, Community-based 797 (72) Smear positive
South Africa Defaulted retreatment cases
Specific community
226
tation of the program to 14% in the 4-year period
after the program.
By contrast, an 8-year study in Greenland showed
that the annual incidence of tuberculosis doubled
from 1990 to 1997, and the percentage of culture-
positive tuberculosis cases in RFLP-defined clusters
increased to 85%, reflecting microepidemics among
adults and young children in small, isolated set-
tlements [113]. Thus, genotyping was a useful in-
dicator of changes in the proportion of cases that
resulted from recent transmission and rapid progres-
sion to disease.
Geographic distribution and dissemination of
Mycobacterium tuberculosis
Genotyping has permitted the tracking of strains
of M. tuberculosis as they spread both locally and
globally. Population-based data from the San Fran-
cisco Bay area suggest that M. tuberculosis does not
rapidly transmit and spread across geographic bound-
aries and that tuberculosis control programs should
focus on transmission within well-defined areas
[114]. In fact, most clusters (66%) from the National
Tuberculosis Genotyping and Surveillance Network
in the United States were restricted to a single site
[115]. Some strains of M. tuberculosis are widely
dispersed both geographically and temporally, how-
ever, suggesting the strains are either older, more
transmissible, or are more likely than other strains to
cause disease. Data from the Genotyping Network
found that 25% of the clusters were in two sites, 5%
were in three, 2% were in four, and 1% each were in
five and six sites [115]. Further research is needed to
determine why some strains seem to be more dis-
seminated than others.
The Beijing family of strains has been detected in
high proportions among the strains in China [116],
other parts of Asia [117], the former Russian Fed-
eration [87], Estonia [118], Europe [119 – 121], and
South Africa [122] and has been associated with large
outbreaks, febrile responses [123], treatment failure
and relapse [124,125], and drug resistance [126]. The
W strain, a multidrug-resistant strain of M. tuber-
culosis that caused many cases of tuberculosis among
patients and health care workers in nosocomial
outbreaks and other institutional settings in New
York City [59,127 – 130], is a member of the Beijing
family [128]. It is unclear why the Beijing family
strains are so widely disseminated [131]. It is possible
that the Beijing genotype has a selective advantage
and is more readily aerosolized, can establish infec-
tion more effectively, or can progress more rapidly
from infection to disease [4,132]. On the other hand,
daley
it is also possible that the Beijing genotype was
introduced into multiple locations before other strains
and had more time to spread.
The future of molecular epidemiology
Molecular genotyping, in combination with con-
ventional epidemiologic investigations, has contrib-
uted greatly to the understanding of the transmission
and pathogenesis of tuberculosis and has identi-
fied inadequacies in tuberculosis control programs.
The development of new tools, such as real-time
amplification-based genotyping, should improve the
ability to genotype strains of M. tuberculosis and con-
duct effective, timely, contact and outbreak investiga-
tions. Other technologies based on the genome of
M. tuberculosis may eventually make it possible s to dif-
ferentiate strains based on important phenotypic char-
acteristics such as transmissibility and pathogenicity.
For these new tools to be used effectively, they
must be used in combination with conventional
epidemiologic investigations. With time, genotyping
should be integrated with new surveillance systems
that will allow more rapid responses to potential
outbreaks of tuberculosis. The integration of geno-
typing and new approaches to surveillance will be
particularly important in low-incidence areas of the
United States where resources are limited and early
detection of outbreaks is difficult. The CDC-funded
national genotyping network should help with the
integration of genotyping tools into standard tuber-
culosis control practices and pave the way for tu-
berculosis control in the future.
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 Clin Chest Med 26 (2005) 327 – 340

New Drugs for Tuberculosis: Current Status and

Future Prospects
Richard J. O’Brien, MDa,*, Mel Spigelman, MDb
a
Foundation for Innovative New Diagnostics, Case Postale 93, 1216 Cointrin/Geneva, Switzerland
b
Global Alliance for TB Drug Development, 80 Broad Street, 31st Floor, New York, NY 10004, USA

Following nearly 3 decades of neglect, there is of high-quality drugs in standardized regimens of

now renewed interest in the development of new
drugs for the treatment and prevention of tuberculosis
[1]. Three reasons are usually given for needing new
tuberculosis drugs: (1) to improve current treatment
of active tuberculosis by shortening the total duration
of treatment or by providing for more widely spaced
intermittent therapy; (2) to improve the treatment of
multidrug-resistant tuberculosis (MDR-TB), and
(3) to provide more effective treatment of latent tu-
berculosis infection (LTBI) in low-incidence coun-
tries where this intervention is a component of the
control strategy. Of these, the first is most compelling.
Despite the great decrease in tuberculosis inci-
dence throughout the latter half of the twentieth cen-
tury in industrialized countries, the disease remains a
significant global health problem, particularly among
adults in developing countries [2]. In countries af-
fected by the AIDS epidemic, notably those in sub-
Saharan Africa, rates of tuberculosis have increased
dramatically, overwhelming control programs [2]. The
World Health Organization (WHO) has recently
promoted the directly observed treatment, short course
(DOTS) strategy as an effective intervention that will
lead to reduced tuberculosis transmission and decreas-
ing numbers of tuberculosis cases [3]. This strategy
has been shown to be among the most cost-effective
global health interventions available today [4]. An
important component of that strategy is the provision
* Corresponding author.
E-mail address: rick.obrien@finddiagnostics.org
(R.J. O’Brien).
short-course, rifampin-based treatment given under
direct supervision.
The current treatment regimens, however, suffer
from a number of drawbacks. With the combination
of available drugs, the duration of treatment required
for curing patients cannot be reduced below 6 months
without a significant increase in relapses. When given
under suboptimal conditions, these regimens are as-
sociated with high rates of patient nonadherence, with
the consequence of increased mortality and creation
of chronic, infectious, drug-resistant cases [5]. It is
recommended that treatment be directly observed by
a health care provider, especially during the first
2 months and whenever rifampin is used. The in-
frastructure required is cumbersome, labor intensive,
and expensive. Thus, shorter treatment regimens or
those that could be administered once or twice a week
would significantly improve treatment outcome.
Development of drug resistance is far more likely
when supervised treatment is not given, when recom-
mended regimens are not used, and when drugs with
poor bioavailability are used. All these factors are
frequently present in countries where DOTS has not
been established. WHO has documented an increas-
ing problem of MDR-TB that threatens to under-
mine recent progress in global efforts to control the
disease [6]. The second-line drugs that are used for
treatment of MDR-TB are much more expensive,
more toxic, or less effective than first-line drugs. Al-
though the development of more effective therapy
for MDR-TB would not alone solve the problem,
providing better treatment would be an important
personal health benefit for those afflicted by MDR-

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.013 chestmed.theclinics.com
328 o’brien
TB and would improve the effectiveness of the
WHO-supported MDR-TB treatment programs
known as DOTS-Plus [7].
The resurgence of tuberculosis in the United
States beginning in the late 1980s, coupled with the
outbreaks of MDR-TB largely associated with HIV
infection, led to increased federal support for both
domestic and global tuberculosis control [8]. That
support has resulted in continued declines in tuber-
culosis in the United States beginning in 1993 and a
renewed call for the elimination of tuberculosis as a
public health problem [9]. An important component
of the tuberculosis elimination strategy in the United
States is the treatment of individuals who have LTBI
and are at increased risk of developing active TB
[10]. The most widely used LTBI treatment regimen,
9 months of isoniazid, is associated with significant
nonadherence, however. Thus, a more easily admin-
istered LTBI treatment regimen is a priority in a
number of low-incidence countries.
Tuberculosis drug development—a changing
environment
Increased resources directed toward tuberculosis
drug development are now being marshaled from
both the public and private sectors. Governmental
organizations, such as the United States National In-
stitutes of Health (NIH), are investing in basic re-
search aimed at the identification of new drug targets
and a better understanding of the phenomena of
mycobacterial latency. Foundations, such as the Bill
and Melinda Gates Foundation, are supporting re-
search and development to enhance the understand-
ing of the basic biology of tuberculosis and to
develop new tuberculosis drugs. A number of small
biotech companies have programs focused on the
identification of new chemical entities with anti-
mycobacterial activities that could become lead com-
pounds in the drug-development process. Several
large pharmaceutical companies, such as GlaxoSmith-
Kline (Brentford, United Kingdom), AstraZeneca
(London, United Kingdom), and Novartis (Basel,
Switzerland), have launched programs directed at the
discovery and development of new tuberculosis
drugs. Other companies, notably Aventis and Bayer,
have made compounds available for clinical studies.
At the same time, the clinical trials infrastructure,
which had been greatly eroded beginning in the early
1980s, is being reestablished with the formation of
groups such as the United States Tuberculosis Trials
Consortium (TBTC) [11] sponsored by the Centers
for Disease Control and Prevention (CDC) and the
& spigelman
Clinical Trials Program of the International Union
Against Tuberculosis and Lung Disease. With sup-
port from the European Community, the European
and Developing Countries Clinical Trials Partnership
aims to provide A600 million over 5 years to per-
form clinical trials and to establish capacity for the
conduct of high-quality clinical trials, including
those for tuberculosis, throughout Africa [12]. Under-
pinning all this effort is the Global Alliance for TB
Drug Development (TB Alliance), a recently estab-
lished organization that is forging public – private part-
nerships with the objective of building a portfolio of
new tuberculosis drugs and bringing a major new
tuberculosis drug to market in the next decade [13].
This article reviews two classes of compounds
that have advanced into phase II and III clinical trials,
long-acting rifamycins and fluoroquinolones, and a
number of other drugs that have entered or it is hoped
will enter clinical development in the near future.
Rifapentine: the search for widely spaced
intermittent treatment
Rifampin is the cornerstone of modern short-
course tuberculosis treatment, but rifampin-based
regimens must be administered for at least 6 months
for optimal effectiveness. Although this treatment is
also highly effective when given three times per week
throughout the course of treatment [14], more widely
spaced regimens are less effective and may be as-
sociated with acquired drug resistance in HIV-
infected patients, even when properly taken.
A number of rifamycin derivatives with much
longer serum half-lives than that of rifampin (2 –
4 hours) have been evaluated in regimens given in-
termittently. The first of these compounds to undergo
clinical investigation was rifabutin [15]. The initial
clinical trials of the drug focused on the prevention
of Mycobacterium avium complex (MAC) infection
in HIV-infected patients [16]. Although the drug was
approved for MAC prophylaxis in the United States
and for the treatment of tuberculosis in several other
countries, it now is used primarily as a substitute for
rifampin in patients who cannot use that drug be-
cause of drug – drug interactions [17]. A TBTC trial
of a rifabutin-containing regimen given twice weekly
in HIV-infected patients found high rates of acquired
rifamycin resistance among patients who had more
advanced immunosuppression, leading to CDC recom-
mendations against the use of widely spaced treat-
ment of tuberculosis with rifamycin regimens in such
patients [18].
 new drugs for tuberculosis
Another long-acting rifamycin derivative, rifalazil,
has an even longer half-life and potent activity in
animal models suggesting that it might be used in
ultrashort treatment regimens [19]. One attractive
feature of the compound is its rather low potential for
enzyme induction and drug interactions [20]. Initial
phase I tolerability studies, however, found relatively
high rates of side effects manifesting as a flulike
syndrome when the drug was administered as a single
50-mg dose [21]. The hypothesized mechanism
causing the dose limiting side effect is release of
cytokines with evidence for increased interleukin-6
levels in the serum. Following an early bactericidal
activity (EBA) study that did not demonstrate drug
activity of once-weekly rifalazil (at 10- and 25-mg
doses) plus isoniazid given for 2 weeks [22], further
clinical development stopped. It is believed that
closely related compounds can be identified that are
better tolerated and lack the propensity for enzyme
induction. Currently, there is significant interest in the
use of rifalazil for the treatment of chlamydia
infections [23].
The greatest interest and investment in long-acting
rifamycins has been in rifapentine, a cyclopentyl-
substituted rifampin with a half-life of 14 to 18 hours
in normal adults. Following a 600-mg dose, serum
levels in excess of the minimum inhibitory concen-
tration (MIC) persist beyond 72 hours, suggesting
that the drug might be useful in intermittent regimens
(Fig. 1). A series of experimental studies in mice
found that a once-weekly continuation phase of rifa-
pentine and isoniazid for 4 months following a stan-
dard 2-month induction phase with daily isoniazid,
rifampin, and pyrazinamide was as effective as stan-
12.00
10.00
Plasma Concentration
8.00
(µg/mL)
6.00
4.00
2.00
0.00
0 12
Fig. 1. Rifampin and rifapentine time-concentration curves following 600-mg dose in normal adults.
329
dard therapy given daily for 6 months [24]. These
studies provided the scientific underpinning for the
large phase III trial that was begun by CDC in
1995 and subsequently became known as TBTC
Study 22.
Study 22 was an unmasked clinical trial that
randomly assigned adults who had newly diagnosed,
drug-susceptible pulmonary tuberculosis to a
4-month (16-week) continuation-phase regimen of
either once-weekly rifapentine-isoniazid or twice-
weekly rifampin-isoniazid following successful com-
pletion of a standard 2-month induction phase [25].
The primary study end points were treatment failure
and relapse and safety and tolerability of rifapentine.
The rifamycins were dosed at 600 mg and isoniazid at
900 mg. Although the trial focused on HIV-negative
patients, HIV-positive patients were also enrolled
initially to gain experience with this important subset
of patients. Enrollment of HIV-positive patients was
stopped early in the trial, however, following the
finding of a high rate of relapse with acquired ri-
fampin monoresistance among HIV-positive patients
assigned to the rifapentine arm [26].
A total of 1003 HIV-negative patients were
enrolled into the completed study. The crude rate of
failure and relapse was significantly higher in the
rifapentine arm (9.2% versus 5.6%, P = 0.04). In a
multivariate analysis, the factors statistically associ-
ated with an adverse outcome were the presence of
cavitary disease on chest radiograph, sputum culture
positivity at study entry (ie, at the end of the intensive
phase of therapy), white race, and weight less than
90% of ideal body weight at time of the diagnosis of
tuberculosis. The treatment regimen was not associ-
Rifaentine
Rifampin
24 36 48 60 72
Time (h)
330 o’brien
Relapse Rate (%)
25
20
15
10
5
0
Culture+ Culture+ Culture-
Cavity+ Cavity- Cavity+
Fig. 2. Tuberculosis Trials Consortium study 22. Relapse rate by arm, cavitary chest radiograph, and 2-month culture. (Adapted
from Tuberculosis Trials Consortium. Rifapentine and isoniazid once a week versus rifampicin and isoniazid twice a week for
treatment of drug-susceptible pulmonary tuberculosis in HIV-negative patients: a randomised clinical trial. Lancet
2002;360:528 – 34; with permission.)
ated with an adverse outcome. Cavitary disease and
culture positivity after 2 months were also predictors
of an adverse outcome among patients in the rifampin
arm (Fig. 2). Among patients who had noncavitary
tuberculosis and negative 2-month sputum cultures,
the relapse rate was low in both arms. Rifapentine
was well tolerated, and rates of adverse events were
similar in both treatment groups, with 3% of pa-
tients in both groups discontinuing treatment be-
cause of a drug-related adverse event. These results
were similar to those from a study in Hong-Kong that
used Chinese-manufactured rifapentine of inferior
bioavailability [27] and with those from a company-
sponsored trial that enrolled patients largely from
Africa [28].
The TBTC study results led to new recommen-
dations for the use of the rifapentine-isoniazid
continuation-phase regimen for HIV-negative adults
who have drug-susceptible, noncavitary tuberculo-
sis and negative acid-fast bacillus (AFB) smears at
2 months [29]. This category includes approxi-
mately 40% of patients in the United States who
have newly diagnosed pulmonary tuberculosis. The
regimen provides substantial cost savings for these
patients, because encounters for directly observed
treatment during the continuation phase are reduced
by 50% [30].
Rifapentine-based treatment is not recommended
for patients who have more advanced tuberculosis or
patients who have HIV infection. Pharmacokinetic
studies undertaken as part of Study 22 indicated that
low levels of isoniazid and rapid isoniazid acetylation
were associated with relapse, suggesting that a more
effective companion drug might improve once-
weekly treatment [31]. Experimental studies have
also suggested that, in addition to a better companion
drug, higher doses of rifapentine might also result in
more effective treatment [24].
& spigelman
Once weekly
rifapentine/isoniazid
Twice weekly
rifampin/isoniazid
Culture-
Cavity-
Following the completion of Study 22, the TBTC
undertook a large phase II trial of higher rifapentine
doses. In Study 25, 150 HIV-negative patients who
had drug-susceptible pulmonary tuberculosis and
completed initial-phase treatment were randomly as-
signed to 600, 900, and 1200 mg rifapentine given
once weekly with isoniazid for 16 weeks. The ri-
fapentine dose was masked with the use of dummy
tablets of rifapentine. The primary study end points
were adverse events and drug discontinuation. All
regimens were well tolerated, and only one patient
assigned to the 1200-mg dose stopped treatment be-
cause of a possible drug-related adverse event [32].
Because the results of Study 22 were known when
this study began, the protocol was modified to pro-
vide extended treatment for an additional 3 months
(or 12 weeks) for patients who had cavitary disease
and had positive sputum cultures at entry (ie, at
2 months). Twenty such patients were enrolled,
received extended treatment, and were followed
prospectively for relapse. Only one patient who was
assigned to the 600-mg dose relapsed. The relapse
rate of 5%, when compared with historical data from
Study 22 (22%), suggests that extended treatment and
higher rifapentine doses may provide more effective
treatment for patients who are at increased risk of
relapse [33]. The results also suggest that the 900-mg
rifapentine dose would be appropriate to use in
subsequent trials.
Experimental studies have also suggested that
once-weekly rifapentine and isoniazid for as short a
period as 3 months may provide effective treatment
for LTBI, comparable to that conferred by 6 months
of daily isoniazid or by 2 months of daily rifampin
and pyrazinamide [34]. Based on these findings,
the TBTC has embarked on an ambitious study of
rifapentine/isoniazid for LTBI treatment, intending
to enroll and randomly assign 8000 patients to either
 new drugs for tuberculosis
9 months of daily self-administered isoniazid or
12 doses of once-weekly rifapentine/isoniazid. Be-
cause of the large sample size required and the
capacity of the TBTC sites to enroll eligible patients,
study completion is not expected before 2008.
Moxifloxacin: the next treatment-shortening
drug?
During the past decade, fluoroquinolone anti-
biotics have become the most important second-line
drugs for treating patients who have MDR-TB. Until
recently, however, these drugs have not been consid-
ered for the treatment of drug-susceptible disease, in
part because the few randomized, controlled trials of
fluoroquinolones for drug-susceptible tuberculosis
that have been conducted have not demonstrated a
benefit. This perspective began to change with the
publication of a clinical trial conducted by the Tu-
berculosis Research Centre in Chennai, India. This
study, which did not have a standard control group,
randomly assigned patients who had newly diagnosed
pulmonary tuberculosis to one of four ofloxacin-
containing regimens [35]. Rates of 2-month sputum
culture conversion, a marker of the sterilizing activity
of tuberculosis drug regimens [36], ranged from 92%
to 98%, which compares favorably to an expected
rate of approximately 80% with standard four-drug
treatment [25]. Rates of relapse during the 2 years
following completion of treatment were 2% and 4%
in patients randomly assigned to 3 months of daily
isoniazid, rifampin, pyrazinamide, and ofloxacin,
9
Mean CFU/Spleen (log 10)
8
7
6
5
4
3
2
1
0
Day 1 Day 30 INH,
25
Controls
Fig. 3. Thirty-day experimental study of isoniazid (INH), sparfloxacin, and moxifloxacin in a mouse model of acute tuberculosis.
Drug doses in mg/kg. (Adapted from Ji B, Lounis N, Maslo C, et al. In vitro and in vivo activities of moxifloxacin and
clinafloxacin against Mycobacterium tuberculosis. Antimicrob Agents Chemother 1998;42:2066 – 9; with permission.)
331
followed by twice-weekly isoniazid and rifampin
for 1 and 2 months, respectively. These results sug-
gest that fluoroquinolones might permit substantial
shortening of tuberculosis treatment from the current
minimum of 6 months.
Recent experimental data also suggest that fluo-
roquinolones may be potent sterilizing drugs that
could allow shortened regimens for the treatment of
active tuberculosis, including MDR-TB, and be
effective against LTBI. Thus, newer fluoroquinolones
have the potential to achieve all three objectives of a
new tuberculosis drug. Several fluoroquinolones with
markedly enhanced in vitro activity against M. tuber-
culosis are now available. Of these, the most potent
are moxifloxacin and gatifloxacin. The MICs of these
two agents are fourfold lower than that of levofloxa-
cin, the fluoroquinolone that is currently preferred for
the treatment of drug-resistant tuberculosis [37,38].
Moxifloxacin also has excellent activity against M. tu-
berculosis in animal models [39,40]. A recent evalua-
tion of fluoroquinolones in a model of mycobacterial
persistence found that moxifloxacin had the greatest
sterilizing activity [41]. The pharmacokinetic profile
of moxifloxacin, with a relatively long half-life and
high area under the time concentration curve, also
suggests that this agent may be an ideal antimyco-
bacterial drug [42].
A series of studies of moxifloxacin in mouse
models of acute tuberculosis have also contributed to
the interest in this drug. The initial study, in which
infected mice were treated for 1 month with several
fluoroquinolones, found that moxifloxacin has the
greatest bactericidal activity, comparable to that of
isoniazid (Fig. 3) [39]. A second study suggested that
100 25 50 100 25 50 100
(1/7)
Sparfloxacin Moxifloxacin
332 o’brien & spigelman

10
Untreated
8

Log CFU in lungs

2HRZ/4HR*
6 2HRZM/4HRM

4 2HRM/4HR
2HZM/4HM
2
2RZM/4RM
0
0 1 2 3 4 5 6
Duration of Treatment, Months
*H=isoniazid, R=rifampin, Z=pyrazinamide, M=moxifloxacin

Fig. 4. Experimental study of moxifloxacin-containing regimens in murine tuberculosis. (Adapted from Nuermberger EL,
Yoshimatsu T, Tyagi S, et al. Moxifloxacin-containing regimen greatly reduces time to culture conversion in murine tuberculosis.
Am J Respir Crit Care Med 2004;169:334 – 5; with permission.)

moxifloxacin also has potent sterilizing activity and
might substantially improve the efficacy of once-
weekly rifapentine treatment, replacing isoniazid that
has been shown in clinical studies to be a poor com-
panion drug [43]. The most recent study found that
the combination of rifampin, pyrazinamide, and
moxifloxacin had substantially greater sterilizing
activity than the standard regimen, again suggesting
the possibility that the drug would permit significant
shortening of treatment (Fig. 4) [44].
The results of two small EBA studies have dem-
onstrated that moxifloxacin has bactericidal activity
superior to that of rifampin and perhaps comparable
to that of isoniazid, the most potent bactericidal drug
in EBA studies [45,46]. The only other published
experience with moxifloxacin treatment of tubercu-
losis is a small case series that indicated good toler-
ability to chronic administration of the drug [47]. The
next step in the clinical development of moxifloxa-
cin for TB is the conduct of a series of phase II
clinical trials in which moxifloxacin replaces various
drugs in the initial 2-month phase of TB treatment
and where sputum culture conversion at 2 months
is the primary study end point [48]. Data from such
studies, which have historically taken 2 years to
complete, are usually required to proceed to the larger
and more costly phase III trials that commonly take
much longer to complete.
To develop clinical data that would justify larger
phase III efficacy trials of moxifloxacin, the TBTC
has embarked on a phase II trial of the drug, Study
27. This study randomly assigns newly diagnosed,
AFB-positive, HIV-positive and -negative patients
who have suspected pulmonary tuberculosis to
one of four 2-month intensive-phase regimens: two
standard-treatment regimens given either daily or
three times weekly or similar regimens in which
moxifloxacin replaces ethambutol, with assignment
masked by placebo moxifloxacin and ethambutol.
The primary study end points are 2 month sputum
culture conversion and withdrawal because of ad-
verse events. Investigators from Johns Hopkins
University are working with colleagues from Rio de
Janeiro on a similar study that is supported by the
United States Food and Drug Administration Office
of Orphan Products Development (R. Chaison, per-
sonal communication, 2004).
A product development team supported by the
United Nations Childrens Fund/United Nations De-
velopment Program/World Bank/WHO Special Pro-
gram for Research and Training in Tropical Diseases
and the European Commission is embarking on
several studies of a gatifloxacin fixed-dose com-
bination product for the treatment of drug-susceptible
tuberculosis. These efforts include preclinical phar-
macology and toxicology studies and a phase I study
designed to compare the drug – drug/pharmacokinetic
interactions of gatifloxacin and isoniazid, rifampin,
and pyrazinamide. A phase II study is being con-
ducted in Durban, South African, randomly assigning
newly diagnosed patients to one of three fluoroqui-
nolone-containing regimens (ofloxacin, moxifloxacin,
and gatifloxacin) in combination with isoniazid,
rifampin, and pyrazinamide during the first 2 months
of treatment. A variety of bacteriologic markers are
being evaluated as potential surrogate markers of
treatment response. A large phase III trial of gati-
floxacin included in a 4-month regimen that intends
 new drugs for tuberculosis
to enroll over 2000 patients at centers in five coun-
tries in sub-Saharan Africa was expected to begin
in late 2004 (C. Lienhardt, personal communica-
tion, 2004).
The emerging tuberculosis drug pipeline
In addition to the rifamycin derivatives and fluo-
roquinolones, a variety of other compounds or classes
of compounds are under investigation as potential
antimycobacterial drugs. These include a diarylquino-
line (R207910), a nitroimidazopyran (PA-824), a
nitro-dihydroimidazo-oxazole (OPC 67,683), a pyr-
role (LL3858), macrolides, oxazolidinones, and a
diamine (SQ109).
Diarylquinolines (R207910)
The diarylquinolines, under investigation by
Johnson & Johnson (New Brunswick, New Jersey),
have been shown to have potent in vitro activity
against M. tuberculosis and seem promising in an
animal model [49]. The lead compound, R207910, is
currently in clinical testing in phase I studies.
R207910 is equally active against drug-sensitive
M. tuberculosis (MIC 0.03 mg/mL) and strains
resistant to a variety of commonly used drugs such
as isoniazid, rifampin, streptomycin, ethambutol,
pyrazinamide, and fluoroquinolones. Similar potency
was also found against other mycobacteria, such as
M. smegmatis, M. bovis, M. avium, and M. fortuitum,
but the compound is not active against several other
bacterial species, such as Nocardia asteroides,
Escherichia coli, Staphylococcus aureus, Enterococ-
cus faecium, and Hemophillis influenzae. Two
resistant M. smegmatis isolates were not cross-
resistant to a wide range of antibiotics, including
the fluoroquinolones. Thus, the mechanism of action
of R207910 seems to be unique among the com-
monly used antimicrobials.
In addition to the in vitro activity of R207910,
the compound has also shown excellent in vivo
activity in mouse models of established and nones-
tablished disease. When R207910 was administered
by gavage 5 days/week from day 1 to day 28 after
intravenous inoculation of Swiss mice with 7-log
colony forming units (CFU) of strain H37Rv M. tu-
berculosis (nonestablished infection model), the com-
pound was able to prevent mortality at the lowest
dosage used (1.5 mg/kg), prevent gross lesions at
6.5 mg/kg, and reduce CFU counts in lungs and
333
spleens at 12.5 mg/kg to the same extent as isoniazid
(25 mg/kg). When therapy was started on day 14 after
inoculation and continued until day 70 (established
infection model), 12.5 mg/kg of R207910 was at least
as active in decreasing CFU count in lung as was
isoniazid (25 mg/kg) or rifampin (10 mg/kg). At a
dose of 25 mg/kg, R207910 was even more active
than at 12.5 mg/kg, reducing lung CFU count from
6 to 0.4 log. The combination of R207910 with any
two of the three commonly used drugs (isoniazid,
rifampin, and pyrazinamide) was more effective than
the standard regimen of isoniazid, rifampin, and
pyrazinamide. In fact, the combination of R207910,
isoniazid, and pyrazinamide and the combination of
R207910, rifampin, and pyrazinamide both resulted
in negative spleen and lung cultures after 8 weeks
of therapy.
Pending results of the phase I studies, the ability
of R207910 to shorten the therapy of active TB will
be tested.
Nitroimidazopyrans (PA-824)
The TB Alliance is developing PA-824, a novel
nitroimidazopyran with a molecular weight of 359,
for first-line therapy of active tuberculosis and for the
treatment of MDR-TB. The history of the nitro-
imidazoles goes back to the 1970s, when Ciba-Geigy
(Basel, Switzerland) explored a novel series of nitro-
imidazole compounds as radiosensitizing agents for
use in cancer therapy. Subsequent studies described
these compounds’ antimicrobial activity, including
activity against M. tuberculosis. Ciba-Geigy halted
development when their lead compound (CGI-17341)
was found to be mutagenic in the Ames assay. In the
1990s, PathoGenesis (Seattle, Washington) decided
this class of compounds warranted further exploration
for potential tuberculosis therapy and synthesized
more than 700 novel compounds. They determined
that the nitroimidazopyran PA-824 was the most
active of these compounds against M. tuberculosis in
a murine infection model [50].
Following Chiron’s (Seattle, Washington) pur-
chase of PathoGenesis in 2000, development of
PA-824 was halted because of the company’s
decision to focus on other therapeutic areas. In 2002,
the TB Alliance and Chiron signed an exclusive
license agreement granting the TB Alliance world-
wide rights to PA-824 and nitroimidazole derivatives.
Since then, the TB Alliance has continued the
development of PA-824.
A series of in vitro pharmacology studies indicate
that PA-824 may be efficacious against both drug-
334 o’brien
sensitive and drug-resistant tuberculosis. In vitro
studies demonstrate that the MIC of PA-824 against
a variety of drug-sensitive tuberculosis isolates
(
0.015 – 0.25 mg/mL) is similar to that of isoniazid
(0.03 – 0.06 mg/mL). PA-824 is highly selective, with
potent activity only against bacille Calmette-Guerin
(BCG) and M. tuberculosis among the mycobacterial
species tested, and without significant activity against
a broad range of gram-positive and gram-negative
bacteria (with the exception of H. pylori and some
anaerobes). In vitro studies using anaerobic culture
models indicate that PA-824 has activity against
nonreplicating bacilli, whereas isoniazid does not
have activity in these models. Finally, PA-824 has
been shown to have activity against strains of tu-
berculosis with known resistance to standard anti-
tuberculosis therapies, indicating a novel mechanism
of action.
To evaluate in vivo activity, PathoGenesis tested
PA-824 in a mouse model of tuberculosis, employing
an M. tuberculosis reporter strain expressing firefly
luciferase. PA-824 was administered orally at 25, 50,
and 100 mg/kg/day in mice for 10 days, with
isoniazid used in the control arm. Administration of
PA-824 at all doses significantly reduced M. tuber-
culosis levels in both spleen and lung compared with
controls and demonstrated a linear dose response. In
longer-term studies, PA-824 at 50 mg/kg/day dem-
onstrated reductions in bacillary burden similar to
isoniazid at 25 mg/kg/day in murine lungs, and all
mice treated with PA-824 survived infection,
whereas all untreated control animals died by day 35.
Daily oral administration of PA-824 at 37 mg/kg/day
for 35 days in a guinea pig aerosol infection model
also caused statistically significant reductions of
M. tuberculosis in lungs and spleens compared
with controls, reductions comparable to those caused
by isoniazid.
The activity of PA-824 against MDR-TB isolates
and against both replicating (aerobic) and nonrep-
licating (anaerobic) M. tuberculosis bacilli indicates
this compound has a novel mechanism of action.
PA-824 seems to inhibit significantly both protein
and lipid synthesis but does not affect nucleic acid
synthesis. PA-824 produces an accumulation of
hydroxymycolic acid with a concomitant reduction
in ketomycolic acids, suggesting inhibition of an
enzyme responsible for the oxidation of hydroxy-
mycolate to ketomycolate.
Unlike the Ciba-Geigy lead compound, CGI-
17341, PA-824 has not demonstrated mutagenicity
in the Ames test (with or without S9 activation), and
initial toxicity studies indicated the doses needed for
therapeutic activity in murine and guinea pig infec-
& spigelman
tion models are below the acute and chronic toxic
thresholds observed for PA-824 in mice.
More recent studies by Grosset et al [51] have
indicated that, in a murine model, the minimum
effective dose (defined as the minimum dose which
prevents the development of gross lung lesions and
splenomegaly) of PA-824 is 12.5 mg/kg/day, that the
absence of lung lesions on gross inspection correlates
well with bacteriostatic activity measured by CFU
count, that the minimum bactericidal dose (defined as
the minimum dose which reduces the long colony
forming unit counts by 99%) is 100 mg/kg/day, and
that the activity of PA-824 at 100 mg/kg is com-
parable to the activity of isoniazid at 25 mg/kg.
The potential genotoxicity of PA-824 was exam-
ined further with chromosomal aberration, mouse
micronucleus, and mouse lymphoma tests. The
results indicate that PA-824 is not genotoxic. Fur-
thermore, in vitro studies indicate that PA-824 nei-
ther inhibits nor is metabolized by major P450
enzyme isoforms.
Pharmacokinetic studies have been performed in
the rat, dog, and monkey, because the systemic
exposure in dogs is low for both males and females
secondary to poor absorption and rapid metabolism.
Results of the single-dose studies indicate that the
half-life of PA-824 is approximately 2 to 5 hours in
male rats and monkeys and trends toward a longer
half-life in female rats (8 – 9 hours). The half-life in
dogs is shorter (1 – 2 hours). In monkeys, single
doses of PA-824 are rapidly absorbed with a time
to maximal concentration (Tmax) of 3.33 hours or
less, whereas Tmax in the rat ranges up to 8 hours.
There was no significant effect of sex on rate of
absorption in any species. There was not a sig-
nificant food-effect on PA-824 pharmacokinetics in
the rat.
The pharmacokinetics of PA-824 was determined
in plasma, heart, liver, kidney, spleen, and lung
following a single 100-mg/kg oral dose of PA-824
in rats. The time to reach maximal concentrations of
PA-824 in these tissues was 4 hours as compared
with 6 hours in plasma. Exposure (area under the
curve) in tissues was approximately three- to eight-
fold higher than that in plasma. These data suggest
that, in the rat model, penetration of PA-824 into
lung, spleen, and other tissues is extensive. In re-
peated dose studies, there was no evidence of accu-
mulation in the rat or monkey.
Two 14-day good – laboratory practice toxicology
studies, one in the rat and one in the monkey, have
been completed. The results of these studies indicate
that toxicity is observed when exposures at or above
approximately 500 mg/hour/mL are achieved. Phase I
 new drugs for tuberculosis
studies of PA-824 are planned for the first quarter
of 2005.
Dihydroimidazo-oxazoles (OPC-67683)
OPC-67683 is a newly synthesized nitro-dihydro-
imidazo-oxazole derivative under development by
Otsuka Pharmaceutical Company (Tokyo, Japan)
for the treatment of tuberculosis and is currently in
phase I study in normal volunteers (Otsuka Pharma-
ceutical Company, personal communication, 2004).
The compound has potent in vitro antimicrobial
activity against M. tuberculosis, with MICs against
H37Rv and 67 clinically isolated strains ranging from
0.006 to 0.024 mg/mL. Furthermore, OPC-67683
shows no cross-resistance with any of the currently
used first-line tuberculosis drugs, most likely indi-
cating a novel mechanism of action. Therefore the
compound may be of benefit both in shortening
duration of therapy in the treatment of active disease
and in the treatment of MDR-TB.
In vivo studies using a chronic mouse model of
tuberculosis have demonstrated the efficacy of OPC-
67683 to be superior to that of the currently used
tuberculosis drugs. In the mouse model, the dose that
provided the effective plasma concentration of
0.100 mg/mL was 0.625 mg/kg, confirming the re-
markable in vivo potency of OPC-67683.
In other nonclinical in vitro and in vivo studies,
OPC-67683 does not have any antagonistic activity
with other first-line tuberculosis drugs when used in
combination. Combinations with other first-line thera-
peutic drugs reveal synergistic, additive, or no appre-
ciable interactions.
Pyrrole (LL3858)
Pyrrole derivatives were first described by Deidda
et al [52] as having fairly potent antimycobacterial
activities against several strains of M. tuberculosis.
The MICs were between 0.7 and 1.5 mg/mL for
the most potent derivative, 1,5-diaryl-2-methyl-3-
(4-methylpiperazin-1-yl) methyl-pyrrole (BM212).
The activity of BM212 against various drug-resistant
strains of M. tuberculosis was similar to its activity
against sensitive strains, probably indicating a novel
mechanism of action. Although some nontuberculosis
mycobacterial strains seemed to be sensitive, the
MICs were higher than for M. tuberculosis.
A novel pyrrole compound, LL3858, is currently
in development for tuberculosis by Lupin Limited
(Mumbai, India). This compound has submicromolar
MICs and seems to be very active in a mouse model
of tuberculosis. In combination with currently used
335
antituberculous drugs, LL3858 sterilizes lungs and
spleens of infected animals in a shorter timeframe
than conventional therapy.
Macrolides
The Institute for Tuberculosis Research, College
of Pharmacy at the University of Illinois at Chicago,
in conjunction with the TB Alliance, is currently
studying the potential for macrolide antibiotics in the
treatment of tuberculosis. Among approved antimi-
crobial agents that do not include tuberculosis as an
indication, the macrolides are one of the more
promising to yield a clinically useful tuberculosis
drug. This potential is based on their oral bioavail-
ability and distribution to the lungs, low toxicity,
infrequent adverse reactions, extensive intracellular
concentration and activity, anti-inflammatory activity,
and, perhaps most importantly, demonstrated clinical
utility and bactericidal activity in infections caused
by several pathogenic and opportunistic mycobac-
teria, including M. avium, M. leprae, M chelonei, and
M. fortuitum.
Erythromycin, the first-generation prototypical
macrolide, is a natural product derived from Strepto-
myces erythreus. The compound interferes with
protein synthesis and possesses most of the favorable
properties mentioned previously but suffers from a
short serum half-life and acid lability, which results in
gastric motility – based discomfort. In addition, activ-
ity is restricted to gram-positive bacteria.
Therefore, second-generation macrolides with
superior acid stability and serum half-life were devel-
oped. Clarithromycin, roxithromycin, and azithromy-
cin represent the most successful second-generation
macrolides. It quickly became apparent that the
second-generation macrolides were, along with rifa-
butin, the most active clinical agents against the
MAC. With the exception of azithromycin (an azalide
that possesses a spectrum of activity different from
that of other macrolides), these compounds also were
found to possess potent activity against M. leprae in
macrophages and mice and were shown to be effec-
tive in clinical trials. Clarithromycin is currently
recommended by the WHO for treatment of leprosy
in cases of rifampin resistance or intolerance. Other
studies demonstrated low MICs or clinical utility of
second-generation macrolides against M. kansasii,
M. marinum, M. xenopi, and other opportunistic
mycobacterial pathogens. The impressive activity of
second-generation macrolides unfortunately did not
include M. tuberculosis.
The third-generation macrolides, represented
largely by the ketolides, were developed with the
336 o’brien
intention of overcoming the ribosome-modification
and efflux-resistance mechanisms found in gram-
positive cocci. Telithromycin was the first such agent
to be brought to market. A comparative study of the
antimycobacterial activity of clarithromycin versus
telithromycin (as well as the fluorinated analogue
of telithromycin) revealed the superior activity of cla-
rithromycin for both the moderately clarithromycin-
susceptible mycobacteria M. bovis BCG, M. avium,
M. ulcerans, and M. paratuberculosis, and the
clarithromycin-resistant mycobacteria M. tuberculo-
sis, M. bovis, M. africanum, and M. simiae [53].
Thus, although the general resistance mechanisms to
macrolides of gram-positive cocci and mycobacteria
seem to be similar, there are significant differences
in their structure – activity relationships.
Studies conducted several years ago confirmed
that clarithromycin was the most active antimyco-
bacterial macrolide among 15 first- and second-
generation macrolides (S. Franzblau, personal
communication, 2004). The most potent of the
commercially available macrolides, cethromycin, still
has a MIC that is higher than the maximum plasma
concentration (Cmax) that is obtainable in man. Further
testing of modifications of the substituents on the
macrolide structure have produced much more potent
antimycobacterial compounds with low toxicity.
These compounds form the basis for the ongoing
work in optimizing the macrolide structure for ac-
tivity against M. tuberculosis.
Oxazolidinones
Oxazolidinones represent a relatively new class
of antimicrobial agents, initially discovered by scien-
tists at DuPont (Wilmington, Delaware) in the 1970s
[54,55]. They act by inhibiting protein synthesis by
binding to the 70S ribosomal initiation complex
[56,57]. The spectrum of activity of the oxazolidi-
nones includes anaerobic and gram-positive aerobic
bacteria, such as methicillin-resistant S. aureus and S.
epidermidis, the enterococci, and also mycobacteria
[58,59].
HO R2
H H
N R1 N N
N N R3
H H
R4
OH
Ethambutol Library of 63,238 diamines
Fig. 5. Chemical structures of ethambutol, compounds in the original combinatorial library, and SQ109.
& spigelman
Linezolid is the first commercially available
oxazolidinone antibiotic. Although not approved for
use in mycobacterial disease, there are convincing in
vitro data that the drug is active against M. tuber-
culosis. A few oxazolidinones have been evaluated
for their activity in murine in vivo systems. The most
active compound seems to be PNU-100480, the ac-
tivity of which seems to be similar to that of isoniazid
or rifampicin [59].
Because of the lack of effective therapeutic
options for patients who have MDR disease, linezolid
has been used sporadically in patients who have
MDR-TB. Although all reports are anecdotal, line-
zolid does seem to have biologic activity as evi-
denced by sputum culture conversion [60]. Somewhat
distressing, however, is the reported occurrence of
peripheral and optic neuropathy associated with pro-
longed use of linezolid [61].
Overall, the class of oxazolidinones seems to hold
promise for the treatment of tuberculosis. Unfortu-
nately, there has not yet been a truly concerted effort
to optimize activity of the oxazolidinones for M. tu-
berculosis. In the meantime, the evidence for po-
tential neuropathies associated with long-term use
of linezolid will require careful use of this drug as it
becomes used more commonly in the treatment of
MDR-TB.
SQ109
N- adamantan-2-yl-N 0-( 3,7-dimethylocta-2,6-
dienyl)-ethane-1,2-diamine (SQ109) was originally
developed as a second-generation antibiotic from a
first-line tuberculosis drug, ethambutol, to improve
efficacy of the drug against M. tuberculosis and
lower its toxicity. Although SQ109 is a diamine, its
structural dissimilarity to ethambutol and differences
in its intracellular target(s) suggest that it is a new
antimycobacterial agent, not an ethambutol analogue
(Fig. 5).
In collaboration with Dr. Clifton Barry at the NIH,
Sequella, Inc. (Rockville, Maryland) synthesized a
diverse combinatorial library of compounds with the
Me Me
Me N
H
SQ109
 new drugs for tuberculosis 337

1,2-diamine pharmacophore of ethambutol and tested
them for activity against M. tuberculosis using an
MIC- and target-based (cell wall) reporter high-
throughput screening assay [62]. These efforts found
2796 mostly lipophilic compounds to be active
against M. tuberculosis in vitro, and 26 demonstrated
in vitro activity equal to or greater than (up to 14-fold)
ethambutol. Sixty-nine of the most potent hit com-
pounds were later studied in a sequential set of in
vitro and in vivo tests: MIC followed by cytotoxicity
screen, followed by activity in infected macrophages,
followed by permeability evaluation, followed by in
vivo efficacy testing, followed by pharmacokinetic
studies. SQ109 was identified as the most potent
compound in the series and was then subjected to in-
tensive pharmacokinetic/ pharmacodynamic testing.
SQ109 is a lipophilic, nonsymmetric derivative of
1,2-ethylenediamine with unsaturated geranyl and
bulky adamantane fragments present. SQ109 has
been synthesized as a stable dihydrochloride salt on
a multikilogram scale with high chemical purity
(99.7%). The formulation to be used in clinical deve-
lopment, hard gelatin capsules, has been developed.
SQ109 has an MIC against M. tuberculosis in the
range of 0.1 to 0.63 mg/mL (broth microdilution,
Alamar blue, BACTEC [Becton Dickinson, Franklin
Lakes, New Jersey]). The compound is bactericidal
with 99% inhibition of M. tuberculosis growth in
macrophages at its MIC. When tested in vivo (in
mice), SQ109 is able to reduce infection in lungs
and spleen by 2 to 2.5 log. It is active against MDR
strains of M. tuberculosis in vitro. SQ109 has a low
mutational frequency in M. tuberculosis in vitro
(2.18  109) and demonstrates enhanced antimyco-
bacterial activity in vitro and in vivo when used
in combination with rifampicin and isoniazid (rapid
mouse model and chronic infection model).
The mechanism of action of SQ109 seems to be
that of a cell wall inhibitor because, like the cell
wall – targeting antibiotics (ethambutol, isoniazid,
ethionamide, and thiacetazone), it induces a pro-
moter, Rv0341, that was employed in the original
luciferase high-throughput screening assay. Because
the Rv0341 luciferase reporter responds with light
production to inhibition of a wide variety of enzyme
targets involved in cell wall construction, the specific
target of SQ109 is not known. To address the issue,
a proteomic study was initiated to identify proteins
in H37Rv M. tuberculosis that are affected by the
drug in comparison with ethambutol and isoniazid.
The results of this study suggest that most of the
44 distinct proteins whose expression is increased
(ESAT-6 and others) or decreased (MPT64 and
others) by SQ109 were similar to those affected by
ethambutol. Only two gene products whose functions
are unknown were regulated differently by ethambu-
tol and SQ109. Similarly, two different genes were
affected, but in opposite directions, by exposure of
M. tuberculosis to SQ109 or ethambutol [63].
The pharmacokinetic/pharmacodynamic profiles
of SQ109 were evaluated in three species (mice,
rats, and dogs). Single-dose pharmacokinetic studies
in mice indicate that SQ109 has 4% oral bio-
availability as measured by drug concentration in
plasma. The high potency of SQ109 in vivo at low
doses (1 mg/kg) combined with tissue distribution
data argue, however, that, despite low bioavailabil-
ity, SQ109 antimicrobial effects can be attributed
to effective concentrations achieved at the sites of
bacterial infection. Although blood concentrations
remain low, SQ109 distributes into lungs and spleen
(target sites of the bacterial infection), greatly
exceeding the MIC (Fig. 6). Oral administration
of SQ109, 30 to 75 mg/m2 (10 – 25 mg/kg in mice)

A B
25000 25000
Concentrations (ng/g)

Concentrations (ng/g)

20000 20000
1h
1h
15000 15000 4h
4h
10 h
10 h
10000 10000

5000 5000

0 0
Ki r
ey

ng

en

M n
e

Ki r
ey

ng

en

rt

M in
e

a
te e
ar

Fa

Fa
ve

ve
in

in

cl

in

cl

m
ac

ai

ac
a

tin

a
dn

dn
le

le
Lu

Lu
He

He
us

us
rg est

st

Br

st

Br
as

as
Li

Li
Sm tom

m
Sp

Sp

rg es
te

Pl

Pl
Sm to
La Int

La nt
in

in
S

lI
l

e
al

al

Fig. 6. Tissue levels of SQ109 after intravenous administration of 3 mg/kg (A) and oral administration of 25 mg/kg
(B) to mice.
338 o’brien
one time per day maintains drug levels above the
MIC without accumulation of the drug in the
target tissues.
The liver may have a first-pass effect on SQ109
metabolism, resulting in low content of the drug in
plasma after oral dosing. P450 reaction phenotyping
suggests exclusive involvement of CYP2D6 and
CYP2C19 in SQ109 metabolism; analysis of metabo-
lites formed upon incubation of SQ109 with human,
mouse, dog, and rat microsomes suggest similar
metabolism of the drug in all tested species. SQ109 is
undergoing formal preclinical 90-day pharmacology
and toxicology studies in preparation for human
clinical trials.
In summary, SQ109 is a novel 1,2-diamine-based
drug candidate with in vitro and in vivo activity
against M. tuberculosis. It has pharmacokinetic/
pharmacodynamic properties that are characterized
by a rapid and broad distribution into various tis-
sues (ie, lungs) that is advantageous for tuberculo-
sis infection.
Summary
During the recent decade, significant progress has
been made in reinvigorating the almost nonexistent
pipeline of novel agents for the treatment of tuber-
culosis and in reestablishing the infrastructure for the
conduct of clinical trials of new tuberculosis drugs
and treatment regimens. Recent studies of long-acting
rifamycin derivatives and potent fluoroquinolone an-
tibiotics are leading to improved regimens for the
treatment of active and latent tuberculosis. A number
of other compounds in late preclinical and early
clinical development show great promise. The rapid
increase in knowledge of mycobacterial pathogenesis
is leading to the identification of new drug targets,
including those believed to play a role in latent in-
fection or in the phenomenon of persistence. A major
challenge will be to sustain and increase funding for
continued developmental and clinical work if the
promise of tuberculosis elimination, or at least sig-
nificant lessening of the global tuberculosis epi-
demic, is to be achieved.
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 Clin Chest Med 26 (2005) 247 – 271

The Diagnosis of Tuberculosis

Daniel Brodie, MD, Neil W. Schluger, MD*
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, 622 West 168th Street,
PH 8 East, Room 101, New York, NY 10032, USA

Tuberculosis is transmitted from person to per-
son by respiratory droplets. Although some people
develop active tuberculosis disease after infection,
almost all tuberculosis infections are asymptomatic
and remain latent. Latent tuberculosis infection
(LTBI) itself progresses to active disease in approx-
imately 5% to 10% of infected persons. The rate of
progression is much greater in immunocompromised
individuals. The estimated 2 billion people living with
LTBI represent a vast reservoir of potential cases of
tuberculosis around the world. This reservoir of LTBI
is therefore a major barrier to the ultimate control and
elimination of tuberculosis.
Strategies to combat tuberculosis in regions that
are resource-rich aim, first, to identify and treat per-
sons who have active disease; second, to find and
treat contacts of cases of active disease who develop
LTBI, and, third, to screen high-risk populations and
treat LTBI [1]. Diagnosis and treatment of LTBI are
crucial in this effort. In most of the world, however,
resources are devoted exclusively to the highest pri-
orities of tuberculosis control: identification and treat-
ment of active disease [1]; for lack of resources, LTBI
is neither diagnosed nor treated.
Diagnostic testing for both LTBI and active dis-
ease has changed little during the last century. Be-
cause of limitations in available tests, there has long
been a clear need for better diagnostic tests. LTBI,
until very recently, has been diagnosed exclusively by
the tuberculin skin test (TST). The TST is fraught
with problems including relatively poor sensitivity
* Corresponding author.
E-mail address: ns311@columbia.edu (N.W. Schluger).
and specificity. Newer tests for LTBI offer the prom-
ise of greatly improved diagnostic accuracy.
Tools for the diagnosis of active disease include
clinical suspicion, response to treatment, chest radio-
graphs, staining for acid-fast bacilli (AFB), culture
for mycobacteria, and, more recently, nucleic acid
amplification (NAA) assays. AFB smears lack both
sensitivity and specificity, and culture is very slow to
produce results, limiting the ability to diagnose active
disease effectively. NAA assays and several other
experimental diagnostic tools can add significantly
to the active disease diagnostic armamentarium. The
suitability of newer diagnostic tests in a given popu-
lation varies according to the resources available to
pay for and implement those tests, however [2].
In resource-poor countries, where options are lim-
ited, current approaches, such as relying almost ex-
clusively on the sputum smear for the diagnosis of
active disease, leave a significant number of cases
undetected [3 – 6]. This approach may be the only
economically feasible strategy given the initial costs
involved in the widespread use of other diagnostic
modalities. Although smear-positive cases are the
most infectious, neglecting smear-negative disease
(approximately half of cases overall) increases the
morbidity and mortality of the disease in those pa-
tients and does not account for the significant burden
of transmission attributable to these smear-negative
cases (17% of all transmission in one study using
molecular epidemiology techniques) [6]. The in-
creased likelihood of smear-negative tuberculosis in
HIV patients, particularly those who have advanced
immunosuppression [7], makes this diagnostic
approach especially problematic, because the regions
most afflicted by tuberculosis are similarly inundated
with HIV infection.

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.012 chestmed.theclinics.com
248
Meanwhile, in resource-rich countries, under-
diagnosis is less an issue than overdiagnosis with
its attendant costs (the production of specimens, the
surveillance of cultures—most of which will ulti-
mately be negative—use of isolation rooms, empiric
therapy for tuberculosis, and expensive or invasive
diagnostic testing) [8]. In part, the need is for more
rapid diagnosis, allowing for earlier treatment of
cases, decreased transmission of active disease, and
decreased expenditure of resources. There is also a
need for increased sensitivity of testing so that cases
do not go unrecognized, and for increased specificity
and negative predictive value to decrease the cost of
having a high suspicion for this disease.
An ideal test for active tuberculosis would
produce rapid results (available within 1 day), would
have high sensitivity and specificity, low cost, and
robustness (ability to provide reproducible results in
a variety of settings), would be highly automated
or easily performed without the need for excessive
sample preparation or technical expertise, and would
be able to provide drug-susceptibility data. Ideally,
such a test would also be able to distinguish between
LTBI and active disease. For LTBI, such a test would
distinguish true infection from bacille Calmette-
Guerin (BCG) vaccination and infection with non-
tuberculous mycobacteria (NTM). In cases of active
disease, it would be valuable to be able to determine
infectiousness, follow response to therapy, distinguish
Mycobacterium tuberculosis from NTM in AFB-
positive specimens and obtain drug-susceptibility
information. No test performs all these functions at
present, but several new tests are being used or are
currently under study that incorporate many of these
features and offer the possibility of improved diag-
nosis of LTBI and of active disease.
100
Per cent reacting
80
60
40
20
0
10-9
Fig. 1. Cumulative frequency of reactors responding to increasing doses of tuberculin among healthy children and patients
with tuberculosis. TU, tuberculin units. (From Reider H. The epidemiologic basis of tuberculosis control. Paris: International
Union Against Tuberculosis and Lung Disease; 1999. p. 32; with permission.)
brodie & schluger
Tests for latent tuberculosis infection
The tuberculin skin test
Tuberculin, a broth culture filtrate of tubercle
bacilli, was first described in detail by Robert Koch
in 1891, a year after he introduced it as a potential
cure for tuberculosis [9]. Although its purported
curative properties proved unfounded, Koch observed
that subcutaneous inoculation of tuberculin led to
a characteristic febrile reaction in patients who had
tuberculosis but not in those who did not have
tuberculosis, giving rise to its use in the diagnosis of
the disease. The technique was refined over the next
2 decades so that cutaneous or intradermal inocu-
lation restricted the reaction to the skin. Subse-
quently, a standardized version of tuberculin, the
purified protein derivative (PPD), was introduced in
1934 [9]. In 1939, the batch of PPD known as PPD-S
was produced by Seibert and Glenn [3]. This batch
remains the international standard for PPD to this day.
In the early years of the TST, the assumption that
tuberculin reactions resulted solely from tuberculo-
sis infections went virtually unchallenged [9]. By the
mid-1930s, however, mounting evidence suggested
that tuberculin reactions might not be restricted to
such infections. In addition, investigators noted that if
the dose of PPD were increased enough, almost
everyone tested positive, including infants unlikely to
have been exposed to tuberculosis [9]. These findings
called into question the specificity of the TST, high-
lighting its limitations for the first time.
The current state of knowledge about the utility of
tuberculin skin testing derives in large measure from
a series of trials performed in epidemiologically well-
defined populations of persons who have known
5 TU PPD-S
Tuberculosis patients
Healthy children
10-8 10-7 10-6 10-5 10-4 10-3 10-2 10-1 100
Dose of tuberculin (mg)
 the diagnosis of tuberculosis 249

Fig. 2. Frequency distribution of skin test reaction with 5-TU PPD-S (solid line) and 2-TU PPD RT 23 (dotted line) among
Eskimo children and United States Navy recruits. TU, tuberculin units. (From Reider H. The epidemiologic basis of tuberculo-
sis control. Paris: International Union Against Tuberculosis and Lung Disease; 1999. p. 33; with permission.)

tuberculosis disease, those at extremely low like-
lihood of having latent infection, and those likely
to be close contacts of persons who have active
tuberculosis. Reider [10] has described these trials
in detail.
The dosing of tuberculin for use in skin testing
was determined in studies such as one done in Ohio,
in which skin testing was performed on tuberculosis
patients and a group of children in orphanages who
had little chance of tuberculosis exposure. At a dose
of 10 4 mg of tuberculin, a clear distinction could be
made between the two groups (Fig. 1). Refinements
in dosing and criteria for positivity were achieved by
using standardized preparations of PPD made by the
Statenseruminstitut in Amsterdam and testing them in
groups of Eskimo children (a group that has a high
likelihood of latent infection acquired from close
contact with active cases and very little exposure to
environmental mycobacteria) and US Navy recruits
who have little chance of contact with active tuber-
culosis but have frequent exposure to environmental
mycobacteria (Fig. 2). Testing of 5440 tuberculosis
patients revealed a normal distribution of extent of
induration, with a mean of 16 to 17 mm (Fig. 3).
Finally, a massive survey of more than 700,000 US
military recruits, of whom 400,000 had no known

Fig. 3. Frequency distribution of tuberculin skin test results (5 – tuberculin unit PPD S) among 5544 tuberculosis patients in
the United States. (From Reider H. The epidemiologic basis of tuberculosis control. Paris: International Union Against
Tuberculosis and Lung Disease; 1999. p. 35; with permission.)
250 brodie
Fig. 4. Frequency distribution of tuberculin skin test results in United States Navy recruits with (dashed line) or without (dotted
line) tuberculosis. The solid line shows the difference between the two groups. (From Reider H. The epidemiologic basis of
tuberculosis control. Paris: International Union Against Tuberculosis and Lung Disease; 1999. p. 36; with permission.)
contact with tuberculosis patients and 10,000 had
definite contacts, provided meaningful data on which
to base recommendations for interpretation of skin
tests that are still useful today (Fig. 4).
Although the TST has been in widespread use for
a century and is the only universally accepted test for
the diagnosis of LTBI, it suffers from significant
inherent limitations. To understand these limitations,
it is useful to review the mechanism of the TST.
Infection with M. tuberculosis results in a cell-
mediated immune response giving rise to sensitized
T lymphocytes (both CD4+ and CD8+ [11]) targeted
to M. tuberculosis antigens. Stimulation by M. tu-
berculosis antigens causes these T cells to release
interferon-gamma (IFN-g). The TST functions by
eliciting this response in previously sensitized indi-
viduals. In such individuals, an intradermal injection
of PPD evokes a delayed-type hypersensitivity re-
sponse mediated by sensitized T cells and results in
cutaneous induration. PPD, however, is a precipitate
of M. tuberculosis culture supernatant which contains
roughly 200 antigens, many of which are shared by
other mycobacteria including many NTM and
M. bovis BCG [12,13]. A response to PPD may sig-
nify infection with M. tuberculosis or, just as readily,
infection with NTM [14 – 18] or vaccination with
BCG [18 – 22]. This cross-reactivity seriously limits
the specificity of the TST in many populations [23].
Given that one quarter to one half of the burden
of tuberculosis in developed countries is found in
foreign-born immigrants from high-prevalence coun-
tries, and this population is made up precisely of
those who are likely to be BCG-vaccinated and to
have been exposed to NTM, the TST is least reliable
in those most in need of screening. Specificity is a
major shortcoming of the TST. In addition, sensitiv-
ity of the TST may also be poorest in patients at high
& schluger
risk for developing tuberculosis. Anergy caused by
an immunocompromised state (especially with HIV
infection or medication-induced immunosuppression)
may lead to false-negative results [24]. False-negative
results also may occur up to about 10 weeks after
infection with M. tuberculosis [25 – 27]. False nega-
tives, particularly in the HIV population where the
implications of active disease are most pressing
[3,28,29], greatly limit the utility of this test.
The exact sensitivity and specificity of the TST
for LTBI is impossible to know with certainty, given
the lack of a reference standard for diagnosis. In that
context, estimates of the global burden of LTBI are
especially problematic. Estimates indicate that the
problem is enormous, but these estimates are based
on the performance of the TST, and such estimates,
particularly in developing countries, are notoriously
unreliable [30,31]. Studies of the prevalence of LTBI
in India, for instance, have yielded prevalence rates
ranging from 9% [32] to more than 80% in various
populations [33]. A more accurate epidemiologic tool
would greatly facilitate a better estimation of the true
scope of the problem.
The TST is limited further by the subjectivity of
its interpretation [34], in particular, by problems with
interreader and intrareader reliability [25,35 – 37] and
digit preference [38,39]. Also, the existence of the
booster phenomenon [24,25,39 – 41], poor standardi-
zation of PPD preparations [31], and, logistically, the
need for a return visit to have the test read make the
TST a highly imperfect diagnostic tool. That it does
not distinguish between LTBI and active disease also
limits its usefulness.
Whether the extent of induration resulting from
tuberculin skin testing can predict the development of
tuberculosis in a linear (or at least dependent fashion)
has also been the subject of considerable discussion
 the diagnosis of tuberculosis
and investigation. Recently, Horsburgh [42] has pro-
vided a well-reasoned and -supported data set that
gives guidance in this area.
Alternatives to the TST are lacking. Serologic
tests for the diagnosis of M. tuberculosis have been
disappointing [43,44]. Although an antibody re-
sponse to M. tuberculosis antigens occurs, there is
great individual variability in the number and type
of serologically reactive antibodies [44], making this
diagnostic tool too unreliable. Because no serologic
tests for tuberculosis are remotely good enough to be
used clinically at present, they are not discussed fur-
ther in this article.
Despite its many limitations, the TST by neces-
sity remains in widespread use. In 2000, the Centers
for Disease Control and Prevention (CDC), the
American Thoracic Society (ATS), and the Infectious
Disease Society of America (IDSA) issued updated
guidelines for the use of the TST in screening for
LTBI [24]. These guidelines stress that in general one
should not place a TST unless treatment would be
offered in the event of a positive test. In addition,
cut-off points of induration (5, 10, or 15 mm) for
determining a positive test vary by the pretest risk
category into which a patient falls. This approach
may further decrease the specificity of the test, but
it increases the sensitivity for capturing those at
highest risk for developing active disease in the short
term. Continued focus on this century-old test high-
lights its continued importance, but the need for a
more accurate diagnostic tool is evident.
Beyond the tuberculin skin test
Development of novel diagnostic tests for LTBI
is hampered by the lack of a true reference standard
for diagnosis. Without such a standard, the best ap-
proach might be to apply a new test to a population in
a controlled study, observe all patients positive by the
novel and reference tests, and determine which test
more accurately predicts the development of active
disease. This approach, however, is limited by ethical
and practical considerations.
Demonstrating that any test is better than the TST
is therefore difficult. Studies of the magnitude of
those cited by Reider [10] for the development of
tuberculin skin testing are unlikely to be repeated.
What approach, then, might be taken? It is well do-
cumented that the greater the proximity to the
source case of active disease and the greater the
duration of exposure to that case, the more likely it is
that a person will develop LTBI. Although the risk of
LTBI cannot be precisely quantified for all degrees of
251
contact, the risk of LTBI may be expressed as an
increasing likelihood of infection with increasing ex-
posure to the source case or increasing amounts of
high-risk behavior. It is against this standard that the
sensitivity of any new diagnostic test must be
compared with the TST itself. A test that is superior
to the TST in sensitivity would be more likely to be
positive given a greater degree of contact with the
source case. Specificity must similarly be gleaned
from the expectation that only infection with
M. tuberculosis and not with NTM or M. bovis BCG
would give a positive result. A test would be superior
in specificity if its results seemed to be independent
of NTM exposure and BCG vaccination status.
Recently, a new generation of tests for LTBI has
been developed. They are the QuantiFERON-TB and
QuantiFERON-TB Gold (QFN-Gold) tests (Cellestis
Limited, St. Kilda, Australia) and the T SPOT-TB test
(Oxford Immunotec, Oxford, UK) The basis of these
tests is the detection in serum of either the release of
IFN-g on stimulation of sensitized T cells by
M. tuberculosis antigens in vitro (QuantiFERON) or
detection of the T cells themselves (T SPOT-TB). In
1990, Wood and colleagues [45] developed a whole-
blood assay for the detection of IFN-g in response to
a specific antigen, PPD, intended for diagnosing
bovine tuberculosis. Later that year, Rothel and col-
leagues [46] introduced a sandwich enzyme immuno-
assay for bovine IFN-g that streamlined the assay,
making it more practical for widespread testing. This
assay was shown to be both sensitive and specific in
field comparisons with the intradermal tuberculin test
[46 – 48] and later was accredited in Australia for use
in the diagnosis of bovine tuberculosis [49]. In 1995,
the test was successfully used in the diagnosis of
M. tuberculosis and M. avium complex infection in
humans [50,51].
Similar to the TST, the QuantiFERON-TB test
detects cell-mediated immunity to tuberculin. In con-
trast to intradermal injection of PPD, however, whole
blood is incubated overnight with PPD from
M. tuberculosis, and the IFN-g that is released from
sensitized lymphocytes is subsequently quantified by
ELISA [38]. As discussed previously, PPD antigens
are shared across mycobacterial species, including
M. bovis BCG [13,52]. A positive response to the
whole-blood IFN-g assay for PPD therefore, like the
TST itself, lacks specificity for M. tuberculosis infec-
tion and may reflect infection with NTM or vacci-
nation with BCG [18]. Early studies were nonetheless
encouraging [38,49,53 – 56], demonstrating decreased
false-positive results relative to the TST in BCG-
vaccinated individuals [38] and those exposed to
NTM [38], with equal or better apparent sensitivity
252 brodie
and specificity than the TST in multiple studies
[38,49,53,56], including in populations of intrave-
nous drug users and HIV-positive patients [54,55].
Few studies purported to demonstrate the superiority
of the TST for LTBI [57,58].
The discovery of M. tuberculosis – specific anti-
gens opened the way to improving the specificity of
the assay. In 1986, Harboe and colleagues [59] re-
ported the first M. tuberculosis – specific antigen,
MPB-64 (later known as MPT-64). In 1995, Ander-
sen and colleagues [60] reported the highly immuno-
genic antigen target of the cellular immune response
to tuberculosis in mice, known as the early secreted
antigenic target 6 (ESAT-6). Subsequently, in 1998,
Berthet and colleagues [61] described culture filtrate
protein (CFP-10) [61], another highly immuno-
genic antigen. MPT-64 has been studied extensively
[62 – 66], but, because it is present in some strains of
BCG and is a less potent target of the immune re-
sponse, it has limited utility [62,63,67]. On the other
hand, ESAT-6 [61 – 64,68 – 70] and CFP-10 [61,71]
have demonstrated great potential.
In 1998, the complete genome sequence of
M. tuberculosis was determined [72]. An earlier com-
parison of the M. tuberculosis genome with the ge-
nomic composition of M. bovis and M. bovis BCG in
1996 by subtractive genomic hybridization [68] and,
subsequently, in 1999, by comparative hybridiza-
tion experiments on a DNA microarray [73] led to
the identification of a genomic region known as
RD1. The gene products of RD1 are found only in
M. tuberculosis, in pathogenic M. bovis strains [64,
68,73], and in four NTM (M. kansasii, M. szulgai,
M. flavescens, and M. marinum) [69,70]. Because, of
these, only M. kansasii overlaps clinically with
M. tuberculosis, and because M. kansasii infection
is uncommon, the RD1 region encodes antigens that
are essentially specific to M. tuberculosis. Among
these antigens are, of course, ESAT-6 and CFP10, as
well as MPT-64. ESAT-6 and CFP-10 are secreted by
M. tuberculosis into the extracellular environment
and are potent targets of the cell-mediated immune
response [61 – 63,71,74]. ESAT-6, which has been
shown to be highly immunogenic in animals [66,
75 – 78], readily discriminated between bovine tuber-
culosis and cattle sensitized to environmental myco-
bacteria [75]. CFP-10 also has demonstrated utility in
diagnosing bovine tuberculosis because of its sig-
nificant specificity [78].
The melding of the ELISA-based QuantiFERON-
TB test and the RD1 antigens, ESAT-6 and CFP-10,
led to a more specific test, now known as the QFN-
Gold. Similarly, the T SPOT-TB test employs the
RD1 antigens but links them to an ELISPOT assay
& schluger
that identifies ESAT-6 – or CFP-10 – specific IFN-g –
secreting CD4+ T cells.
Studies of the IFN-g release assays employing
ESAT-6 or CFP10 in humans have been promising
[79 – 88]. ESAT-6 is a major target of the cellular
immune response in humans [62,63]. Early on, assays
employing ESAT-6 were shown to be more specific
although less sensitive than PPD-based assays for
active disease [79,82,89 – 91]. This improved speci-
ficity over PPD with loss of sensitivity was later
shown by Arend and colleagues [80,81] to hold true
in LTBI as well. More importantly, they also dem-
onstrated improved specificity over the TST. They
reported loss of sensitivity with respect to the TST,
but, because the TST was used as the reference
standard for LTBI, this result probably reflected the
improved specificity rather than poorer sensitivity
[80]. The improved specificity over the Quanti-
FERON-TB assay for PPD and over the TST was
confirmed in a study by Johnson et al [79] of 60 Aus-
tralian medical students who did not have BCG
vaccination or known exposure to M. tuberculosis or
NTM. The specificity of both the QuantiFERON-TB
for PPD and the TST were reduced after BCG vac-
cination was administered to the students, but the
QuantiFERON-TB for ESAT-6 was unaffected [79].
Brock and colleagues [85] also demonstrated im-
proved specificity for both the ESAT-6 and CFP-10
over PPD in BCG-vaccinated versus nonvaccinated
subjects. Recently, Brock and colleagues [88] pub-
lished an outbreak study based on a case of active
disease in a Danish high school student and the
student’s mostly non – BCG-vaccinated contacts. The
TST was used as the reference standard for LTBI in
this population, and there was excellent agreement
between the TST and the QuantiFERON-TB ESAT-6/
CFP-10 assay (94%) [88]. Superiority of the assay
could not be established in this study, because the
TST was itself the reference standard. Nonetheless,
significant specificity with regard to BCG status was
suggested by the findings in subjects who were BCG-
vaccinated. Of these, 50% in the high-exposure
group had a positive assay, compared with 53% of
high-exposure subjects who did not have BCG vacci-
nation. In the low-exposure group, 5% of BCG-
vaccinated persons were assay positive, similar to the
6% of those who did not have BCG vaccination [88].
Finally, Mori and colleagues [87] studied a group of
216 Japanese student nurses who had no identified
risk for M. tuberculosis exposure, all of whom had
been vaccinated with BCG [87]. In this group 64.6%
of the subjects had a TST response measuring 10 mm
or more, yielding a specificity of 35.4% for the TST if
it is assumed that none had true LTBI using exposure
 the diagnosis of tuberculosis
history as the reference standard. The QuantiFERON-
TB ESAT-6/CFP-10 assay, on the other hand, yielded
a specificity of 98.1% in this group, far superior to
the TST. The sensitivity of the assay, 89.0%, was
determined in a separate group of patients who had
culture-proven active disease. Extrapolating the sen-
sitivity for LTBI from the sensitivity for active dis-
ease is problematic, however, because both IFN-g
activity and TST reactivity are reduced in active
disease; extrapolation probably underestimates the
sensitivity for LTBI [12,92,93].
Ajit Lalvani and colleagues [94] have adapted the
ELISPOT technique, an ex vivo T-cell – based assay
for the detection of cell-mediated immunity, for use in
detecting M. tuberculosis. The technique detects and
enumerates peripheral blood IFN-g – secreting T cells
that respond to ESAT-6 or CFP-10. In 2001, Lalvani
and colleagues [94] established a sensitivity of 96%
in active disease (100% in the subpopulation that had
extrapulmonary tuberculosis) as compared with 69%
sensitivity for the TST. In healthy BCG-vaccinated
controls, the ELISPOT was not confounded by BCG.
In TST-positive household contacts of a case of ac-
tive disease (expected cases of LTBI), 85% were
ELISPOT positive, suggesting a sensitivity for LTBI
of 85% if the TST is taken to be the reference
standard [94].
In 2001, Pathan and colleagues [92] also exam-
ined a low-exposure population of mostly BCG-
vaccinated subjects. None of the 32 healthy controls
were positive on ELISPOT. That year, Lalvani and
colleagues [95] also reported on an outbreak study
[95]. The odds ratio (OR) of a positive ELISPOT with
increasing proximity and duration of exposure to the
index case was 9.0, whereas the OR of a positive TST
(by Heaf test, a less well-standardized approach
to skin testing than the tuberculin test) was only
1.9. Another study published in 2001 by Lalvani
and colleagues [12] looked at 40 healthy controls in
the United Kingdom, 82% of whom were BCG-
vaccinated and all of whom were ELISPOT negative.
Another study in the United Kingdom similarly found
that none of 40 healthy controls were ELISPOT
positive [96].
In 2003, Ewer and colleagues [97] published a
meticulously investigated outbreak study that evalu-
ated the ESAT-6/CFP-10 – based ELISPOT assay for
LTBI. Two years earlier, in the United Kingdom, a
secondary school student had been diagnosed with
sputum smear – positive cavitary pulmonary tuber-
culosis. The health authority screened 1128 students
at the school with the TST (HEAF test). Screening
detected 69 cases of active disease and 254 cases of
LTBI, 87% of whom had been vaccinated with BCG.
253
Five hundred thirty-five representative students
were enrolled in the study and underwent ELISPOT
testing. The significance of the study derives from
the detailed contact information available for each
student by virtue of their mandatory, scheduled daily
activities. Degree of exposure to the source case
could be readily quantified and grouped as (1) same
class, same year, with regularly shared lessons;
(2) same year with only weekly shared events; and
(3) other years. Using ORs, the authors provide an es-
timate of the increase in odds of a positive ELISPOT
for each increase in level of exposure. The ELISPOT
correlated significantly better than the TST with
increasing exposure across each group. The relative
risk (RR) of direct exposure to the index case if one
was both TST and ELISPOT positive was 17.6. If one
was ELISPOT positive but TST negative, it was 11.7.
If one was ELISPOT negative and TST positive, the
RR was only 2.97. Also, TST positivity was sig-
nificantly associated with BCG vaccination status
and with birth in a region of high prevalence for
NTM, whereas no significant association was found
for the ELISPOT. The superior correlation with de-
gree of exposure strongly suggests improved sensi-
tivity with the ELISPOT. The lack of confounding
by BCG or NTM suggests improved specificity with
the ELISPOT.
The role of IFN-g – or T-cell – based assays in the
diagnosis of LTBI is being defined. These tests show
promise as replacements for the TST in diagnosing
LTBI among persons at risk for infection in the
developed world. Both the QFN-Gold and T SPOT-
TB tests are approved for diagnostic use throughout
the European Union. In addition, the QFN-GOLD
was approved by the United States Food and Drug
Administration (FDA) in December 2004. Clinical
experience with these tests should accumulate rap-
idly. The less accurate original QuantiFERON-TB
is approved for use in the United States by the FDA,
but guidelines for its use are confusing, and the test
has not been widely adopted in clinical settings.
The improved sensitivity of these tests over the
TST would capture a cohort of patients who other-
wise would go without treatment of LTBI. Within that
cohort, those that would have progressed to active
disease would be spared the attendant morbidity and
mortality. The future contacts of those destined to
progress to active disease would likewise be spared.
This cohort would be overrepresented by those most
likely to have false-negative TST results, namely im-
munosuppressed individuals. This population is
precisely the one in which it is most important to
identify LTBI because of their increased risk for
developing active disease [3]. Unanswered is whether
254 brodie
there is something different about this cohort that
gives positive results on these assays and negative
results on the TST and whether their risk for de-
veloping active disease is less than that of those who
are also TST positive. The TST has predictive value
for the subsequent development of active disease in
both HIV-negative [9,25] and HIV-positive patients
[98]: a stronger skin test response indicates an in-
creased risk of developing active disease [99,100].
Longitudinal studies linking positive assays with risk
for development of active disease are ongoing and
are crucial to demonstrating the true role of these
tests. If they demonstrate a high degree of accuracy,
treatment of LTBI might, under the right conditions,
become a viable strategic component of tuberculosis
control efforts in high- and low-prevalence countries
[97]. One small study of 24 healthy household con-
tacts of persons who had smear-positive pulmonary
tuberculosis in Ethiopia looked at QuantiFERON-TB
ESAT-6 responses at the initial visit and approxi-
mately 2 years later. The subjects were not treated for
LTBI. Seven of 24 patients went on to develop pul-
monary active disease. The subjects who responded
to ESAT-6 at study entry were significantly more
likely to develop active disease than those who were
not responsive [101].
The improved specificity would decrease unnec-
essary treatment in those who are not truly infected,
thereby avoiding the costs to the health care system
for medication, follow-up, and management of com-
plications. It would also spare the individual patient
these same costs.
Costs would also likely be reduced by the in-
creased capture of cases of LTBI, because their
identification would eliminate the future—much
greater—costs of treating an outbreak of active
disease. Costs also might be reduced by the decreased
number of clinic visits required, because the TST
requires a follow-up visit for reading the TST and
may require a second skin test to overcome the
booster phenomenon.
At present, LTBI is neither diagnosed nor treated
in most high-burden, resource-poor countries, except
in certain situations, such as young children who are
close contacts of active cases. The expense of a novel
diagnostic test must be justified in terms of the cost
savings realized from treating LTBI. Such savings
could accrue by reducing the number of cases of
active disease that develop from the vast reservoir of
LTBI that exists in the developing world.
Overall, the potential advantages of the IFN-g –
release and T-cell – based assays over the TST in
diagnosing LTBI seem to include improved specific-
ity (lack of confounding by BCG and NTM) and
& schluger
improved sensitivity. Operator bias and inter- and
intrareader variability are significantly reduced.
Only a single patient visit is required. There is no
booster effect. The results are obtained rapidly, within
24 hours. There may well be cost savings to the
health care system. The assays have proven to be
robust in different populations and in different
settings, in both the developed and developing
worlds. The technology for running the assays has
improved so that requirements for equipment and
technical expertise are reasonable.
Further study is needed. Longitudinal data, as
mentioned previously, are critical. To date there are
no large-scale trials of these assays, and few studies
have employed the Mantoux test while using current
ATS/CDC/IDSA criteria for a positive TST. Study of
the effect of treatment on assay results in LTBI may
provide the data necessary to monitor therapy for
LTBI, allowing the clinician, for example, to distin-
guish response to therapy from lack of response
caused by noncompliance or isoniazid resistance.
Another area of interest would be the ability to
distinguish past exposure to M. tuberculosis without
ongoing infection from true ongoing LTBI. It may
be that detection of T cells specific for ESAT-6 or
CFP-10 suggests that tubercle bacilli continue to
secrete these antigens [12]. Identification of an anti-
gen that is expressed either during LTBI or during
active disease, but not during both, and that could
distinguish these two states would greatly enhance
the role of the assays in active disease and would
increase the specificity for LTBI. Finally, the point
after infection at which the RD1 antigens become
detectable has yet to be defined precisely and has
significant implications for testing in contact inves-
tigations and for reducing false-negative results soon
after infection with M. tuberculosis.
Tests for tuberculosis disease
The reference standard for diagnosing active dis-
ease remains largely clinical: documented response
to appropriate therapy. Of course, establishing a mi-
crobiologic diagnosis is preferable. AFB smear,
mycobacterial culture, and NAA assays may all be
used in confirming a diagnosis of active disease (both
pulmonary and extrapulmonary). In the case of pul-
monary tuberculosis, the method of obtaining a
sample greatly affects the sensitivity of testing. Ex-
trapulmonary tuberculosis frequently poses a diag-
nostic challenge because specimens may be difficult
to obtain. After identifying M. tuberculosis, the most
pressing issue is drug-susceptibility testing, in which
 the diagnosis of tuberculosis
traditional culture techniques are giving way to more
advanced technologies that produce rapid results.
Mode of diagnosis of pulmonary tuberculosis
Is there a role for the tuberculin skin test in the
diagnosis of active disease?
The TST was originally a test for active disease
[9]. It is unsuited for that purpose because its
specificity is limited by cross reactions with NTM
and M. bovis BCG, and, more importantly, by its
detection of LTBI itself, and by alterations in general
immune responsiveness that may occur in cases of
active tuberculosis. The sensitivity of the TST for
active disease varies considerably, from 65% to 94%
[31,34,58,87,89,94]. A study of 3600 hospitalized
patients done by the World Health Organization in
the 1950s found a sensitivity of 93% for reactions of
10 mm or more and a sensitivity of 78% when a
cut-off of 14 mm or more was used [31]. The sen-
sitivity is decreased in certain populations (eg, to less
than 50% in critically ill patients who have dissemi-
nated tuberculosis) [25]. Lacking both specificity
and sensitivity for active disease, the TST is not par-
ticularly useful in this setting.
Sputum-based diagnosis
To establish a diagnosis of pulmonary tuber-
culosis, respiratory samples are submitted to the
laboratory for microscopy (AFB smear) and for my-
cobacterial culture. NAA assays may also be used in
the diagnostic algorithm, as discussed later.
The technique used to obtain the respiratory
sample strongly influences the ability to detect pul-
monary tuberculosis. Expectorated sputum is gener-
ally the starting point. Three samples are collected on
three separate days and stained for AFB [102,103].
Although, the utility of collecting three samples has
been questioned [104], the overall yield for smear and
culture is superior to collecting fewer specimens
[105,106]. Samples are generally sent simultaneously
for smear and culture, because culture data are es-
sential for confirmation of the diagnosis. In resource-
poor countries, the cost of culture is often too great,
resulting in reliance solely on AFB smears.
The sensitivity of sputum AFB smears for de-
tecting pulmonary tuberculosis is limited by the need
for 5000 to 10,000 bacilli per milliliter to be present
in a specimen to allow detection [3]. The sensitivity
255
of expectorated sputum ranges from 34% to 80%
[3 – 5,104,107 – 116]; the sensitivity tends to be high-
est in patients who have cavitary disease and lowest
in patients who have weak cough or less advanced
disease. In no way does a negative sputum smear
eliminate the diagnosis of active tuberculosis, particu-
larly if the clinical suspicion is high. Instituting ther-
apy in such cases often is warranted while awaiting
culture results. If a patient is suspected of having
pulmonary tuberculosis but is smear negative on ex-
pectorated sputum or is unable to produce sputum for
testing (30% of patients in one series [117]), further
diagnostic testing may be warranted. The options
include sputum induction (SI), fiberoptic bronchos-
copy (FOB), and perhaps gastric washings (GW).
The following discussion refers specifically to patients
who are expectorated sputum smear negative or who
cannot produce an expectorated sputum sample.
Sputum induction
SI in the diagnosis of active disease was first de-
scribed in 1961 by Hensler and colleagues [117].
They adapted an earlier technique used to obtain
sputum for cytology in diagnosing lung cancer. Early
studies compared SI with the well-established method
of gastric aspiration [117 – 119]. In patients unable to
expectorate or who had smear-negative sputum
samples, SI was superior to GW in obtaining a suit-
able sample for culture, although the two techniques
were noted to be complementary [119]. GW probably
adds to overall diagnosis, and, according to one au-
thor, its value has been underestimated in recent years
[120]. The role of GW in adults is probably quite
limited, however. SI, on the other hand, has proven
effective in patients clinically suspected of having
pulmonary tuberculosis who are either unable to pro-
duce sputum or are sputum smear negative.
SI has performed well in resource-poor countries
with little added cost [121 – 123]. In South Africa, SI
performed on 51 patients yielded a suitable sample in
36 [123]. Fifteen of the 36 patients (42%) were smear
positive, 12 of whom were ultimately culture positive
as well. In Malawi, Parry and colleagues [122] were
able to obtain SI specimens in 73 of 82 patients.
Eighteen of the 73 (25%) were smear positive, and
30 of 73 (42%) were culture positive. Similarly, of
1648 patients in China, 558 (34%) were smear posi-
tive on SI samples. The direct cost per SI in that study
was 37 cents [121]. In these studies, SI provided
appropriate samples for diagnosis and increased the
early diagnostic yield significantly. SI also seems to
be cost-effective in the resource-poor setting.
256 brodie
Conversely, in a retrospective review of 114 pa-
tients who had culture-positive M. tuberculosis in-
fection at an urban hospital in New York, SI added
little to overall diagnosis and was deemed costly by
the investigators [124]. In 1 year, they performed
1566 SIs yielding only 16 positive smears in 10 pa-
tients. At a cost of $28.65 per SI, the annual cost of
$45,000 would indeed be difficult to justify [124]. A
study in the United Kingdom confirmed a low yield
but suggested there might be a role for SI [125].
Is there a role for SI in resource-rich countries?
A large, prospective study from Montreal, Canada,
assessed 500 patients who were either smear negative
(5%) or could not produce sputum (95%) with re-
peated SI [126]. An adequate sample was obtained
in 99.8% of patients. The cumulative yield of SI for
smear-positive samples with successive attempts was
64%, 81%, 91%, and, after four inductions, 98%. The
culture yield also increased with each attempt from
70% to 91% to 99% to 100%. This study suggests
that the use of repeated SI has a high yield in this
setting and that repeated SI should be considered
seriously in this subset of patients [126].
Sputum induction versus fiberoptic bronchoscopy
How does SI compare with FOB in the diagnosis
of pulmonary tuberculosis in expectorated-sputum
smear-negative patients or patients unable to produce
sputum? A study by McWilliams and colleagues
[127] from New Zealand compared repeated SI with
FOB, which was performed if at least two SIs were
smear negative. They prospectively studied 129 pa-
tients who underwent both procedures. Each succes-
sive SI, up to three in total, increased the yield for
culture-positive samples significantly. SI was per-
formed without difficulty in 96% of patients and had
an overall yield of 96.3% after three tests, confirm-
ing the utility of repeated SIs. By contrast, the yield
of FOB was only 51.9%, making SI significantly
more sensitive in this population. The authors also
noted that the overall cost of FOB was three times
that of doing three SIs. They offered several strategies
for diagnosis: FOB alone was too insensitive, whereas
SI alone was sensitive (missed only one case) and cost
effective. Although the combination of SI and FOB
would have captured all culture-confirmed cases of
pulmonary tuberculosis, it would have done so at four
times the cost. The preferred strategy, according to
the authors, would employ SI followed by FOB only
in patients who were negative on SI but had features
of pulmonary tuberculosis on chest radiograph. This
strategy missed no cases and was only 2.5 times
the cost of SI alone [127]. This strategy may be
& schluger
worthwhile in resource-rich settings but may be less
applicable in resource-poor settings where repeated
SI alone would diagnose most of the cases at a
substantially reduced cost.
Anderson [128] prospectively compared SI and
FOB with bronchoalveolar lavage (BAL) in 101 pa-
tients who had suspected pulmonary tuberculosis
in Montreal. SI yielded a positive smear in 19% of
cases; the yield of FOB smear was 12%. The yield
was much higher in obtaining culture-positive sam-
ples: 87% with SI, as compared with 73% for FOB.
Overall, SI performed better than FOB, and direct
costs of FOB were more than eight times those of
SI [128].
A Brazilian study compared SI with FOB in
HIV-positive and HIV-negative patients [129]. One
hundred forty-three patients were diagnosed with pul-
monary tuberculosis, 17% of whom were HIV posi-
tive. The sensitivity of SI smear was 33.8%, and
that of FOB was 38.1% in HIV-negative patients. In
HIV-positive patients, the sensitivities were similar:
36% for SI smear and 40% for FOB smear. SI
produced an adequate sample in 97% of patients in
this study [129].
SI performs well in both resource-poor and
resource-rich countries, is useful in HIV-positive
and -negative patients and compares favorably with
FOB in diagnostic yield and cost. Some authors argue
that neither SI nor FOB should be performed unless
absolutely necessary, given the risk of exposure of
health care workers and other patients to the aerosol-
generating procedures [130]. This warning, however,
applies mostly to environments where proper respi-
ratory protective equipment and exhaust ventilation
devices or appropriate isolation rooms are in short
supply [130].
The role of fiberoptic bronchoscopy
FOB encompasses BAL, bronchial washings
(BW), bronchial brushings (BB), transbronchial
biopsy (TBB), and postbronchoscopy sputum collec-
tion (PBS). FOB has been studied by several inves-
tigators (although usually in relatively small studies)
in pulmonary tuberculosis suspects who are smear
negative or unable to produce a sputum sample. The
utility of FOB (or SI) in this setting is twofold. First,
generating a sample in patients who do not have
spontaneous sputum creates the potential for making
a diagnosis. Second, rapid diagnosis (by positive
smear or histopathology) in either subset of patients
provides the potential for earlier intervention and
treatment while awaiting culture results.
 the diagnosis of tuberculosis
In 1988, Chawla and colleagues [131] at the
University of Delhi in India prospectively studied
50 pulmonary tuberculosis suspects who were smear
negative or unable to produce sputum. Overall, cul-
tures of M. tuberculosis from FOB were positive in
90%. More significantly, a rapid diagnosis was made
in fully 72% of cases. Smear-positive samples were
obtained in 28% of PBS specimens, 24% of BW
specimens, and 56% of BB specimens. In the case of
BB specimens, 10 patients (20% of those studied)
were rapidly diagnosed exclusively by this means.
PBS and BW each provided the exclusive diagnosis
for 6% of patients. TBB was performed in 30 pa-
tients, and histopathology was positive in 9 (3 were
exclusively diagnosed on biopsy). The authors com-
ment that the high yield from the BB smears was a
result of brushing caseous material in the bronchi
when visible [131].
In a study from Hong Kong in 1982, So and
colleagues [132] also prospectively examined the
capability of FOB for rapid diagnosis. They per-
formed FOB in 65 pulmonary tuberculosis suspects.
Overall, rapid diagnosis was achieved in 42 of 65
(65%). TBB gave a rapid diagnosis in 33 of the
57 patients in whom it was performed (58%) and was
the exclusive means of rapid diagnosis in 12% [132].
Willcox and colleagues [133] conducted a study
in Cape Town, South Africa, in 1982 that looked at
275 pulmonary tuberculosis suspects. Seventy-nine
were diagnosed with pulmonary tuberculosis. FOB
made the culture diagnosis in 60 of 79 (76%). BB
gave a rapid diagnosis in 33%, and TBB did so in
43%. Similarly, Sarkar and colleagues [134] prospec-
tively performed FOB in 30 pulmonary tuberculosis
suspects in Rajasthan, India. Rapid diagnosis was
made in 22 of 30 persons (73%).
In a retrospective review of 41 patients who had
culture-proven pulmonary tuberculosis and under-
went FOB, a rapid diagnosis was obtained in 34% of
patients [135]. Finally, Mehta and colleagues [112]
looked retrospectively at 30 patients who had culture-
positive pulmonary tuberculosis and a negative spu-
tum smear or no sample. FOB (BW and BB) made a
rapid diagnosis in 18 of 30 patients (60%).
The potential utility of BAL and TBB for rapid
diagnosis in HIV-positive and HIV-negative patients
was demonstrated in a study by Kennedy and col-
leagues [136]. They retrospectively reviewed 67 HIV-
positive and 45 HIV-negative patients who had
culture-proven pulmonary tuberculosis. Of those
who had smear-negative sputum, BAL provided a
rapid diagnosis in 24% of HIV-positive and 8% of
HIV-negative patients. BAL was the exclusive means
of diagnosis in seven HIV-positive patients and in one
257
HIV-negative patient. TBB yielded a rapid diagnosis
in 16% of HIV-positive and 42% of HIV-negative
patients. Overall, TBB provided the exclusive early
diagnosis in 10% of patients [136].
Although not all studies report such high yields
from FOB [137 – 142], it definitely has utility [103].
The ability to achieve rapid diagnosis—a crucial step
in the management of pulmonary tuberculosis—with
FOB generally ranges from around 30% to 70%, and
the overall yield of culture from FOB specimens is
much higher [112,113,131,132,134 – 136,143 – 147].
Although the yield of the different techniques varied
significantly among studies, each one clearly con-
tributed to the overall yield of FOB.
The most productive use of FOB is in pulmonary
tuberculosis suspects who produce no sputum or
who are smear negative and in patients in whom there
is considerable diagnostic uncertainty, where lung
biopsy may produce an alternative diagnosis. These
benefits must always be weighed against the costs of
the procedure, concerns regarding infection control,
and the risk of TBB in any given patient.
Cultures
Cultures of mycobacteria require only 10 to
100 organisms to detect M. tuberculosis. As a result,
the sensitivity of culture is excellent, ranging from
80% to 93% [3,107]. Moreover, the specificity is quite
high, at 98% [3]. Cultures increase the sensitivity for
diagnosis of M. tuberculosis and allow speciation,
drug-susceptibility testing, and, if needed, genotyping
for epidemiologic purposes [3]. Therefore, all speci-
mens should be cultured.
There are three types of culture media: solid
media, which includes egg-based media (Lowenstein-
Jensen) and agar-based media (Middlebrook 7H10
and 7H11), and liquid media (Middlebrook 7H12 and
other broths). Solid media, long the standard for
culturing mycobacteria, are slower than liquid media,
which now are widely used alongside solid media to
increase sensitivity and decrease recovery time [148,
149]. In fact, Lowenstein-Jensen 7H10 and 7H11
media may detect mycobacteria in less than 4 weeks
[148,150,151], but they require incubation for as
long as 6 to 8 weeks before they can be classified as
negative. In contrast, broth media combined with
DNA probes for rapid species identification typically
provide results in less than 2 weeks with smear-
positive samples and somewhat longer with smear-
negative samples [148,151,152]. Broth media
formulations include both manual and automated
systems using radiometric or colorimetric methods for
detection of mycobacteria. Examples of broth media
258 brodie
include the BACTEC 460TB and BACTEC MB9000
radiometric methods, the Mycobacterial Growth
Indicator Tube or MGIT nonradiometric method, and
the manual Septi-Chek AFB system (all from Becton
Dickinson Microbiology Systems, Franklin Lakes,
NJ), the MB/Bac T (Biomerieux, Durham, NC), Extra
Sensing Power (ESP) and Myco-ESPculture System
II (Trek Diagnostic Systems, Cleveland, OH), and
BacT/ALERT MB Susceptibility Kit (Organon
Teknika, Durham, NC).
Broth media also may allow more rapid determi-
nation of drug susceptibilities, particularly if direct
susceptibility testing is used. Direct susceptibility
testing may be done with smear-positive samples that
are simultaneously inoculated into bottles lacking and
containing antibiotics. With this technique, drug
susceptibilities can be known at the same time as
culture results.
Newer culture technologies are in development.
One such product is TK Medium (Salubris, Inc.,
Cambridge, MA). TK Medium uses multiple-color
dye indicators to identify M. tuberculosis rapidly. It
can also be used for drug-susceptibility testing and
can differentiate a contaminated specimen. Informa-
tion is available at www.salubrisinc.com.
Nucleic acid amplification assays
NAA assays amplify M. tuberculosis – specific
nucleic acid sequences using a nucleic acid probe.
NAA assays enable direct detection of M. tuber-
culosis in clinical specimens. Such assays comple-
ment the conventional laboratory approach to the
diagnosis of active disease. Whereas AFB smears are
rapid but lack sensitivity and specificity, and culture
is both sensitive and specific but may take from 2 to
8 weeks to produce results, NAA assays allow rapid,
sensitive, and specific detection of M. tuberculosis.
The sensitivity of the NAA assays currently in
commercial use is at least 80% in most studies, and
these assays require as few as 10 bacilli from a given
sample under research conditions [3]. Although the
sensitivity of these assays in AFB smear-negative
samples is lower than for smear-positive samples,
newer assays perform much better in this regard than
earlier versions, increasing the sensitivity for smear-
negative specimens as well as overall sensitivity
[4,108]. NAA assays are also quite specific for
M. tuberculosis, with specificities in the range of
98% to 99%.
At present two FDA-approved NAA assays are
widely available for commercial use: the AMPLI-
COR M. tuberculosis (Roche Diagnostic Systems,
& schluger
Inc., Branchburg, NJ), and the Amplified Mycobate-
rium Tuberculosis Direct (MTD) Test (Gen-Probe,
Inc., San Diego, CA).
The AMPLICOR assay uses DNA polymerase
chain reaction (PCR) to amplify nucleic acid targets.
The FDA approved its use in smear-positive respira-
tory specimens in December 1996. The COBAS
AMPLICOR is an automated version of the AMPLI-
COR MTB. The MTD assay is an isothermal strategy
for detection of M. tuberculosis rRNA. The FDA
approved its use for use with smear-positive respira-
tory specimens in December 1995. A reformulated
MTD (AMTDII or E-MTD, for enhanced MTD) was
approved by the FDA in May 1998 for smear-positive
specimens and in September 1999 for detection of
M. tuberculosis in both smear-positive and smear-
negative respiratory specimens.
In clinical and laboratory studies, the original
MTD assay ranged in sensitivity from 83% to 98% for
smear-positive respiratory samples [107,153 – 160]
and from 70% to 81% for smear-negative respiratory
samples. In a recent study in Zambia (one of rela-
tively few studies in a resource-poor country), the sen-
sitivity was only 64% [116]. The specificity in these
studies was 98% to 99%. The AMPLICOR assay
performed similarly. The sensitivity was 74% to 92%
for smear-positive respiratory samples [5,107,109,
157,161 – 166] and 40% to 73% for smear-negative
samples [5,107,161,164 – 166]. Specificity ranged
from 93% to 99%. In Switzerland, Laifer and col-
leagues [167] recently tested the AMPLICOR assay
in 3119 war refugees from Kosovo and found a sen-
sitivity of only 64% for pulmonary tuberculosis
[167]. They noted, however, that the negative pre-
dictive value of three consecutive PCRs (in two sputa
and one BAL) was 100%. In studies where MTD
and AMPLICOR have been compared directly,
MTD has consistently had a small advantage [107,
157,159].
The E-MTD brings with it an improved sensitivity
[4,108,153,168], especially in smear-negative speci-
mens [4,108]. Bergmann and colleagues [4] inves-
tigated the E-MTD in a 1999 study of Texas prison
inmates [4]. One thousand four respiratory specimens
from 489 inmates tested with E-MTD were compared
with culture, smear, and clinical course. Twenty-two
inmates were diagnosed with pulmonary tuberculosis
(10 smear-positive and 12 smear-negative.) Overall,
the E-MTD had a sensitivity of 95.2% and a
specificity of 99.1%. In smear-positive patients, the
sensitivity and specificity were both 100%. In smear-
negative patients, the sensitivity was 90.2%, and the
specificity was 99.1% [4]. A 1999 study from the
Central Public Health Laboratory in Etobicoke,
 the diagnosis of tuberculosis
Ontario, looked at 823 specimens (616 respiratory)
over a 1-year period [108]. Using clinical diagnosis
as the reference standard, the specificity approxi-
mated 100%, and the sensitivity for either smear-
positive or smear-negative respiratory samples was
100%, an exceptionally high value, especially for the
smear-negative specimens. Specimens that were
smear negative were preselected for testing with the
E-MTD based on a clinical determination that the
patients were at high risk for tuberculosis. Preselec-
tion no doubt contributed to the high sensitivity and
specificity in this study, but results indicate there is
great utility in selecting appropriate patients for
testing [108].
An investigation of the E-MTD with particular
clinical relevance was undertaken by Catanzaro and
colleagues [169] who evaluated the performance of
the E-MTD in a multicenter, prospective trial. In
this study, the E-MTD was evaluated against the
backdrop of a patient’s clinical suspicion for pul-
monary tuberculosis, which was stratified into low,
intermediate, or high risk as determined by physi-
cians who had expertise in evaluating patients for
tuberculosis. Clinical investigators determined the
risk for 338 patients. The specificity of the E-MTD
was high in all groups. The sensitivities were 83%,
75%, and 87% respectively. The positive predictive
value, however, was low in the low-risk group
(59%, as compared with 100% in the other two
groups). The negative predictive value was espe-
cially high in the low-risk group (99%) and
remained high (91%) in the intermediate- and
high-risk groups. These results compared favorably
with the AFB smear, which had positive predictive
values of 36% (low), 30% (intermediate), and 94%
(high), respectively, and negative predictive values
of 96% (low), 71% (intermediate), and 37% (high),
respectively. This study demonstrates the clear
utility of the E-MTD test and suggests that it may
be particularly helpful for confirming disease in
intermediate- and high-risk patients and for exclud-
ing cases in low-risk patients [169].
Other NAA assays have been tested, such as a
ligase chain-reaction – based test (LCx test; Abbott
Diagnostics Division, Abbott Park, IL), and the
strand displacement amplification (SDA) test known
as the BDProbeTec ET Mycobacterium tuberculo-
sis Complex Direct Detection Assay (DTB) (Becton
Dickinson Biosciences, Sparks, MD). DTB is a
1-hour assay that couples SDA to a fluorescent
energy-transfer detection system. DTB performs
similarly to the E-MTD [170,171]. A variety of less
standardized PCR assays have been developed and
tested [172 – 175]. Real-time PCR assays have com-
259
pared favorably with AMPLICOR [174,175] and
E-MTD [173]. None of these tests has been approved
for use in the United States.
In 2000, the CDC updated its recommendations
for use of NAA tests for the diagnosis of active
disease [176]. The CDC now recommends that AFB
smear and NAA be performed on the first sputum
smear collected. If smear and NAA are both positive,
pulmonary tuberculosis is diagnosed with near
certainty. If the smear is positive and the NAA is
negative, the statement recommends testing the
sputum for inhibitors by spiking the sputum sample
with an aliquot of lysed M. tuberculosis and repeating
the assay. If inhibitors are not detected, the process
is repeated on additional specimens. If the sputum
remains smear positive without inhibitors and NAA
negative, the patient can be assumed to have NTM.
If a sputum sample is smear negative but E-MTD
positive (only the E-MTD is approved for smear-
negative specimens), the CDC recommends testing
additional samples. If further samples are E-MTD
positive, the patient can be assumed to have pul-
monary tuberculosis. If both the smear and E-MTD
are negative, an additional specimen should be tested
by E-MTD. If negative, the patient can be assumed
not to have infectious pulmonary tuberculosis. The
recommendations conclude by noting that clinicians
must always rely on clinical judgment and that, ulti-
mately, definitive diagnosis rests on response to
therapy and culture results [176]. Although they have
a certain logic, these recommendations are expensive
and based on few published data.
Overall, a reasonable use of NAA assays for rapid
diagnosis of pulmonary tuberculosis is as follows:
NAA assays should be used to confirm that a positive
AFB smear does indeed represent M. tuberculosis. If
both smear and NAA are positive, pulmonary tuber-
culosis is diagnosed with near certainty. If the smear
is positive and the NAA is negative, testing the
sputum for inhibitors and repeating the assay is war-
ranted [177]. If inhibitors are not detected, and the
process is repeated on additional specimens and is
negative, the patient can be presumed to have NTM.
If smears are negative, but clinical suspicion is inter-
mediate or high (based on the impression of expe-
rienced observers [169,178,179]), NAA should be
performed on a sputum sample, and a presumptive
diagnosis of tuberculosis is made if the test is posi-
tive. NAA should not be performed on sputum sam-
ples from cases in which the AFB smear is negative
and the clinical index of suspicion is low [169,
179,180]. Testing should also be limited to those
who have not been treated recently for active dis-
ease [177].
260 brodie
Cost is the main consideration limiting the use of
the NAA assays, particularly in the developing world.
A study in Nairobi, Kenya, compared the cost-
effectiveness of AMPLICOR and that of an AFB
smear [181]. The AFB smear was 1.8 times as cost-
effective. The authors, however, concluded that
AMPLICOR could be cost-effective if ‘‘the largest
contributing component, the costs of the PCR-kit, can
be reduced substantially.’’ A cost-effectiveness analy-
sis conducted in Finland in 2004 showed that the
addition of COBAS AMPLICOR PCR to smear and
culture was not cost-effective unless limited to smear-
positive specimens [182]. Extending this assay to
smear-negative specimens may be possible when g
the E-MTD is used, however, because of its superior
sensitivity in smear-negative patients who have pul-
monary tuberculosis. Furthermore, centralized labo-
ratories offer the ability to invest in technology,
conduct batch testing, develop expertise, and bene-
fit from economies of scale. In such settings, regu-
lar NAA testing may be economically feasible
[108,183].
A major limitation of NAA tests is that they give
no drug-susceptibility information. In addition, they
are able to detect nucleic acids from both living and
dead organisms and may be falsely positive for ac-
tive disease in patients who have a recent history
of infection and have been adequately treated [156,
184 – 186]. In contrast to NAAs that employ DNA or
rRNA, the use of an assay to detect M. tuberculosis
mRNA, with a half-life of only minutes, offers an
indicator of the viability of M. tuberculosis. Assays
that detect mRNA remain positive only while viable
mycobacteria persist and therefore are useful as
sensitive indicators of adequate treatment and for
rapid determination of drug susceptibility [187]. This
technology is under study.
Extrapulmonary tuberculosis
Diagnosing extrapulmonary tuberculosis presents
the clinician with many challenges. In most cases, the
samples are paucibacillary, decreasing the sensitivity
of diagnostic tests. Testing for extrapulmonary tuber-
culosis follows the same principles as for pulmonary
tuberculosis, but, because accuracy of diagnosis is
attenuated in extrapulmonary tuberculosis, clinicians
must rely more heavily on clinical judgment and
response to treatment to diagnose extrapulmonary
tuberculosis. Meanwhile, the increased incidence of
extrapulmonary tuberculosis in HIV patients makes it
all the more urgent to improve diagnostic strategies
for this entity.
& schluger
AFB smear and culture are used but generally are
less sensitive in nonrespiratory samples. Respiratory
samples are sometimes of benefit in extrapulmonary
tuberculosis. In the case of pleural tuberculosis, the
finding of M. tuberculosis in the sputum is diagnostic
of tuberculosis in patients who have an effusion. Such
patients may not easily give expectorated sputum
samples, however. In this setting, IS has been shown
to have a sensitivity of 52% for M. tuberculosis
[188], compared with the 60% to 80% sensitivity of
the more invasive pleural biopsy [189].
In the case of miliary tuberculosis, sputum smears
are warranted, but if smears are negative, FOB may
play a significant role. FOB was performed in
41 patients who had miliary tuberculosis and smear-
negative sputum [190]. Diagnosis was obtained in
34 patients (83%). BB captured 57% of cases, and
TBB was diagnostic in 73% of cases. A rapid di-
agnosis was made in 27 of 34 patients [190]. In a
separate study, 22 patients who had smear-negative
miliary tuberculosis underwent FOB with brushings,
aspirate, and TBB. Tuberculosis was diagnosed in
16 of the 22 patients (73%). A rapid diagnosis was
made in 14 of 16, from brush smears alone in
3 patients, aspirate alone in 1, and biopsy alone in
7 [191]. Sampling multiple sites may also be of
benefit in miliary tuberculosis.
There is clearly a role for NAA assays in the
diagnosis of extrapulmonary tuberculosis, although
this role needs to be better defined. The overall sen-
sitivity in nonrespiratory specimens for the MTD or
E-MTD ranges from 67% to 100% [108,153 – 155,
160,168,170,192]. In smear-negative samples, the
sensitivity was 52% in one study [160] and 100%
in another [108]. The AMPLICOR had a similar
sensitivity [162,193], and the specificity of both
assays remains high in nonrespiratory samples. The
assays do not perform equally well in all sample
types; for example, they are much more sensitive in
cerebrospinal fluid [192,194] than in pleural fluid
[154]. The sensitivities vary significantly among
studies, as shown in recent meta-analyses of the use
of NAA tests in tuberculous meningitis [195] and
tuberculous pleuritis [196]. In one study, the combi-
nation of AFB smear and MTD in cerebrospinal fluid
had a sensitivity of 64%, which increased to 83% by
the third sample tested [197]. The DTB system
delivers sensitivity similar to the E-MTD in non-
respiratory samples [170,198,199].
The use of adenosine deaminase (ADA) levels,
especially in pleural fluid samples, to diagnose extra-
pulmonary tuberculosis has shown great promise. A
recent meta-analysis of 40 studies investigating ADA
for the diagnosis of tuberculous pleuritis yielded the
 the diagnosis of tuberculosis
summary measure of test characteristics derived from
the receiver operator characteristic curve where sen-
sitivity equaled specificity at 92.2% [200]. Similarly,
a meta-analysis of 31 studies on ADA in pleural
tuberculosis yielded a joint sensitivity and specificity
of 93% [201]. The performance of ADA in diagnos-
ing pleural tuberculosis is inconsistent across studies,
however. In one study, the sensitivity and specificity
were both 55% [202]; in another, they were 88% and
85.7%, respectively [203]. Some authors report the
need to combine ADA determination with PCR
analysis, yielding a combined sensitivity of 87.5%
[204], but others argue that ADA alone is superior to
ADA combined with PCR [205].
ADA use outside the pleural space has been
explored as well. ADA may be of limited value
in diagnosing tuberculous meningitis [206] but
was sensitive for tuberculous pericarditis in one
study [207].
Another test that has received some attention for
the diagnosis of pleural and pericardial tuberculosis
is pleural or pericardial fluid IFN-g, which has proven
comparable to or even better than ADA in some
studies [201,203,207]. Finally, there may be a role for
the serum IFN-g assays, discussed earlier, in the di-
agnosis of extrapulmonary tuberculosis [81,208].
Rapid detection of drug resistance
Multidrug-resistant (MDR) tuberculosis poses a
major public health problem in many parts of the
world. Traditional methods of drug-susceptibility
testing rely on cultures of M. tuberculosis inoculated
with antibiotics and can take weeks for results to be
known. The ability to detect drug resistance rapidly
would be vitally important to tuberculosis-control ef-
forts, enabling expeditious administration of appro-
priate treatment and a decrease in transmission of the
MDR strain. The detection of rifampin resistance may
be used as a surrogate for uncovering multidrug
resistance, because most rifampin-resistant isolates
are also isoniazid-resistant [209,210]. Rifampin re-
sistance signals the need for treatment with second-
line drugs. It is currently feasible to detect rifampin
resistance rapidly. One approach takes advantage
of genotypic abnormalities by identifying mutations
primarily in the region of the M. tuberculosis rpoB
gene associated with most rifampin-resistant strains
of M. tuberculosis. Coupling a variety of assays that
identify genetic mutations (line probe assays and
molecular beacons, for instance) to PCR or related
technologies allows rapid detection of the drug-
resistant mutations from smear-positive respiratory
261
specimens or from culture specimens [209,211 – 215].
Another approach detects actual phenotypic resis-
tance seen as persistence of the organism in a
rifamycin-containing medium (eg, luciferase reporter
phage assays.)
Line probe assays
Line probe assays use PCR and reverse hybridi-
zation with specific oligonucleotide probes fixed to
nitrocellulose strips in parallel lines. These assays
may be used for the detection and identification
of mycobacterial species or for rapid identification
of mutations in the rpoB gene. The INNO-LiPA
MYCOBACTERIA v2 (Innogenetics, Ghent, Bel-
gium) and GenoType Mycobacterium (Hain Diag-
nostika, Nehren, Germany) are line probe assays for
the simultaneous detection and identification of
mycobacteria; both are very sensitive [216]. The
INNO-LiPA Rif.TB assay detects M. tuberculosis and
is very sensitive for detecting rifampin resistance
[213 – 215,217,218].
Molecular beacons
Molecular beacons are nucleic acid hybridiza-
tion probes. They are designed to bind to target
DNA sequences in regions, such as the rpoB, where
resistance mutations are known to occur. Molecular
beacons fluoresce only when bound to their targets,
so that a mutation—even a single-nucleotide sub-
stitution—prevents fluorescence. A PCR assay using
molecular beacons can identify drug resistance in
sputum samples in less than 3 hours and is both
sensitive and specific [219]. Lin and colleagues [211]
designed a set of molecular beacons for the detection
of isoniazid- and rifampin-resistant mutations in
M. tuberculosis organisms from both culture-
and smear-positive respiratory specimens [211]. The
sensitivity and specificity for detection of isoniazid
resistance were 82.7% and 100%, respectively, and
for rifampin resistance were 97.5% and 100%,
respectively. Piatek et al [220] previously reported
similar findings.
Phage amplification
Phage amplification uses a bacteriophage to detect
M. tuberculosis in a given sample within 48 hours.
FASTPlaqueTB (Biotec, Ipswich, Suffolk, UK) uses
phage amplification technology to detect viable M. tu-
berculosis in sputum samples and has had mixed
results with excellent specificity (96% – 99%) but
lesser overall sensitivity (70% – 87%) [116,221 – 223].
262 brodie
It detected 48.8% of smear-negative cases in one
study [223]. The FASTPlaqueTB-MDRi or FAST-
PlaqueTB-RIF uses the phage amplification technol-
ogy to determine rifampin resistance in culture or
sputum specimens. Albert and colleagues [224]
demonstrated a sensitivity of 100% and a specificity
of 97% for identifying rifampicin-resistant strains in
solid culture media and in a separate study demon-
strated similar results using a liquid culture system
[210]. A more recent study by Albert and colleagues
[225] showed a 100% sensitivity and specificity for
determining rifampin resistance directly from smear-
positive sputum, with results also available within
48 hours.
Luciferase reporter phages
Firefly luciferase catalyzes the reaction of lucif-
erin with ATP to generate photons efficiently and
thereby emit light. Mycobacteriophages expressing
the firefly luciferase gene may be introduced into
viable mycobacteria [226]. The presence of cellular
ATP in viable mycobacteria causes visible light to
be emitted when exogenous luciferin is added. The
emitted light is measured by a luminometer or on
film (eg, with the Bronx box [227,228]). In the
presence of adequate antimycobacterial therapy, my-
cobacteria are rendered nonviable, and the light
is extinguished. Drug-resistant strains of M. tuber-
culosis continue to produce light in the presence of
antimycobacterial therapy, revealing their resistance.
This method can determine drug susceptibility in 1 to
4 days, and it is also a sensitive and specific means
for identifying M. tuberculosis [228 – 232].
Cost and the need for advanced technology and
laboratory skills limit the applicability of most of
these technologies. Efforts to reduce costs and sim-
plify the technology may make these tests practical
for widespread use in the near future in resource-rich
and, perhaps, even in resource-poor countries.
Summary
Diagnostic testing for tuberculosis remained un-
changed for nearly a century, but newer technologies
hold the promise of a true revolution in tuberculo-
sis diagnostics. The IFN-g release and T-cell – based
assays may well supplant the TST in diagnosing
LTBI in much of the world. NAA assays are proving
their worth in more rapidly diagnosing both pulmo-
nary and extrapulmonary tuberculosis with great
sensitivity and specificity. The role of line probe as-
says, molecular beacons, phage amplification, and
& schluger
luciferase reporter phages in diagnosing tuberculosis
and rapidly detecting drug resistance is still being
defined. These tests are likely to play an ever-
increasing role in the coming years. Ultimately, the
appropriate and affordable use of any of these tests
depends on the setting (low or high prevalence of
active disease, low or high clinical suspicion in a
given patient, available resources, and laboratory
capabilities) in which they are employed.
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 Clin Chest Med 26 (2005) 197 – 205

The DOTS Strategy for Controlling the Global

Tuberculosis Epidemic
Thomas R. Frieden, MD, MPHa,*, Sonal S. Munsiff, MDa,b
a
New York City Department of Health and Mental Hygiene, 125 Worth Street, New York, NY 10013, USA
b
Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA, USA

In 1997, the Director General of the World Health
Organization (WHO) called the directly observed
treatment, short-course (DOTS) strategy ‘‘the most
important health breakthrough of the decade in terms
of the number of lives it will save’’ [1]. DOTS is
nothing new; Karel Styblo developed the essential
principles of DOTS in the 1980s [1a]. The five
principles of the WHO-recommended DOTS strategy
[2] are:
1. Political and administrative commitment.
2. Case detection, primarily by microscopic ex-
amination of sputum of patients presenting to
health facilities.
3. Standardized short-course chemotherapy given
under direct observation.
4. Adequate supply of good-quality drugs.
5. Systematic monitoring and accountability for
every patient diagnosed.
This article reviews the principles, scientific basis,
and experience with implementation of DOTS and
discusses the relevance of DOTS in the context of
This article is adapted from: Frieden TR. Directly
observed treatment, short course (DOTS): the strategy that
ensures cure of tuberculosis. In: Sharma SK, Mohan A, edi-
tors. Tuberculosis. 2nd edition. New Delhi: Jaypee Brothers
Medical Publishers; 2005 [in press]; with permission.
* Corresponding author.
E-mail address: tfrieden@health.nyc.gov (T.R. Frieden).
multidrug-resistant tuberculosis (MDR-TB) and the
HIV epidemic.
Political and administrative commitment
By any measure, the global burden of tuberculosis
is staggering. There are nearly 9 million new cases
and 2 million deaths from tuberculosis worldwide
every year [3,4]. More than 100 million people have
died of tuberculosis since the tubercle bacillus was
discovered by Koch in 1882 [5]. Cases are likely to
increase, particularly in parts of the world with a
poorly controlled HIV epidemic. Tuberculosis dis-
proportionately affects young adults, impoverishes
families, and undermines economic development [6].
Despite the heavy burden of disease, tuberculosis-
control efforts are often inadequately funded and
supported. Shortages of drugs and equipment are
common, and key posts within tuberculosis-control
programs suffer from low prestige or high turnover
and are often vacant. Physicians, in their role as
community leaders, are responsible for promoting the
existence of effective tuberculosis-control programs
and for supporting and coordinating their own efforts
with these programs. Although tuberculosis control is
a core government function, it cannot be accom-
plished by any one individual or sector. It requires
communication and collaboration among local and
national health authorities, the primary health care
system, hospitals, medical schools, private physi-
cians, nongovernmental organizations, and others.

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.001 chestmed.theclinics.com
198 frieden
Diagnosis by sputum microscopy of patients
attending health facilities
Two important concepts are combined in this
aspect of the DOTS strategy: first, diagnosis should
be based primarily on microscopy rather than on
chest radiograph, clinical examination, or culture; and
second, case finding should be done primarily among
patients presenting at health facilities and not by
active case finding in the community.
Sputum microscopy is a highly specific test and
should be the primary tool for diagnosis. In contrast,
the unreliability of chest radiograph is well docu-
mented; 30% or more of patients classified as having
active tuberculosis on the basis of chest radiograph,
even by experts, are found not to have tuberculosis
[7 – 10]. The acid-fast bacillus (AFB) smear also
correlates with severity of disease, infectiousness,
and mortality [11,12] and is a low-cost, appropriate
technology that can be done reliably even in remote
areas [13]. Decisions based on the standard WHO-
recommended diagnosis algorithm [14] are often more
rapid than those based on culture [15]. Technical and
logistic requirements make culture unsuitable as a
primary diagnostic tool in developing countries.
Serologic and amplification tests on sputum samples
are currently more expensive and less informative
than the AFB smear and are not of proven utility in
global tuberculosis control; amplification techniques
can be useful in areas with low tuberculosis
prevalence. Future developments in this area may
further facilitate diagnosis, particularly of smear-
negative and extrapulmonary tuberculosis cases [16].
The second component of this aspect of the DOTS
strategy is the approach to case finding. Active
tuberculosis case finding in the community should
not be undertaken; it usually results in low cure rates
and is of limited or no value in tuberculosis control
[17]. Most patients with active tuberculosis seek care,
especially if care is provided free of charge, and the
few who do not seek care are less likely to complete
treatment [11,18]. In countries or regions with
generalized HIV epidemics, however, programs for
intensified tuberculosis case finding should be im-
plemented in all HIV counseling and testing set-
tings [19].
Standardized short-course chemotherapy given in
a program of directly observed treatment
This principle also has two aspects, both of which
are crucial. The efficacy of short-course, intermittent
treatment has been conclusively demonstrated in
& munsiff
numerous controlled clinical trials, [20 – 24] and is
effective for extrapulmonary tuberculosis [25,26].
Standard short-course regimens can cure more than
95% of cases of new, drug-susceptible tuberculosis
[27]. Most recommended treatment regimens have
two phases: an initial intensive phase with four drugs
lasting 2 months, followed by a 4-month continua-
tion phase with at least two drugs. Corticosteroids
have been shown to be useful in patients with peri-
cardial and meningeal tuberculosis and are recom-
mended in these situations [14,28]. Attempts to
reduce the length of treatment to less than 6 months
have failed, indicating that as of 2005 no practical
regimen shorter than 6 months using currently avail-
able medications is effective for patients with smear-
positive tuberculosis [29,30].
Patients previously treated for tuberculosis may
require a more intensive treatment regimen. In areas
where drug-susceptibility testing is not available, the
WHO re-treatment regimen should be used [14]. In
areas where drug susceptibility can be determined,
the susceptibility results of the isolate should guide
the treatment regimen [28].
It is now well documented that intermittent treat-
ment given two or three times a week is, in general,
as effective as daily therapy. This finding should not
be surprising, because Mycobacterium tuberculosis
doubles in 18 to 24 hours, compared with 12 to
20 minutes for most bacteria [31]. In fact, in one
animal model, intermittent treatment was more effec-
tive than daily treatment [32]. Supervised intermittent
short-course therapy for tuberculosis is shown to be
highly effective and extremely well tolerated in
patients whether or not they are HIV infected [24].
Intermittent treatment should be given only in a
program of direct treatment observation [33].
Once- or twice-weekly dosing with rifamycins in
HIV-infected tuberculosis patients with CD4 cell
counts less than 100/mm3 has been associated with
the development of acquired rifamycin resistance
[34]. The Centers for Disease Control (CDC) and
American Thoracic Society (ATS) now recommend
that patients with HIV-associated tuberculosis not be
treated with once-weekly regimens and that those
with CD4 cell counts of less than 100/mm3 not be
treated with any highly intermittent (ie, once- or
twice-weekly) regimens. The CDC and ATS now
recommend that such patients receive daily therapy
during the intensive phase and daily or thrice-weekly
therapy during the continuation phase, regardless of
whether they are also receiving antiretroviral drugs.
The international relevance of this recommendation
is unclear and should be further examined; thrice-
weekly regimens in the intensive phase are recom-
 the dots strategy for controlling tuberculosis
mended by the WHO and the International Union
Against TB and Lung Disease (IUATLD) and are of
proven efficacy for tuberculosis treatment regardless
of HIV status. If rifabutin is used, its dose may need
to be adjusted depending on the antiretroviral medi-
cations used [28,35].
Drugs can be effective only if they are taken [36].
Virtually all clinical studies of short-course chemo-
therapy were conducted using directly observed ther-
apy [37], and it can be argued that unobserved use of
rifampicin-containing regimens is experimental and
potentially dangerous. In particular, the initial phase
of treatment regimens that include rifampicin should
always be directly observed to ensure adherence and
prevent emergence of resistance to rifampicin [37].
Direct observation is the standard of care for tuber-
culosis in most countries [38]. About one third of
patients do not take medications regularly as pre-
scribed, and it is not possible to predict accurately
which patients will not adhere to treatment [33,36,
39 – 42]. Nonadherence is not related to adverse ef-
fects, dosage, or prior receipt of supervised treatment
[40,43] and is as high with placebo as with active
drugs. Surprise home visits revealed a much greater
degree of nonadherence than did pill counts or urine
tests, despite ongoing efforts to obtain and maintain
the cooperation of patients and their families during
the full course of chemotherapy [44].
Directly observed therapy is the most difficult and
most controversial aspect of the DOTS strategy.
(DOTS is the comprehensive five-point tuberculosis-
control strategy; directly observed therapy is one
essential component of that strategy.) Observation
must be done by a person who is accessible and
acceptable to the patient and who is accountable to
the health system [14]. In some countries, directly
observed therapy is given in hospital for the first
2 months [45]. In other countries, health staff
[46 – 48], community volunteers [49,50], members
of nongovernmental organizations [51], religious
leaders [52], and combinations of health staff and
a broad cross-section of community workers or vol-
unteers [53] have given directly observed therapy.
Each community has particular leaders, and the
challenge in implementing this aspect of the DOTS
strategy is to identify and enlist the support of
these leaders. Even in the unstable environment of
a refugee camp, directly observed therapy has been
shown to be feasible [54].
Directly observed therapy involves more than
merely watching patients as they take medications.
Rather, direct observation succeeds by building a
human bond between the patient and the health care
worker or community volunteer and acknowledging
199
the value of treatment success to patients and to
their communities. It also implies recognition of
the responsibility of the program and of the com-
munity to ensure successful treatment through
showing respect for the patient and by providing
treatment at convenient times and in appropriate fa-
cilities [55].
It may be impossible to arrange directly observed
therapy for some patients, but directly observed
therapy should be possible in more than 90% of
cases in a well-functioning program. When directly
observed treatment is impossible, the patient may
need to be given self-administered treatment, in which
a family member may be able to assist the patient.
Assistance by a family member is unreliable, how-
ever [39,56]. There are no examples of successful
large-scale DOTS programs in which immediate
family members have been used as primary providers
of directly observed therapy. Organizing DOTS,
including directly observed therapy, may not be
simple, but it is the only method that can ensure a
high cure rate on a program basis.
Adequate supply of good-quality drugs
Because long-term treatment with a combination
of drugs is required [57], it is important that sufficient
supplies of all necessary antituberculosis drugs are
available so that patients can complete the prescribed
treatment. In addition, it is important that drugs
are of good quality, with adequate bioavailability. Of
particular concern are the bioavailability of rifampicin
in combination tablets, particularly when combined
with pyrazinamide, and the stability of ethambutol,
which may be compromised by poor-quality pack-
aging or excessive humidity during storage.
Combination tablets of proven bioavailability
have the theoretical advantage of preventing mono-
therapy. Fixed-dose combination (FDC) tablets incor-
porate two or more medications into the same tablet
and prevent providers and patients from using a
single antituberculosis drug. This precaution should
reduce the likelihood of development of drug
resistance and the possibility of physician prescrip-
tion error or patient medication error. FDCs can
also simplify treatment for patients and logistics for
program managers. FDCs of low bioavailability
could result in treatment failure and drug resistance,
however, and FDCs generally have a shorter shelf life
and increase the cost of antituberculosis drugs [14].
The benefits of FDCs on a program basis are difficult
to document, and, of course, FDCs still cannot ensure
that the drugs are taken.
200 frieden
Systematic monitoring and accountability
Although record keeping is often seen as unim-
portant, an effective system of registering patients is
the heart of the DOTS strategy because it ensures
accountability. The information system designed
by Styblo [1a] and recommended by WHO is simple
but remarkably robust, allowing effective program
management as well as operational research.
At each microscopy center, a good-quality micro-
scope and reagents are supplied, and the laboratory
technician is trained, supervised, and included in a
quality control network. Every patient whose sputum
is examined is recorded in the tuberculosis laboratory
register. Every patient whose sputum is found
positive for AFB and started on treatment is re-
corded in the tuberculosis register, with all patient
outcomes recorded.
Quarterly reporting of diagnosed cases allows
simple but revealing analysis of diagnostic quality
and the descriptive epidemiology of tuberculosis.
Smear-positive patients are monitored for sputum
conversion to negative at the end of the intensive-
treatment phase, and this conversion rate is monitored
as an early indicator of program effectiveness.
Finally, treatment outcomes are systematically
recorded in one of six strictly defined categories
[14]. The global target for successful treatment of
new smear-positive patients is 85% or more [2].
Information in the tuberculosis laboratory register
and the tuberculosis register can be easily checked for
internal consistency and consistency between records
and can also be externally verified by reviewing spu-
tum slides, interviewing patients and health workers,
and monitoring consumption of drugs and supplies.
Results of the directly observed treatment, short
course strategy
The DOTS strategy has been implemented suc-
cessfully in many countries and contexts. Through
2003, DOTS has been implemented in 182 of
211 countries, covering 77% of the world’s popula-
tion [3]. In 132 countries, including most of the
industrialized world, DOTS is available to more than
90% of their populations [3]. Average treatment
success among all national DOTS programs is 82%,
close to the 85% global target [3]. By 2005, more
than 20 million patients have been treated under
DOTS, with an expected case detection rate of close
to 50% [3]. While the case detection rate has been
increasing over the past decade, it is still below the
70% target [3].
& munsiff
In Baltimore, Maryland, DOTS achieved a
marked reduction in case rates despite a high rate
of HIV infection [58]. In New York City, by 1991,
half of tuberculosis patients were HIV-infected, and
one in five had MDR-TB; [59]; DOTS, in addition
to an MDR-TB control program, resulted in a rapid
decrease in both tuberculosis and in multidrug re-
sistance [60]. Application of universal directly
observed therapy and subsequent adoption of short-
course chemotherapy were associated with a sub-
stantial decline in tuberculosis in Beijing, China, and
in Cuba to levels below those of some industrialized
countries [47,61]. In Peru, where DOTS was intro-
duced in 1990, high rates of case detection and cure
have decreased the incidence of pulmonary tuber-
culosis by at least 6% per year [62]. In China,
prevalence of smear-positive tuberculosis fell 32%
more between 1990 and 2000 in areas where DOTS
was implemented than in non-DOTS areas [63]. Ef-
fective DOTS programs have been established and
have functioned well even in the context of civil war
[45,46]. In addition, DOTS has been shown to be
highly cost effective [45,64].
Multidrug-resistant tuberculosis
The emergence of drug resistance is a symptom of
ineffective tuberculosis control [65]. If patients take
appropriately prescribed antituberculosis treatment,
development of resistance is extremely rare. In
contrast, in situations where prescribing practices,
case holding, or both are poor, drug resistance can
emerge. Effective treatment programs can prevent
drug resistance [66,67] and may even result in a
decrease in drug resistance if it has emerged [60,
68 – 74]. Treatment of MDR-TB is difficult, expen-
sive, and often unsuccessful. Treatment of MDR-TB
may be important for tuberculosis control in some
contexts, but it should be undertaken only with the
appropriate expertise and resources [65].
In most contexts, preventing development of
MDR-TB by ensuring cure of new smear-positive
patients is a much higher public health priority than
treatment of MDR-TB. Low cure rates among new
tuberculosis cases will result in the creation of drug-
resistant cases at a faster rate than these cases can be
cured, even if unlimited resources are available [75].
For disease control, if multidrug resistance is present
in congregate facilities (eg, prisons, hospitals) where
immunosuppressed (eg, HIV-infected or malnour-
ished) individuals are present, it is essential to diag-
nose patients with MDR-TB promptly and to treat
them effectively to avoid rapid spread of the disease.
 the dots strategy for controlling tuberculosis
Where resources permit (eg, targets for case detection
and treatment success are met and resources are in
place to continue DOTS implementation), treatment
of MDR-TB can save lives and prevent further spread
of disease.
There were an estimated 273,000 cases of MDR-
TB worldwide (3.1% of all tuberculosis cases) in
2000. Most MDR-TB is estimated to be concentrated
in 10 countries [76]. These data may underestimate
the number of MDR-TB cases worldwide, however,
because MDR-TB has been found in most regions of
the world that have been surveyed [77]. Systematic
surveys of several areas of the world with high
tuberculosis incidence, such as most parts of sub-
Saharan Africa and most of Asia, have not yet been
done. Resources need to be directed at areas with
the highest burden of this disease. There is limited
experience treating MDR-TB in resource-limited
settings, but successful programs can be imple-
mented [78]. International collaboration and re-
sources probably will be required to implement
such programs [79].
Although MDR-TB can be successfully treated in
a variety of settings, including community-based
treatment by trained community health workers
[78], treatment should be given only under a program
of directly observed therapy in conjunction with
clinicians who are expert in the management of
MDR-TB. All attempts should be made to obtain
susceptibility results so that regimens can be tailored
for individual patients. Most studies of MDR-TB
treatment have used individualized regimens [80].
Patients must be treated with a regimen of at least
three to five antituberculosis medications to which
the strain is known or likely to be susceptible, in-
cluding an injectable agent and a fluoroquinolone
[14,81]. Although longer use of injectable medica-
tions is associated with significant adverse effects,
longer-term injectable therapy increases culture con-
version and survival rates in persons with MDR-TB
[82]. Intermittent regimens should not be used. The
drugs for treating MDR-TB are much more expensive
and have markedly more adverse effects than stan-
dard drugs [83]. The duration of treatment is 18 to
24 months; patients need to be monitored carefully,
because the risk of default can be high.
HIV
Infection with HIV is the most potent known risk
factor for progression to active tuberculosis among
adults [84]. In outbreaks of tuberculosis in wards for
AIDS patients in the United States, the median time
201
from tuberculosis exposure to disease was 3 months,
and in some outbreaks more than one third of
exposed patients developed tuberculosis [85].
The HIV epidemic is a stress test for tuberculosis-
control programs and can relentlessly reveal program
weaknesses. The increase in tuberculosis incidence in
Africa is strongly associated with the prevalence of
HIV infection [86]. Tuberculosis case rates increased
approximately twice as fast in countries with high
HIV infection rates, but the increase was lower in
countries with good-quality tuberculosis-control ser-
vices. Improving the quality of national tuberculosis
programs can mitigate HIV-associated tuberculosis
[87]. Where prevalence of HIV infection is high,
tuberculosis treatment alone cannot reverse the rise in
tuberculosis incidence. At present, the most effective
way to address HIV-associated tuberculosis is
through a sound DOTS program coupled with com-
prehensive, effective HIV prevention and care that
incorporates active case finding in settings where
HIV counseling and testing are offered [19,88 – 92].
In settings with high incidences of HIV and
tuberculosis, diagnosing active tuberculosis in HIV-
infected persons is challenging. Sputum smear-
negative and extrapulmonary tuberculosis are more
common in HIV-infected persons [90,93]. In such
settings, consideration should be given to using ra-
diographs and, if feasible, mycobacterial cultures to
assist the clinician in diagnosing tuberculosis if spu-
tum smears are negative.
Recommended treatment regimens are similar for
all tuberculosis patients, whether HIV-infected or
uninfected [27], and patients with HIV respond well
to standard antituberculosis treatment and do not need
additional drugs [90,94,95]. Death during antituber-
culosis treatment is more common in HIV-infected
individuals but is primarily from non – tuberculosis-
associated causes [33]. Patients with HIV infection
and tuberculosis survive longer if given short-course
chemotherapy with rifampicin-containing regimens
than if given non – rifamycin-containing regimens
[96] and longer still if short-course chemotherapy is
given in a program of directly observed therapy
[97,98]. In addition, antituberculosis regimens con-
taining rifampicin can be administered safely with
several effective, highly active antiretroviral drugs,
making it easier to deliver simultaneous treatment for
tuberculosis and HIV [35,90,99]. Rifabutin, a more
expensive alternative to rifampicin, can be used with
most antiretroviral regimens with some dose adjust-
ments [35].
Tanzania and Malawi have had DOTS programs
for more than 10 years. Despite high rates of HIV
infection (which is present in more than 60% of tu-
202 frieden
berculosis patients in some sub-Saharan African
countries, including Malawi, Zimbabwe, Ethiopia,
and Botswana [3]), there has been no evidence of
an increased rate of relapse among HIV-infected
patients, and rates of drug resistance remain low
[66,67]. Avoiding the creation of drug-resistant tu-
berculosis is the best way to prevent the spread of
such strains.
Summary
The technology to control tuberculosis has been
known for decades. The DOTS strategy can double
cure rates. Successful global implementation of
DOTS could save millions of lives over the next
10 years. Success will require effective governmental
programs along with active communication, collabo-
ration, and participation on the part of the health
care system and governmental and nongovernmen-
tal sectors.
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 Clin Chest Med 26 (2005) 341 – 347

The Global Alliance for Tuberculosis Drug

Development—Accomplishments and Future Directions
Charles A. Gardner, PhDa,*, Tara Acharya, PhD, MPHa,
Ariel Pablos-Méndez, MD, MPHb
a
The Rockefeller Foundation, 420 Fifth Avenue, New York, NY 10018, USA
b
The World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland

Nearly 2 billion people, one third of the world’s
population, are infected with tuberculosis (TB). Eight
million of these people develop active TB every year,
leading to 2 million deaths annually [1]. Although
an effective vaccine against active disease would be
key in ultimately eradicating TB as a public health
problem, there is, as yet, no satisfactory vaccine for
the disease. The commonly used bacille Calmette-
Guérin vaccine is reasonably effective when admin-
istered to infants but is much less effective against
the pulmonary form of TB in adults. Despite a re-
cent increase in vaccine research, ongoing efforts
to develop a new, more effective vaccine are not
expected to yield results for at least a decade, and an
effective vaccine would not substantially diminish the
TB epidemic for several decades after that. Both
effective drugs and an effective vaccine will probably
be needed for many decades to come, until the pool
of current TB patients and latently infected individu-
als is eliminated. Drugs that improve or shorten
therapy, in contrast, would affect treatment of current
patients almost immediately upon their adoption.
The World Health Organization’s directly ob-
served treatment, short course (DOTS) strategy is an
effective TB control strategy but reaches only one
third of the people who need it [2]. Moreover, it is
expensive, labor-intensive, and usually involves a 6- to
12-month, four-drug combination regimen consisting
The views expressed by the authors do not necessarily
reflect the views of their institutions.
* Corresponding author.
E-mail address: cgardner@rockfound.org (C.A. Gardner).
of isoniazid, rifampin, pyrazinamide, and ethambutol.
Patients find it difficult to adhere to this complicated
regimen, leading to an increase in drug-resistant
strains [3]. Second-line drugs for multidrug-resistant
tuberculosis (MDR-TB) are expensive and more toxic
than the standard treatment.
It has been more than 30 years since a novel TB
drug has been introduced into clinical practice. The
estimated costs of discovery and development of a
new TB drug (including the costs of failure) are
between $115 million and $240 million [4]. Adopting
a portfolio approach, the Global Alliance for TB
Drug Development (TB Alliance) expects to pursue
multiple candidate drugs. The global TB market
could reach $700 million by 2010 but is concentrated
in developing countries, and the pharmaceutical in-
dustry, guided by the perception that the TB market
remains too small and diverse to guarantee return on
investment, has not driven a comprehensive devel-
opment program for new TB drugs.
The Global Alliance for Tuberculosis Drug
Development
In response to these challenges, and with initial
support from the Rockefeller Foundation and other
international organizations, the TB Alliance [5] was
established in 2000 with a mission to accelerate the
discovery and development of new drugs to fight TB
and to ensure their affordability and accessibility. The
initiative was born at a pivotal meeting in Cape
Town, South Africa [6], and soon gained substantial
support from the Bill and Melinda Gates Foundation.

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.008 chestmed.theclinics.com
342 gardner et al
As one of a new breed of nonprofit product-
development public – private partnerships (PD PPPs),
the TB Alliance draws on strengths of the public and
private sector to achieve its objectives—new and
better TB treatments that
 Shorten or significantly simplify the treatment
of active tuberculosis
 Provide effective treatment of MDR-TB
 Improve the treatment of latent tuberculosis
The TB Alliance operates like a nonprofit com-
pany based on an innovative partnership designed to
share risks and incentives. The range of organizations
that partner with the TB Alliance includes academic
institutions, government research laboratories and
public health institutions, nongovernmental organi-
zations, the pharmaceutical industry, and contract
research organizations worldwide. Its headquarters
are in New York, but it also maintains offices in Cape
Town, South Africa, and Brussels, Belgium.
The strategy of the Global Alliance for
Tuberculosis Drug Development
The TB Alliance has five strategic objectives:
1. Identify and access promising compounds
2. Oversee the preclinical development of candi-
date drugs
3. Spearhead clinical trials and drive regula-
tory approval
4. Ensure affordability, adoption, and access
(AAA strategy)
5. Mobilize expertise and resources for tuber-
culosis drug development
These objectives and selected accomplishments
for each objective are outlined below [5].
Objective 1: identify and access promising
compounds
Through proactive business development and
periodic requests for proposals from public, private,
and academic institutions, the TB Alliance selects,
assembles, and manages a portfolio of promising
candidate drugs. The TB Alliance collaborates with
or outsources (and provides funding for) the devel-
opment of these candidates to public and private
partners but retains overall responsibility for these
projects, with dedicated project management, prede-
fined and measurable milestones, and clear go/no-go
decision points. So far, the TB Alliance has as-
sembled a portfolio of projects that are in various
phases—lead identification, lead optimization, and
preclinical development (Fig. 1).
Since 2000, the TB Alliance has catalyzed the
expansion of the TB drug pipeline. In 2005, up to
seven compounds are expected to be in or to enter
clinical trials, many of them with novel modes of
action. For comparison, in 2000 only two TB candi-
date drugs were in development, and these products
represented only slight modifications to existing
molecules. The sequencing of the genome of
Mycobacterium tuberculosis is expected to yield
useful results for drug discovery, although not before
substantial investment by the global research com-
munity. Examples of compound families reviewed
by the TB Alliance for drug candidacy over the last
several years include
 Nitroimidazoles, with potentially sterilizing ac-
tivity and effectiveness against MDR-TB
 Fluoroquinolones and quinolizine derivatives
that may hold the key to significantly shorter
treatment regimens
 Longer-acting rifamycins for more widely
spaced intermittent treatment that have a poten-
tial for avoiding cross-resistance to other rifa-
mycins and antiretroviral drug interactions
 Macrolides, an excellent antibiotic class with
significant potential to yield a tuberculosis drug
because of its excellent pharmacologic features
and its promising antibacterial activity against
M. tuberculosis
 Oxazolidinones, broad-spectrum antimicrobials,
which may have substantial antimycobacte-
rial activity;
 Pleuromutilins, a novel class of antibiotics of a
natural product origin, which have tuberculosis
efficacy in early tests, do not have cross-
resistance with other antibiotics, and seem to
produce resistance very slowly
 Pyrroles, a previously largely unexplored class
of compounds with antimycobacterial activity in
vitro and in preclinical animal models, with a
novel mechanism of action.
Selected lead compounds in the Global Alliance for
Tuberculosis Drug Development portfolio
A lead compound in the portfolio, the nitro-
imidazopyran PA-824, has successfully passed estab-
lished milestones and is expected to be in clinical
trials by the first half of 2005. PA-824 was the first
compound acquired by the TB Alliance, in June
 global alliance for tuberculosis drug development 343

Discovery Preclinical Clinical Testing

Nitroimidazole Analogs
Nitroimidazole PA-824 Moxifloxacin
(TB Alliance, Novartis Institute for Tropical Diseases,
(TB Alliance, Chiron) (TB Alliance, Bayer Pharmaceuticals)
NIAID)
Compounds, Analogs and Derivatives

Carboxylates Pyrrole LL-3858 Diarylquinoline R207910

(TB Alliance, Wellesley College) (LupinLimited) (Johnson & Johnson)
Quinolones Diamine SQ-109 Proprietary Compound
(TB Alliance, KRICT/Yonsei University) (Sequella, Inc.) (PrivateSector Company)
Macrolides Gatifloxacin
(TB Alliance, University of Illinois at Chicago) (OFLOTUB – TDR)
Pleuromutilins
(TB Alliance, GlaxoSmithKline)
Isocitrate Lyase (ICL)
(TB Alliance, GlaxoSmithKline)
InhA
(TB Alliance, GlaxoSmithKline)
Focused Screening
(TB Alliance, GlaxoSmithKline)
Methyltransferase inhibitors
(AnacorPharmaceuticals)
Screening and Target Identification
(AstraZeneca)

Fig. 1. Global tuberculosis drug pipeline, March 2005. (Courtesy of the Global Alliance for TB Drug Development, New York,
NY; with permission.)

2002, through an exclusive license agreement with of rifampicin. Developed by Bayer AG (Leverkusen,
Chiron Corporation (Emeryville, California). The Germany), the drug currently has been approved by
compound has bactericidal activity similar to isonia- the Food and Drug Administration (FDA) for treat-
zid and sterilizing activity that rivals that of rifam- ment of skin and upper respiratory tract infections
picin. During the discovery stage, PA-824 and its and pneumonia. In vivo experiments using a murine
analogues demonstrated activity against both drug- model at the Center for Tuberculosis Research at
sensitive and MDR strains of TB. Preclinical develop- Johns Hopkins University and funded by the TB
ment results so far have demonstrated the feasibility Alliance have affirmed moxifloxacin’s early promise
of increasing synthesis for animal and clinical trials. for shortening therapy. Support from the TB Alliance
In preliminary toxicology testing, PA-824 did not helps ensure that this murine model, one of the TB
demonstrate teratogenic or toxic effects on normal Alliance’s platform technologies, will continue to be
metabolic or hormonal systems. Additional animal available for the development of other TB drugs. The
studies to assess the safety and efficacy of PA-824 Johns Hopkins team substituted moxifloxacin in
have also yielded encouraging results. As a result, various combinations to replace or enhance aspects
PA-824 will be entering phase I clinical trials in the of existing treatment. Substitution of moxifloxacin
first half of 2005. The TB Alliance is also working to for isoniazid significantly increases efficacy, and
optimize the synthesis of PA-824 to reduce production studies have suggested that inclusion of moxifloxacin
costs. To ensure further development of this promising in a combination regimen can shorten the time of TB
class of drug candidates, the TB Alliance is pursuing treatment [7].
research into analogues of PA-824. To this end, the The next step is to confirm these results in clinical
Alliance has also launched a partnership with Novartis trials. To that end, the TB Alliance is working with
Institute of Tropical Diseases in Singapore to explore Bayer and several partners, including the Centers for
new avenues within the nitroimidazole class, working Disease Control and Prevention (CDC), Johns Hop-
closely with the National Institutes of Allergy and kins University, and University College, London
Infectious Diseases (NIAID), among others. (with funding from the European and Developing
Moxifloxacin is a quinolone that has shown high Countries Clinical Trials Program), to formulate and
levels of activity against M. tuberculosis in vitro and support a global clinical development plan for
has generated significant interest from the TB moxifloxacin in the treatment of TB. This under-
community for its potential to become the first major taking would build on an existing Cooperative
advance in TB therapy since the 1965 introduction Research and Development Agreement between
344 gardner et al
Bayer AG and the CDC that the TB Alliance
facilitated in 2002. As part of this plan, the CDC
TB Trials Consortium is conducting phase II clinical
trials in Spain, North America, and Africa to evalu-
ate the safety and efficacy of a regimen in which
moxifloxacin is substituted for ethambutol in the
treatment of patients who have newly diagnosed TB.
Objective 2: oversee the preclinical development of
drug candidates
The TB Alliance has established an effective
process and enabling technologies to develop can-
didate drugs. It has developed a comprehensive
management plan, created a diverse network of
outsourced, global expertise, and established go/no-
go decision gates to advance candidates along the
development pipeline.
A research plan and development timeline is
established for each compound or project selected
for the portfolio. The development plan requires a
series of tests, each designed to provide a go/no-go
decision point for continued development. At pre-
clinical stages, a comprehensive program of safety
and toxicology pharmacologic investigations is per-
formed. Because TB drugs must be designed to
optimize combination therapy, the cornerstone of
resistance control, these safety considerations must
include drug – drug interactions with companion anti-
TB medications. Furthermore, because an increas-
ing percentage of TB patients are also infected with
HIV, it is critical to determine the compatibility with
antiretroviral treatments and in particular to ensure
the lack of induction or metabolism by cytochrome
P450 enzymes.
Objective 3: spearhead clinical trials and drive
regulatory approval
The TB Alliance is working to ensure that there
is adequate capacity for clinical trials to test the com-
pounds that successfully pass preclinical milestones.
These facilities must meet the highest regulatory
standards, including those of the FDA and European
Medicines Agency. The aim is to reduce unnecessary
regulatory hurdles to ensure that new drugs are made
available to patients as soon as possible. Therefore,
the TB Alliance is also working to harmonize regu-
latory approval processes to expedite the inclusion of
new products in standardized treatment.
As in any drug discovery and development
program, general delays or setbacks are expected in
the process of TB drug development. The TB
Alliance hopes to reduce these risks by maintaining
a diverse portfolio and working with countries to
build capacity for drug development. For instance,
the TB Alliance is working with the International
Union Against Tuberculosis and Lung Disease to
build clinical trials capabilities at international loca-
tions in Africa, South America, and Asia. The TB
Alliance is exploring multiple approaches to stream-
lining clinical development, including simultaneous
rather than sequential testing of new compounds and
validation of novel surrogate markers.
Objective 4: ensure affordability, adoption, and
access
In developing countries, the TB Alliance is
working to ensure the AAA strategy for the products
it develops. Affordability of the final product depends
on both technical and business factors. The costs of
production and development of potential compounds
are evaluated, and all agreements are structured to
limit royalties in countries where TB is endemic and
to include licensing provisions and manufacturing
rights to keep prices low. The TB Alliance is also
working with the World Health Organization and
national TB control programs to ensure early adop-
tion of a new product in existing programs and thera-
peutic regimens. Access ensures that medicines reach
all patients, particularly the poorest of the poor. As
part of the AAA strategy, the TB Alliance is ex-
ploring innovative intellectual-property strategies to
balance access and incentives. The TB Alliance
hopes to retain the ability to deliver new anti-TB
drugs equitably to those areas most in need while
helping to maintain incentives for the pharmaceutical
industry to develop new TB medicines. The costs of
production and development of potential compounds
are evaluated, and all agreements are structured to
limit royalties in endemic countries and to include
licensing provisions and manufacturing rights to keep
prices low.
The TB Alliance is also working with the World
Health Organization, the Stop TB Partnership, and
national TB control programs to ensure early adop-
tion of a new product in existing programs and
therapeutic regimens. Unlike PD PPPs developing
novel prevention tools lacking any existing distribu-
tion mechanisms, the TB Alliance will be able to rely
on a decade of investments in DOTS programs and
their drug procurement and distribution mechanisms
such as the Global Drug Facility. Although further
improvements in access to DOTS are imperative,
these mechanisms are in place, and the TB Alliance
can rely on them for the distribution of the new drugs
in combination therapy.
 global alliance for tuberculosis drug development
Objective 5: mobilize expertise and resources for
tuberculosis drug development
Following initial funding by the Rockefeller and
The Bill and Melinda Gates Foundations, the TB
Alliance has secured further public funding from the
United States Agency for International Development
and the Dutch Ministry of Development Coopera-
tion and in-kind support from the NIAID. The TB
Alliance has leveraged this funding to position itself
as the catalyst in developing new TB drugs. The TB
Alliance has mobilized worldwide expertise and
resources by establishing solid relationships with
pharmaceutical and biotechnology companies, proac-
tively seeking new sources of support, and actively
participating in global forums to promote its mission.
For example, the TB Alliance is the lead agency of
the Stop TB Partnership Working Group on TB Drug
Development, which coordinates a forum to facilitate
research and development collaborations worldwide
for new TB drugs. While building its own portfolio
through the partnerships described previously, the TB
Alliance has helped catalyze the global TB drug
pipeline by engaging all relevant industry entities and
by enhancing technologies to support drug develop-
ment in general. The TB Alliance has taken both
advisory and advocacy roles to support corporate
efforts for TB, such as those currently underway
at Novartis, Anacor, AstraZeneca, Lupin, Glaxo-
SmithKline, and other companies. For example,
AstraZeneca has committed $25 million over 5 years
at its newly established research facility in Bangalore,
India [8], and Novartis has established a $122 million
tropical disease research institute in Singapore to
focus on tuberculosis and dengue fever [9]. More-
over, the TB Alliance Scientific Advisory Committee
includes drug discovery and TB experts from
GlaxoSmithKline, Pfizer, and Johnson & Johnson.
Additionally, to enhance the scope and depth of
the global pipeline, the TB Alliance has invested in
platform technologies that expedite, support, and
lower hurdles in TB drug development. One es-
sential platform technology is the mouse model for
preclinical testing, which has been instrumental in
affirming preclinical efficacy of lead compounds.
Others include the establishment of a worldwide
inventory of preclinical and clinical capacity/exper-
tise and clinical trial site standardization in selected
countries to ensure the necessary clinical infra-
structure as portfolio compounds advance to clinical
trials. In this context, the involvement of endemic
countries is central to the mission of the TB
Alliance. On the drug development front, these
countries may have compounds to expand the
345
portfolio and could offer their laboratories’ preclinical
capacity to develop the portfolio. For instance, in April
2003 the TB Alliance signed a 2-year agreement with
the Korea Research Institute of Chemical Technology,
where scientists will synthesize more than 400 com-
pounds, including novel quinolones, pyridones, and
quinolizines. This project aims to yield up to three
lead candidates for the TB Alliance portfolio and is
the TB Alliance’s first research and development
partnership in Asia as well as the first in a country that
has a significant TB burden. Patient enrollment plays
a central role in the clinical development stage.
Because of TB’s global impact, most patients reside
in developing countries, where clinical trial infra-
structure is limited but where reasonable cost struc-
tures help fulfill the ultimate goal of affordability.
Furthermore, DOTS infrastructure, expanded during
the last 10 years, offers an excellent starting point for
clinical trial capacity building.
The TB Alliance is also working closely with
other PD PPPs with similar goals, such as Medicines
for Malaria Venture, the Malaria Vaccine Initiative,
the International AIDS Vaccine Initiative, the Interna-
tional Partnership for Microbicides, and others, to
coordinate overall activities and to strengthen the
incentive for investment in new tools to solve global
health problems. The TB Alliance has welcomed the
creation of a new research effort, the Foundation for
Innovative New Diagnostics (FIND) to develop bet-
ter diagnostic tests for infectious diseases, with an
initial emphasis on TB [10]. The TB Alliance and
FIND plan to work together to encourage the
development of new tools for tuberculosis.
Global product development public – private
partnerships
Globally based nonprofit PD PPPs emerged in the
1990s as a way to
1. Link public-sector goals with private-sector
expertise as a means of accelerating drug and
vaccine development for neglected diseases
2. Raise awareness of global health inequities and
attract substantial new funding to the field
3. Promote culture change, incorporating methods
and models from the private sector into public-
sector practice and encouraging more private
entities to enter the field of neglected dis-
eases [11]
In many ways, PD PPDs can be seen as not-
for-profit companies.
346 gardner et al
Building on its history, mission, and comparative
advantages, The Rockefeller Foundation provided social
venture capital toward the creation of the International
AIDS Vaccine Initiative, Medicines for Malaria Ven-
ture, the TB Alliance, International Partnership
for Microbicides, and Pediatric Dengue Vaccine Initia-
tive [12]. At the same time, other organizations
established a Malaria Vaccine Initiative, Aeras Global
TB Vaccine Foundation, Foundation for Innovative
New Diagnostics, Drugs for Neglected Diseases Ini-
tiative, Institute for One World Health, and others. Most
of these PD PPPs, including the TB Alliance, owe their
continued financial well being to donors—principally
the Bill and Melinda Gates Foundation—along with
other philanthropies, government development agencies,
and multilateral organizations.
The Rockefeller Foundation based its disease-
product priorities (eg, in the creation of the TB
Alliance) on expert assessment of a combination of
high social demand and maturity of the science. The
Foundation pushed for pharmacoeconomic analy-
ses, business plans, and scientific blueprints for the
organizations with which it was involved, and these
approaches have now become the norm.
Like private for-profit companies, PD PPPs use
business practices in staffing and in managing a
portfolio of candidate products. Most have explicit
policies affecting portfolio turnover, including a guil-
lotine strategy based on milestones in the project’s
business plan and criteria for acquiring new product
candidates. Go/no-go decisions are based on advice
from a scientific advisory board made up of experts
in the field. Thus, for some donors, PD PPPs repre-
sent a way to delegate the tough decisions to profes-
sional experts.
Each PD PPP seeks to deliver products that will
be cheaper and easier to supply than existing in-
terventions [13]. The quintessential example would
be a vaccine, just as the polio vaccine replaced the
iron lung half a century ago. A shorter-course TB
treatment regimen to replace the existing 6- to
12-month regimen represents a similar breakthrough
goal. Such products will make access to better health
more attainable. In addition, PD PPPs focus directly
on ensuring that their products will be affordable
and accessible to the poor. Criteria for acquisition of
new candidate products include low manufacturing
cost (often with manufacture in developing countries),
ease of delivery in tropical conditions, and advanta-
geous intellectual-property arrangements that entice
private-sector participation and help ensure fulfill-
ment of the AAA strategy in endemic countries. It is
important that a series of strategic partnerships be
established to deliver products to the neediest.
Together, these organizations provide a true, new,
and coherent field of initiatives designed to bridge
the gap between basic research and product develop-
ment, aligning public health goals with private-sector
expertise to develop essential new products to pre-
vent, control, and treat diseases of the poor. The field
is still young. Sufficient time has not yet passed to
determine whether PD PPPs will achieve their
ultimate goals. A recent analysis of interim indicators
and organizational best-practice benchmarks gives
room for hope, even enthusiasm [14]. Impressive
new public-sector support has arisen, and product-
development pipelines have expanded significantly
both within and outside of PD PPP portfolios. To
build on this progress successfully, still more re-
sources will be needed to carry the work forward
to the next stages including regulatory approvals,
clinical trials, manufacturing, and distribution.
Future directions for the Global Alliance for
Tuberculosis Drug Development
Among the TB Alliance’s achievements to date
are the rapid scaling-up of their project portfolio,
securing of endorsements at the highest national and
international levels, and enlisting the assistance of
leading global pharmaceutical and biotechnology
companies. Most significantly, the TB Alliance is
developing a growing, robust pipeline, a quantum
leap from the situation 5 years ago when TB drug
development was at a standstill.
The ideal scenario in the next decade is one in
which the TB Alliance successfully creates and
manages a portfolio of therapeutic alternatives and
develops a novel anti-TB drug regimen that is as
effective or more effective than the current treatment
and that shortens the duration of treatment to less than
2 months. The reduction in the duration of treat-
ment would represent a significant reduction in the
cost and complexity of DOTS. A drug that simplifies
the regimen and shortens treatment by 3 months
would also have a significant, positive impact
(although not as dramatic as the previous scenario).
In either case, the benefits of a new, faster-acting TB
regimen would go beyond the direct impact on TB
incidence and prevalence and the indirect effect on
the global economy. The success of the TB Alliance
could encourage donors, mobilizing more funding
for additional projects. Demonstration of the success
of the PD PPP model could spur support for other
PD PPPs. Other institutions might apply the TB
Alliance’s platform technologies and lessons learned
during the process of TB drug development to
 global alliance for tuberculosis drug development
their own objectives. Finally, a success from one of
the PD PPPs might energize the entire field of
global health.
Acknowledgments
The authors thank Ann Ginsberg, Gwynne Ooster-
baan, Melvin Spigelman, and Joelle Tanguy at the
TB Alliance for their valuable comments.
References
[1] World Health Organization Fact sheet no 104, revised
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[2] Médecins sans Frontières. Campaign for access to
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reports/2004/tbreport_2004.pdf. Accessed March
4, 2005.
[3] World Health Organization. WHO/IUATLD Global
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[4] Global Alliance for TB Drug Development. The
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[5] Global Alliance for TB Drug Development. Overview
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tballiance.org. Accessed March 4, 2005.
[6] Pablos-Méndez A for the Working Alliance for TB
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[8] Astrazeneca. Astrazeneca opens multi-million dollar
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[9] Novartis. Novartis Institute for Tropical Diseases opens
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March 4, 2005.
[10] Foundation for Innovative New Diagnostics (FIND).
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[11] Internal strategic planning document. New York7 The
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[13] Wheeler C, Berkley S. Initial lessons from public-
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 Clin Chest Med 26 (2005) 207 – 216

The Origin and Evolution of Mycobacterium tuberculosis

Serge Mostowya, Marcel A. Behr, MDa,b,*
a
McGill University Health Centre, 1650 Cedar Avenue, Montreal, QC H3G 1A4, Canada
b
Division of Infectious Diseases and Medical Microbiology, A5-156, Montreal General Hospital, 1650 Cedar Avenue,
Montreal, QC H3G 1A4, Canada

With tuberculosis (TB) having plagued mankind
for centuries, there can be no doubt that Mycobacte-
rium tuberculosis, the causative agent of human TB,
has been successful in adapting for human infection.
M. tuberculosis belongs to the Mycobacterium tuber-
culosis complex (MTC), itself comprised of bacte-
rial agents responsible for TB or TB-like disease.
Members of the MTC are known to infect mam-
malian hosts, and the extent and consequence of
this infection is gaining greater recognition in part
because of the availability of diagnostic tools to
classify specific isolates appropriately. This article
introduces the tools and terminology used for this
classification and illustrates their utility by discussing
work from independent laboratories that have es-
tablished a genome-based phylogeny for the MTC
[1 – 5]. Next, it considers the use of these markers
to distinguish atypical isolates not conforming to
attributes of traditional MTC members [6,7]. Finally,
it discusses the current genomic evidence regarding
the origin and evolution of M. tuberculosis in the
context of its relevance for TB control in humans and
other mammalian hosts.
Characteristics of the Mycobacterium tuberculosis
complex
The MTC consists of bacteria that genetically
share identical 16S rRNA sequence and greater than
99.9% nucleotide identity. M. tuberculosis, M. af-
ricanum, M. microti, and M. bovis have been re-
garded as the four traditional species of the MTC,
although the extent of MTC speciation is not yet
resolved. In this article, MTC organisms are referred
to as members, and the nomenclature provided in the
most recent literature is used.
Members characteristically differ in their host
range, epidemiology, clinical presentation in humans,
and laboratory phenotype, although little is known
about these differences or why these differences have
evolved. The human form (M. tuberculosis sensu
stricto) and the bovine form (M. bovis) have been
nominally distinct for more than a century; other mem-
bers have been identified more recently (Table 1).
The members classically were described by their
biochemical properties or by targeting their specific
genetic regions. Genomic insights now show a new
approach to MTC speciation outside the scope of
these more traditional tools [8].

Genetic resources to study the Mycobacterium

* Corresponding author. Division of Infectious Dis-
eases and Medical Microbiology, A5-156, Montreal Gen-
eral Hospital, 1650 Cedar Avenue, Montreal, QC H3G
1A4, Canada.
E-mail address: marcel.behr@mcgill.ca (M.A. Behr).
tuberculosis complex
With the availability of complete sequence in-
formation, several methodologies have developed to
understand the MTC genetically. These methods can

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.004 chestmed.theclinics.com
208 mostowy & behr

Table 1
Myobacterium tuberculosis complex members
Virulence
MTC member Natural host Mouse Guinea pig Rabbit Unique attribute
M.canettii Human? + + Most ancestral recognized MTC member,
anecdotal isolation
M. tuberculosis Human + + Predominant cause of human TB
a
M. africanum subtype II Human + + Reclassified as atypical M. tuberculosis
b
M. africanum subtype I (a) Human? + + Rarely isolated
c
M. africanum subtype I (b) Human? + + Phenotypically heterogeneous
M. pinnipedii Pinnipeds + + + Closely related to M. microti
M. microti Vole Attenuated, used as live vaccine in humans
Dassie bacillus Dassie More attenuated than M. microti
M. caprae Goat + + + Only described in Europe?
M. bovis Cow + + + Dynamic pathogen with wildlife reservoirs?
M. bovis BCG None Family of laboratory adapted strains of
M. bovis used as live vaccine

Abbreviations: +, animal typically succumbs to infection; , animal typically survives infection.

a
Although previously suggested as a unique member of the MTC, M. africanum subtype II isolates cannot be genomically
distinguished from M. tuberculosis [7]; and throughout this article, M. africanum subtype II is included within the M. tu-
berculosis lineage.
b
Refers to the genotype ‘(a)’ of M. africanum subtype I having deleted RD9, but not RD7, RD8, and RD10.
c
Refers to the genotype ‘(b)’ of M. africanum subtype I having deleted RD9, RD7, RD8, and RD10.
Data from Refs. [38,39,42,43,62,63].

be categorized as genetically fast or slow and as Sequenced genomes

having phenotypic consequences or not. Each meth-
odology has advantages and disadvantages. Whereas
each methodology has proven useful, a tool is only as
informative as the question toward which it is
applied. Responsible contributions ideally should
draw information from all available typing methods
to conclude with the most parsimonious scenario.
Fingerprinting patterns
The use of DNA fingerprinting patterns, in which
samples are genotyped by restriction-fragment-length
polymorphisms using genetic attributes specific to the
MTC as markers, has proven valuable for tracking
MTC disease [9]. Molecular epidemiologic markers
used include the MTC-specific insertion sequence
IS6110 [10], polymorphic glycine- and cytosine-rich
sequences [11], the direct-repeat region [12], spacer-
oligonucleotide typing (spoligotyping) [13,14], and
variable-number tandem repeats of genetic elements
termed mycobacterial interspersed repetitive units
[15,16]. Although these genetic markers are known
to mutate at rates suitable for tracing a chain of dis-
ease transmission, their patterns of change are po-
tentially too common to act as reliable markers over
longer periods of evolutionary time. Therefore, they
do not seem to be reliable for phylogenetic studies
and speciation of clinical isolates.
A wealth of genomic insight for the Mycobacte-
rium genus is available through whole-genome
sequence information for several species (Table 2),
including six entire MTC genomic sequences com-
pleted or in progress. These are M. tuberculosis
H37Rv [17], M. tuberculosis CDC1551 [18], M. tu-
berculosis 210 [18a], M. microti OV254 [19],
M. bovis 2122 [20], and M. bovis bacille Calmette-
Guerin (BCG) Pasteur [20a]. Mycobacteria se-
quenced or being sequenced outside the MTC include
M. leprae [21], M. ulcerans [22], M. avium 104 [51],
M. paratuberculosis K10 [22a], M. marinum [22b],
and the relatively fast-growing M. smegmatis MC2
155 [18a]. Even the most distant of these sequenced
mycobacterial genomes are minimally related by 60%
DNA/DNA homology, and comparative genomic
analysis has shown that gene loss is a significant
part of the ongoing evolution of the slow-growing
mycobacterial pathogens [23].
Single-nucleotide polymorphisms
Single-nucleotide polymorphisms (SNPs) can re-
sult in a silent amino acid substitution in which the
protein coding sequence remains unchanged (syn-
onymous) or can alter the protein-coding sequence
(nonsynonymous) and hence act as a substrate for
Table 2
Overview of mycobacterial genome sequencing projects

mycobacterium tuberculosis complex evolution

First author/date Genome size No. of protein- G + C nucleotide
Species [reference] (base pairs) coding genes content (%) Insight from sequencing project
M. tuberculosis H37Rv Cole, 1998 [17] 4,411,532 3995 65.6 First sequenced mycobacterial genome
M. tuberculosis CDC1551 Fleischmann, 2002 [18] 4,403,836 4249 65.6 Polymorphisms among M. tuberculosis strains more
extensive than initially anticipated
M. tuberculosis 210 The Institute for Genomic 4,400,000a NA NA Describes hyper-virulence of ‘Beijing’ strain family?
Research [18a]
M. bovis 2122 Garnier, 2003 [20] 4,345,492 3951 65.6 M. bovis is derivative compared to M. tuberculosis
M. microti Brodin, 2002 [19] 4,400,000a NA 64.0a Loss of RD1 contributed to attenuation of M. microti
M. bovis BCG Pasteur Sanger Institute [20a] 4,083,000a NA NA Describes live vaccine administered to humans
M. marinum Sanger Institute [22b] 6,636,827 NA 65.73% Describes causative agent of TB-like disease in fish
and ‘fish tank granuloma’ of humans
M. ulcerans Stinear, 2004 [22] 6,032,000a NA 65.0a Plasmid-encoded toxin responsible for Buruli ulcer
M. leprae Cole, 2001 [21] 3,268,203 1604 57.8 Massive gene decay in the leprosy bacillus
M. avium avium 104 Semret, 2004 [51] 5,475,491 4480 69 Extensive genomic polymorphism among M. avium
sub-species
M. avium paratuberculosis K10 GenBank [22a] 4,829,781 4350 69.3 Describes causative agent of Johne’s disease in cattle
M. smegmatis MC2 155 The Institute for Genomic 7,000,000a NA NA Describes fast growing, model organism for
Research [18a] mycobacteria
Mycobacteria are listed is the order of 16S rRNA sequence relatedness to M. tuberculosis [64].
Abbreviations: G + C, guanine plus cytosine; NA, not available.
a
Parameter estimates.

209
210 mostowy
evolutionary selection. Both types of mutations have
been applied toward differentiation and diagnostics of
MTC members [24 – 26]. In a landmark study, a first
sequence analysis of MTC isolates revealed that
allelic polymorphism is impressively rare, occurring
on the order of 1 in 10,000 base pairs (bp), suggesting
that the complex could be dated to about 15,000 to
20,000 years of age [24].
Genomic comparison of multiple sequenced MTC
strains has made possible the identification of SNP
markers for studies of evolution, pathogenesis, and
epidemiology in clinical M. tuberculosis [27] and
M. bovis [20], supporting a clonal evolution of the
MTC without detectable lateral gene exchange. The
ratio of SNP types within a genome can act as a mo-
lecular clock [28] in which the high ratio of non-
synonymous to synonymous mutations across coding
sequences within MTC genomes suggests a recent
divergence of M. bovis and M. tuberculosis [20].
Large-sequence polymorphisms
Unlike other mycobacterial species in which
horizontal gene transfer has been demonstrated [22],
this mode of generating genomic diversity has not
been observed for the obligately intracellular MTC.
Genomic comparisons for the MTC reveal a promi-
nent role of genomic deletions relative to the
sequenced strains of M. tuberculosis. For example,
the complete genome sequence of M. bovis 2122
contains 66,037 bp less than M. tuberculosis H37Rv,
and no genomic region exclusive to M. bovis but
consistently absent from M. tuberculosis has been
detected [20].
To uncover deletions in nonsequenced strains
efficiently, one can hybridize whole genomic DNA
of a MTC member against a spotted array [29] or an
Affymetrix GeneChip (Santa Clara, California) [30]
representative of the entire M. tuberculosis H37Rv
genome [17]. Regions of the prototype strain that
seem to be absent from the test strain are then
confirmed by performing polymerase chain reaction
(PCR) with primers approximating the deleted region,
to amplify across the deletion. This amplicon is then
sequenced to define the deletion point precisely.
Isolates are said to share a genomic deletion when
sequencing shows the deletion occurs in different
isolates at exactly the same cut point [2]. Because
independently arisen chromosomal rearrangements
sometimes involve the same strategically located
elements, only upon exact description of the specific
genomic event (ie, genomic location within a refer-
ence strain) can one determine with confidence
whether genomic deletions behave as unidirectional
& behr
event polymorphisms (UEPs). These UEPs, which re-
present one-time events in the evolution of the organ-
ism, can serve as robust markers of clonal organisms,
useful for determining phylogenetic classification.
A valuable use of these genomic deletions pertains
to their application in defining specific MTC mem-
bers and accurately assessing their prevalence in
clinical specimens [8,26]. Unlike biochemical testing,
which for individual results had imperfect sensitivity
and specificity, the use of genomic events in these
studies provided unambiguous classification, thereby
simplifying the process considerably. To explore the
basis for the previously observed biochemical attri-
butes used for MTC speciation, an association was
sought between deleted sequences and phenotypic
results for isolates assigned as M. africanum. Results
indicate that convergent biochemical profiles can be
independently obtained in different MTC members.
For instance, organisms presenting the distinct
deletion profile of M. africanum and M. bovis can
manifest the same biochemically based profile [7].
These results confirm the limitations of biochemically
derived speciation and, by extension, challenge the
taxonomic divisions currently in place for classifying
members of the MTC.
Beyond diagnostics, different studies have all sup-
ported the potential value of most MTC genomic de-
letions (with the exception of mycobacteriophage
DNA) as evolutionary markers. In separate genomic
studies of M. bovis BCG vaccine strains, it has been
documented that BCG-specific deletions superimpose
perfectly on the historical record [3,29]. In studies of
genomic deletions within clinical isolates of M. tu-
berculosis [31,32], mycobacterial clones shared the
same genomic deletions, again suggesting that
deletions can be used to reconstruct phylogenetic
trees. Finally, a recent analysis of 100 M. tuberculosis
clones from San Francisco has again confirmed that
these deletions are UEPs [5], and therefore genomic
deletions can effectively brand a particular clone [33].
A practical use of this approach will be to provide
a secure genomic definition for prominent strains,
such as the Beijing [34] and Manila [35] strains of
M. tuberculosis, and to assess their prevalence
through space and time.
Genomic deletions and the origin and evolution of
the Mycobacterium tuberculosis complex
The long-recognized presence of a human TB
bacillus and a closely related bovine form has given
rise to speculation that TB originally came to hu-
mans as a zoonotic infection from cattle [36]. In
 mycobacterium tuberculosis complex evolution
retrospect, this view was probably influenced by
the types of M. tuberculosis isolates available for
study, biased toward hosts (namely cattle and hu-
mans) for which a diagnosis of TB would lead to
microbiologic investigation. To explore the evolu-
tionary relationship of members of the MTC, the
presence or absence of deletions was tested within
complex isolates derived from different hosts and
from isolates in various geographic locales [1,2].
Analysis revealed a stepwise accumulation of ge-
nomic deletions among isolates interrogated, but
the distribution of genomic deletions argued against
present-day M. bovis as the evolutionary precursor
of M. tuberculosis, making it improbable that human
TB originated with the domestication of cattle. In-
stead, a number of MTC organisms, both long estab-
lished and more recently described, present genomic
profiles that seem to be intermediate between the
ancestor of modern M. tuberculosis and that of
present-day M. bovis.
The availability of improved laboratory tools has
facilitated the description of a number of novel
variants of the MTC, including M. canettii [37,38],
M. caprae [39,40], M. pinnipedii [41,42], and the
dassie bacillus [2,43] (Table 1).
Before these tools were available, MTC members
had presented a well-established host range, presum-
ably biased by expectations: M. tuberculosis (and
sometimes M. africanum) is classically isolated from
humans, M. microti from voles, and M. bovis from a
broad range of hosts including (but not limited to)
cows. More careful study, however, has revealed a
wider range of host animals. A practical issue arising
from these studies involves the generally held belief
that M. bovis infects an extensive range of animal
species, including the badger, opossum, elk, cougar,
and buffalo. Until recently, M. caprae and M. pin-
nipedii were considered to be forms of M. bovis
[40,42]. Although M. bovis might be versatile enough
to accommodate such a dynamic host range, the
inclusion of such organisms probably overestimates
the true host range of M. bovis. Detailed genomic
analysis of isolates from unusual hosts is underway,
with the expectation that results will continue to
challenge accepted notions of MTC speciation and
taxonomy [2].
Just as genomic deletions have proven unique to
isolates of M. tuberculosis affecting only human
hosts [5,30], deletions unique to these other MTC
members permit resolution of their phylogenetic
situation (Fig. 1) [1,2]. A first observation from this
distribution of organisms is that the MTC affects a
number of undomesticated and domesticated mam-
mals, both terrestrial and aquatic. M. marinum can be
211
considered a piscine/amphibian mycobacterium [44]
and M. avium an avian mycobacterium [45]. The
MTC is a relatively broad-ranging mammalian
mycobacterium. Organisms of the four most ancestral
lineages (M. canettii, M. tuberculosis, and both
genotypes of M. africanum subtype I) have been
cultured predominantly from humans. Because iso-
lation of M. canettii has been extremely rare [37,38],
an unrecognized nonhuman reservoir might exist,
with humans representing an accidental or circum-
stantial host. The next three MTC lineages (M. mi-
croti, M. pinnipedii, and the dassie bacillus) affect
undomesticated mammals irrespective of their geo-
graphic location. M. microti, first identified in
Europe, infects the field vole [19], the dassie bacillus
infects the dassie and the surikat from Africa [6,43],
and M. pinnipedii globally infects a variety of seals
and sea lions from Oceania to South America [4,42].
Finally, more derivative forms of the MTC are seen in
goats (M. caprae) and subsequently cattle (classic
M. bovis), suggesting that the organism was intro-
duced into livestock in the order of their domestica-
tion. More recently, spillover of M. bovis from farms
has been seen in the case of badgers in the United
Kingdom [46] and the brushtail opossum in New
Zealand [46a]. Far from suggesting that human TB
originated with livestock, the genomic record sug-
gests that, directly or indirectly, humans were respon-
sible for bringing MTC to the farm, with secondary
foci of spread now observed in animals associated
with this setting.
Geographic, chronologic, and ecologic origins of
the Mycobacterium tuberculosis complex
An absolute chronology of the TB epidemic is
difficult to discern by genomic deletions, because
they do not evolve on a predictable time scale. The
genetic record can potentially point to the geographic
origins, however, because the ancestral form M. ca-
nettii [1,4,25] has been isolated only in persons liv-
ing in Africa [37,38]. If the origins of human TB
are situated in the same the continent as the origins of
man, it is conceivable that the organism spread with
humans during the paleomigration, explaining the
presence of MTC DNA in 5000-year-old samples
from Egypt [47] and pre-Columbian mummies from
Ecuador [48]. Because more derivative organisms are
found in hosts domesticated 10,000 to 12,000 years
ago, these clues suggest that the organism accessed
humans before that era and subsequently spread to
other hosts, either from man directly or through an
unrecognized vector.
212 mostowy & behr

Ancestral tubercle bacillus

Deletions unique to M. canettii M. canettii

Deletions unique to M. tuberculosis M. tuberculosis

(including M. africanum subtype II)
RD9

Deletions unique to M. africanum (a) M. africanum (a)

RD7
RD8
RD10
Deletions unique to M. africanum (b) M. africanum (b)

Deletions unique to M. pinnipedii M. pinnipedii

Deletions unique to M. microti M. microti

dassie bacillus
Deletions unique to dassie bacillus
RD5
RD12
RD13
N-RD25
Deletions unique to M. caprae M. caprae
RD4
Deletions unique to M. bovis M. bovis

Deletions unique to M. bovis BCG

Tubercle bacillus of other M. bovis BCG

mammalian hosts?

Fig. 1. Deletion-based phylogeny of the MTC based on deleted regions demonstrated through genomic analysis. The vertical axis
presents the stepwise accumulation of unidirectional evolutionary polymorphisms (RDs and N-RD) previously characterized
among members of the MTC [1,2]. Clustered along each horizontal axis are organisms for which one or more genomic deletions
specific to this evolutionary branch have been revealed in supporting citations [4,6,7,19,32,58] and unpublished observations.
N-RD, new deletions. (Serge Mostowy, Marcel Behr, MD, unpublished data, 2005.)

Using deletions to assign directionality to the
MTC phylogeny, one can employ sequence-based
analysis to estimate the chronology of this scenario
and refine the previous nucleotide-based analysis that
suggested a 20,000-year divergence between M. tu-
berculosis and M. bovis [24]. Another approach to
date these events uses testing for genomic regions
directly on paleo-DNA samples [49] (Mostowy et al,
unpublished data). Because these samples can be
carbon dated independently, it is possible to provide
genomic signatures for samples of human or non-
human provenance and to derive minimal estimates
for the ages of genomic events portrayed in Fig. 1.
Turning to the ecologic origins of the MTC, a
livestock source seems to be unlikely, because human
forms diverged before the modern caprine and bovine
forms. Although it is attractive to consider another
mammalian host as the ancestral niche, observations
for other mycobacteria suggest that nonmammalian
reservoirs such as plant or insects deserve consid-
eration [50]. With the ability to test rapidly for
genomic deletions by PCR, one can test putative
wildlife reservoirs for variants of the MTC to find
the natural host of relatively ancestral forms such as
M. canettii.
What is being deleted from the Mycobacterium
tuberculosis complex?
When compared with other bacterial species,
members of the MTC present relatively little genomic
diversity. Estimates of large-sequence polymorphism
diversity among MTC members [32], in agreement
with similar conclusions drawn from estimates of
SNPs [25], have been consistently described as low
in comparison with other microbes. Nonetheless,
 mycobacterium tuberculosis complex evolution
genomic flexibility does seem to exist within the
MTC for specific host adaptation, and a similar
potential is beginning to reveal itself among other
mycobacterial complexes. Although the amount of
diversity revealed within the Mycobacterium avium
complex is 10-fold more than that of the MTC [51],
host-specific genomic contents are being observed
there as well (M. Semret and M. Behr, unpublished
data). Taken together, these data highlight a com-
parative genomics approach to understanding an
evolutionary potential of mycobacterium pathogene-
sis, in which genomic content can suggest DNA
features for host-specific adaptation.
Genomic deletions and virulence
With host-specific MTC extending beyond a
domesticated setting, how TB spreads from host to
host is difficult to ascertain. From what is known
about humans and cows with TB, it is reasonable to
expect that transmission would occur through aero-
sols from a diseased animal to a contact animal. If
so, a requisite of host adaptation is a certain degree
of virulence in that host. Although greater virulence
might facilitate transmission, too much virulence
could be detrimental if host mortality is excessive
or if the organism causes an invasive form of TB that
is generally nontransmissible (such as TB meningi-
tis). Thus, optimal transmissibility requires some
degree of virulence (ie, pulmonary pathology) but a
sufficiently contained disease process to generate the
agents required for spread (ie, aerosols).
Support for this notion comes from studying the
content of the genomic regions that have been deleted
in different MTC members. A general observation is
that although each deletion noted in Fig. 1 is unique
to the bp, both genomic regions and the predicted
function of implicated genes are nonrandom. Several
regions of difference (RD) seem to be prone to
genomic deletion, with different specific deletions
having occurred near the same locus [6,7]. Most
prominent among these is RD1, a series of nine genes
implicated in the attenuation of M. bovis BCG strains,
that has suffered three distinct genomic deletions.
Although this confluence of deletions might point
to genetic instability at this locus, a study of 100 cir-
culating M. tuberculosis clones documenting 176 de-
letions failed to detect a single deletion in this region,
arguing against an inherently elevated mutation rate
[32]. The absence of RD1 was first observed for
BCG vaccines [51a]; subsequently, targeted disrup-
tion of RD1 from M. tuberculosis was shown to
decrease bacterial replication and educe pulmonary
pathology in a mouse model [52,53]. More recently,
213
M. microti and the dassie bacillus also were shown to
have deletions in the RD1 region; notably, both have
been characterized as having low virulence in animal
models [19,43]. More detailed analysis of the RD1
region revealed it contains genes encoding a novel
secretion system of two important secreted antigens
(CFP-10, ESAT-6) [53,54]. Presumably a metabol-
ically expensive process, the loss of this region in
BCG was probably advantageous with no selective
pressure in favor of synthesizing and secreting
antigenic proteins in vitro. Although the independent
loss of CFP-10 and ESAT-6 in M. microti and the
dassie bacillus explains their attenuated phenotype,
the selective pressures for their deletion in vivo are
more speculative.
Given the documented impact of the RD1 region
on virulence, the observation of its deletion in both
the vole and dassie hosts is provocative. Nothing
evident points to why the genetically distant vole
(a rodent) and dassie (closely related to the elephant)
would share some unique immunologic susceptibil-
ity. A more likely explanation might involve social
conditions and transmissibility [55], given that voles
and dassies congregate in high-density underground
communities, unlike other MTC hosts that predomi-
nantly live aboveground in open-air conditions. Such
congregate living settings would be extremely favor-
able for TB transmission, and an organism of lesser
virulence might be successful in such burrowing
hosts so long as host populations remain sufficiently
abundant [56]. Conversely, conditions for transmis-
sion aboveground between goats and seals are less
ideal and would probably require an organism of
relatively high virulence to optimize transmissibility.
Summary of catalogued deletions
From Fig. 1, deletions represented along the
vertical line of the phylogeny preceded spread of
the bacillus into new hosts; those along the horizontal
axes arose during coevolution of the organism with
new hosts. Evidence supporting this scenario is that
organisms lacking RD7, RD8, RD9, and RD10 have
been recovered from the entire MTC host range,
whereas the precise deletions seen along the horizon-
tal lineages are observed in only restricted, one-host
settings. To derive a scenario for the loss of genomic
regions in vivo, genes lost on the vertical axis and
those lost along horizontal lineages can be directly
compared, pointing to nonrandom distinction be-
tween the functional classification of these two sets
of deleted genes. Although such studies generate
hypotheses regarding the evolution of MTC members
in different hosts, these studies are naturally biased
214 mostowy
to successful pathogenic strains, as opposed to those
that caused infection but not disease. In this light,
an examination of BCG vaccines provides telling
insights into MTC evolution when the selective
pressures for virulence were absent in the host and
limited to the culture media employed. Remarkably,
the sheer volume of genomic disturbance incurred by
BCG vaccines during a half-century of laboratory
evolution is on the same order as observed among
virulent M. tuberculosis isolates that have been
circulating through the human hosts through millen-
nia [3]. Here, the preponderant message is that BCG
evolution has favored the elimination of regulatory
elements and antigens. These results reinforce the
notion that the capacity to engage the host immune
system is selected for during in vivo conditions, con-
sistent with MTC members being professional patho-
gens [57]. More practically, the absence of numerous
antigens from BCG vaccines may in part explain its
limitations as an immunizing agent [58].
Summary and concluding thoughts: lessons for
tuberculosis control
M. tuberculosis has probably been with humans
for millennia and thus probably became adapted to
humans during times of low population density and
predominantly outdoor living. Unlike diseases such
as HIV that rapidly spread in epidemic form soon
after introduction into humans, the TB epidemic
peaked in Western Europe during the nineteenth
century and has arguably yet to peak in certain parts
of the world. Although it is possible that the organ-
ism has evolved toward greater virulence in recent
centuries, it seems more probable that that social
changes brought about by industrialization were
paramount in altering the transmission dynamics.
This argument would also apply to M. bovis, in which
an organism that evolved to persist in free-ranging
cattle would predictably wreak havoc in the environ-
ment provided by modern-day factory farming.
Finally, whereas tuberculous animals in the wild
might normally succumb to predation, the increasing
protection of these hosts in wildlife refuges and zoos
should provide a greater chance for progression to
TB, as attested to by reports of TB in farmed deer
[59], zoo tigers [60], and seal-trainers [61]. Although
these cases are generally rare, these anecdotes do
serve notice that MTC has the capacity to adapt to the
immunologic environment it engages and suggest
that nonhuman reservoirs may become pertinent to
human TB control.
& behr
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 Clin Chest Med 26 (2005) 273 – 282

Treatment of Active Tuberculosis: Challenges and Prospects

Behzad Sahbazian, DOa, Stephen E. Weis, DOb,*
a
John Peter Smith Hospital, Viola Pitts/Como Community Health Clinic, 4701 Bryant Irvin Road, Fort Worth, TX 76107, USA
b
Department of Medicine, University of North Texas Science Center, Texas College of Osteopathic Medicine,
3500 Camp Bowie Boulevard, Fort Worth, TX 76107, USA

In the past 5 years, the Tuberculosis Trials Con-
sortium (TBTC) of the Centers for Disease Control
and Prevention has completed several large studies
that have improved the understanding of pharmaco-
therapy of tuberculosis. Insights gained from these
studies have resulted in major changes in drug
therapy of tuberculosis in HIV-infected and non-
infected individuals [1 – 5]. These advances require
that tuberculosis drug therapy now be individualized.
Recommended treatment regimens are based on a
patient’s risk profile that is determined by a combi-
nation of hematologic, microbiologic, clinical, and
radiographic findings [6]. These studies have resulted
in substantial changes in the treatment guidelines.
Although they are more complicated than the pre-
vious guidelines, they allow treatment to be refined
so that it can be extended in patients at high risk for
treatment failure and allow shorter, more convenient
treatment regimens in patients who can be identified
as being at very low risk for failure [2]. This article
reviews the basic principles of drug treatment of
tuberculosis, individual pharmacologic agents, cur-
rent treatment recommendations, and several special
situations that clinicians are likely to encounter in
medical practice.
Axioms of chemotherapy of tuberculosis
Effective tuberculosis drug therapy requires not
one but at least two effective drugs. This axiom
* Corresponding author.
E-mail address: sweis@hsc.unt.edu (S.E. Weis).
emerged from the first studies of drug therapy of
tuberculosis initiated in the late 1940s. These studies
evaluated monotherapy with streptomycin and sub-
sequently para-aminosalicylic acid (PAS) [7 – 9].
They demonstrated that drug resistance developed
frequently in persons treated with monotherapy.
During 3 months of monotherapy with streptomycin,
92% of persons who remained culture-positive
developed streptomycin resistance [3]. Resistance
also developed commonly during monotherapy with
PAS and was found in approximately one third of
patients during 4 months of treatment [9]. It was also
observed that resistance was much less common in
persons treated with the combination of streptomycin
and PAS, and that many more patients treated with
the two-drug regimen became bacteriologically nega-
tive with 4 months of therapy [9]. Ten percent or less
of persons treated simultaneously with streptomycin
and PAS developed streptomycin resistance [7,8]. It
also was observed that development of resistance
was associated with a worse prognosis and with more
severe disease [3]. From these early observations
came the principle that tuberculosis treatment must
include simultaneous treatment with at least two ef-
fective drugs.
The microbiologic basis for these early observa-
tions was not identified until the early 1960s and
remains as important today to understand the design
of current treatment regimens [10]. Persons with cavi-
tary disease are estimated to have bacterial popu-
lations of approximately 108 organisms in each cavity
[10,11]. During division, Mycobacterium tubercu-
losis bacilli mutate from drug-susceptible to drug-
resistant status spontaneously, randomly, and at a
predictable rate [12]. The proportion of naturally oc-

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.011 chestmed.theclinics.com
274 sahbazian
curring organisms that are resistant to antituberculosis
drugs is variable, approximately 10 5 for ethambutol,
10 6 for isoniazid and streptomycin, and 10 8 for
rifampin [8]. The probability of a single organism
mutating simultaneously and becoming resistant to
two drugs is the product of individual probabilities
of mutation. It can therefore be estimated that the
likelihood of an organism having mutations simulta-
neously for isoniazid and rifampin is approximately
[(1  10 6)  (1  10 8)] or (1  10 14), and the
bacillary burden in human tuberculosis is several
orders less than this [13]. This mutation rate is the
basis for the observation that successful drug ther-
apy requires that at least two drugs be given
concurrently to prevent selection of drug-resistant
organisms. If a single drug is used for treatment,
selection of the resistant organisms occurs, and the
patient rapidly becomes resistant to that drug. This
mutation rate is also the basis for designing regimens
with an intensive initial phase that uses more medi-
cations and a less intense continuation phase that uses
fewer medications.
Corollaries of the treatment axiom that tubercu-
losis treatment must include simultaneous treatment
with at least two effective drugs are important for
designing effective tuberculosis regimens and tu-
berculosis control programs. Because of the possi-
bility of resistance, a single drug is never added to
a failing drug-treatment regimen. Optimal design of
re-treatment regimens should include at least two
medications to which the patient is naı̈ve, and
clinicians designing initial treatment regimens must
consider prevailing tuberculosis-susceptibility pat-
terns in the community where the infection probably
was acquired. It is equally important to successful
treatment that the patient actually take the two proba-
bly effective drugs. The only way to ensure that a
patient actually takes drug therapy as prescribed is
direct observation of therapy. If three separate drugs
are prescribed for a patient with tuberculosis, the
patient may, for many reasons, take a single drug at
a time. Short-term single-drug therapy in a person
with high bacillary burden can lead to emergence
of drug resistance [7 – 9]. If a patient happens to
be initially resistant to one drug and takes a combi-
nation of two drugs, including the one to which he
or she is resistant, drug resistance to the second
drug will emerge. Similarly, if the patient is resistant
to two drugs and takes these two drugs and a single
effective drug, resistance to the third will emerge.
Therefore, poor adherence, inadequate prescribing,
or both may result in the development of multidrug
resistance. Although these axioms may seem self-
evident, the growing number of persons worldwide
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with drug-resistant tuberculosis is testimony that
these principles are not being implemented success-
fully [14].
The last 50 years of tuberculosis drug treatment
can be summarized succinctly. First, it was demon-
strated that proper chemotherapy and the cooperation
of the patient are the most important factors influenc-
ing response to treatment [15]. Second, it has been
proven that the social factors such as those corrected
during sanatoria treatment of tuberculosis (which pro-
vided bed rest, airy accommodations, a well-balanced
diet, good nursing care, and psychologic balance)
have had no effect on outcome in persons prescribed
drug therapy and cooperating with treatment [15].
Third, a few new antituberculosis drugs have been
developed. For the most part, however, progress has
been made in learning to use available drugs more
effectively, with treatment regimens becoming re-
fined to the current treatments that are shorter, have
fewer side effects, and are more convenient [6].
Pharmacology and toxicity of antimycobacterial
agents
The current drugs approved by the Food and Drug
Administration (FDA) for the treatment of tuber-
culosis include isoniazid, pyrazinamide, rifampin,
rifapentine, ethambutol, cycloserine, ethionamide, ca-
preomycin, PAS, and streptomycin. Drugs that com-
monly are recommended by expert panels for use in
the treatment of tuberculosis but are not FDA ap-
proved include rifabutin, the aminoglycosides includ-
ing amikacin, kanamycin, and the fluoroquinolones
including ciprofloxacin, moxifloxacin, and levofloxacin.
Of the approved drugs, isoniazid, rifampin, ethambu-
tol, and pyrazinamide are considered first-line anti-
tuberculosis drugs. Rifapentine and rifabutin can also
be considered first-line drugs under special condi-
tions discussed later. The others are categorized as
second-line drugs, which are used when the first-line
drugs are unsuitable because of drug intolerance
or infection with drug-resistant tuberculosis. Addi-
tionally clarithromycin, amoxicillin/clavulanate, and
linezolid have been used in the treatment of patients
with drug-resistant tuberculosis.
Drug-level monitoring is not routinely an impor-
tant aspect of treatment in a patient with active
tuberculosis. Therapeutic drug monitoring is most
useful when there is a direct relationship between
serum concentrations and therapeutic response and
when serum concentrations serve as a surrogate for
drug concentrations at the site of action. Therapeutic
 treatment of active tuberculosis
drug monitoring is also important when there is a
narrow range of concentrations that are effective
and safe and when toxicity or lack of effectiveness
puts the patient at great risk [16,17]. Examples of
situations in which therapeutic drug monitoring is
useful for safety include persons treated with amino-
glycosides and persons treated with ethambutol or
cycloserine with renal impairment.
Isoniazid
Isoniazid is used for the treatment of both latent
and active tuberculosis and works primarily by
inhibiting cell wall synthesis. It is usually adminis-
tered orally but has been given successfully intra-
muscularly or intravenously [6]. Isoniazid is cleared
predominantly through the liver by acetylation. A
patient’s acetylation status and the associated differ-
ences in plasma isoniazid concentrations are not as-
sociated with isoniazid-induced liver injury [18].
Additionally, no association was found between
plasma isoniazid concentrations and isoniazid-induced
liver injury [19]. Isoniazid is distributed throughout
the body with peak concentrations occurring within
1 to 2 hours after the administration of an oral dose
[20]. The usual dose for isoniazid is 3 to 5 mg/kg
body weight/day in adults with a maximum dose
of 300 mg/day [6].
Isoniazid generally is well tolerated. Hepatic side
effects are perhaps the best known of the untoward
effects associated with isoniazid use. Less well
known is the asymptomatic elevation of liver amino-
transferases of up to five times the upper limits of
normal, which occurs in approximately 20% of
patients receiving isoniazid. This asymptomatic mild
elevation of liver aminotransferases is not progres-
sive, is not an indication of progressive liver toxicity,
and when asymptomatic does not require discon-
tinuation of isoniazid treatment [6]. Isoniazid-induced
hepatitis does occur, but recent studies indicate it is
less common than previously thought. Isoniazid-
induced hepatitis is estimated to occur in 0.15% of
those starting and in 0.15% of those completing
treatment for latent tuberculosis infection [21]. The
rate of isoniazid-induced hepatitis is higher when
isoniazid is combined with rifampin [22]. It is also
more common in older persons, heavy alcohol
consumers, and persons with underlying liver disease
[23]. Based on a large survey, the risk of isoniazid-
induced fatal hepatitis is much lower than previously
thought—0.001%—when patients are monitored rou-
tinely for liver toxicity [24,25]. The risk increases
slightly in patients over the age of 35 years.
275
Peripheral neuropathy also is associated occasion-
ally with use of isoniazid. Neuropathy occurs more
commonly among persons who have other risks
for neuropathy. Persons at increased risk of periph-
eral neuropathy include those who are nutritionally
deficient, alcoholics, diabetics, pregnant women,
breastfeeding mothers, and patients with renal dis-
ease. Vitamin B6 (pyridoxine) supplements usually
are given with isoniazid to prevent development of
peripheral neuropathy [6].
Hypersensitivity reactions including arthralgias,
irritability, seizures, and lupuslike syndrome have
also been reported in patients receiving isoniazid.
Although as many as 20% of patients treated with
isoniazid develop a positive antinuclear antibody test,
systemic lupus rarely occurs [26].
Isoniazid has clinically important reactions with
other concomitantly used medications. Isoniazid
can affect the levels of certain antiseizure medica-
tions, such as phenytoin and carbamazepine. Levels
of these medications must be monitored during iso-
niazid therapy [6].
Rifamycins
The rifamycins, which include rifampin, rifabutin,
and rifapentine, work by interfering with RNA
synthesis, even in bacilli with minimal metabolic
activity [27]. The rifamycins are variable inducers of
the cytochrome P450 system. Rifampin, rifabutin,
and rifapentine are each first-line drugs for the treat-
ment of tuberculosis in different circumstances.
Rifampin generally is given orally, but formulations
are available for parenteral therapy. The usual dose
for rifampin in adults is 10 mg/kg to a maximum of
600 mg daily. It is distributed well throughout the
body and reaches effective concentrations in all tis-
sues [6]. Rifampin is a necessary component of all
short-course regimens [6].
Rifampin is generally a well-tolerated drug. The
most common side effect of rifampin use is an
orange discoloration of the urine, tears, and other
body fluids. The change in the color of the urine or
other body fluids can be disconcerting to persons
treated with rifampin if they are not warned. This
discoloration has been associated with discoloration
of soft contact lenses and clothing. This staining
must be rare, however, because the author and col-
leagues have treated many contact lens wearers with
rifampin and never have had a complaint of dis-
coloration of contacts lens, even though they rou-
tinely warn patients of this potential side effect.
Rifampin can also cause pruritus [28]. Gastroin-
276 sahbazian
testinal upset, including diarrhea, nausea, and ab-
dominal pains, can occur but rarely require drug
discontinuation and are usually self limiting [29].
Transient elevation of serum bilirubin may be ob-
served during rifampin administration. Hepatitis is
more common when rifampin is administered with
isoniazid [30].
A more serious side effect of rifampin use is an
influenzalike syndrome. Symptoms often mistaken
by patients and physicians for influenza, including
fevers, chills, faintness, headaches, myalgia, and ar-
thralgia, occur alone or in combination. This hyper-
sensitivity syndrome seems to be immune mediated
and develops primarily when rifampin is given
intermittently or in larger doses than are currently
recommended. It most commonly develops after 3 to
6 months but can occur at any time during treatment
[31]. Among persons receiving once-weekly rifampin
as part of the antituberculosis regimen, 35% to 57%
of persons who received 1200 to 1800 mg rifampin
developed a flulike syndrome; the rates were 22% to
31% among those receiving 900 mg/week and 10%
among persons taking 600 mg/week [32]. In contrast,
for persons who received twice-weekly rifampin, a
flulike syndrome was reported in 8% of those
receiving 900 mg/week and in 4% of those receiving
600 mg/week. Symptoms usually appear 1 to 2 hours
after administration of the drug and last up to 8 hours
[31,32]. The hypersensitivity syndrome can be ac-
companied by other manifestations that may be
severe and, rarely, life threatening. The incidence
of individual adverse drug reactions included in
the hypersensitivity syndrome is not well described
for persons treated for tuberculosis. A study of
20,667 patients treated for leprosy with rifampin,
600 mg/day for 3 months, noted the following
incidence rates: rash (0.07%), acute renal failure
(0.1%), thrombocytopenia (0.01%), and hypotension
(0.01%) [33]. Rifabutin use is also associated with
rare immune-related reactions. These reactions tend
to be hematologic, such as leukopenia and thrombo-
cytopenia [33,34].
Rifampin can interact with a large number of
medications because it is a potent inducer of several
enzymes. Rifampin induction of hepatic enzymes can
reduce serum concentrations of oral contraceptives,
resulting in pregnancy, and women relying on hor-
monal methods of contraception need to use addi-
tional means of contraception. Rifampin can increase
the metabolism of methadone and glucocorticoids,
resulting in narcotic withdrawal syndrome and ad-
renal insufficiency or exacerbation of the illness
being treated by glucocorticoid. The interactions of
rifampin with other drugs are so extensive that all
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concurrent medications must be checked for inter-
actions with rifampin.
Ethambutol
Ethambutol is used in combination with isoniazid
and rifampin in the initial treatment of active tuber-
culosis and has been proven effective in primary
treatment of pulmonary tuberculosis [35]. Ethambutol
is used with isoniazid and rifampin to prevent
selecting resistant organisms when resistance to
one of the primary drugs is present. Like isoniazid,
ethambutol inhibits cell wall synthesis. It is available
only in the oral form. Because it is secreted through
the kidneys, it can accumulate in patients with renal
insufficiency. The usual dose for ethambutol is 15 to
20 mg/kg/day or 50 mg/kg two times per week.
Ethambutol generally is very well tolerated, but,
rarely, it can cause retrobulbar neuritis. This syn-
drome first manifests as decreased red-green color
discrimination and visual acuity. Although it can
result in irreversible vision loss, recognition of the
symptoms and prompt discontinuation of the drug
usually results in return of normal vision. Reducing
the dose of ethambutol to 15 mg/kg/day can minimize
the risk [36].
Fluoroquinolones
Levofloxacin, moxifloxacin, and gatifloxacin
all are active against mycobacterium tuberculosis
[37,38]. Although they are not approved by the
FDA for the treatment of tuberculosis, they are
used frequently in treating drug-resistant tubercu-
losis or when patients are intolerant of first-line
agents [39,40]. The adult dose for levofloxacin is
500 to 1000 mg/day orally. Moxifloxacin is admin-
istered at 400 mg/day. Central nervous system (CNS)
concentrations of fluoroquinolones have been found
to be around 16% to 20% of serum after admin-
istration of a standard dose of levofloxacin [41].
Microbial resistance to fluoroquinolones is common
in the community setting; therefore it is imperative
that fluoroquinolones be used only when appropriate.
The most common side effects reported with the use
of this group of antimicrobials are gastrointestinal
symptoms such as nausea, anorexia, dyspepsia, ab-
dominal pain, followed by CNS disturbances (head-
ache, dizziness, drowsiness, abnormal vision) and
liver enzyme abnormalities [42]. Fluoroquinolones
were not developed with the expectation that they
would be used for months; however most experts in
the field of TB have reported a good safety profile
and tolerability with long-term use. Controlled stud-
 treatment of active tuberculosis
ies are in progress by CDC/TBTC to look at fluo-
roquinolones as there is a dearth of information on
the efficacy of long-term fluoroquinolone treatment
(either daily or intermittently) as is required for multi-
drug resistant TB.
Pyrazinamide
Pyrazinamide is the primary drug used in the ini-
tial intensive phase of active tuberculosis therapy
to reduce the total length of therapy. It has a steril-
izing effect and helps eliminate potential persisters
and consequently is used in the first two months of
intensive therapy to reduce the total length of ther-
apy [43]. It is administered orally and is first broken
down by the liver. The remaining metabolites are
excreted through the kidney [44]. It is more hepa-
totoxic than isoniazid; therefore, liver function tests
should be monitored. It can exacerbate gout and
arthralgias by elevating serum uric acid levels [45].
The adult dose for pyrazinamide, based on estimated
lean body weight, is 25 mg/kg for daily oral ad-
ministration orally, 37.5 mg/kg for trice-weekly
administration, and 50 mg/kg for twice-weekly ad-
ministration [6].
Aminoglycosides
Amikacin [46], kanamycin [47], and capreomycin
are three aminoglycosides that are second-line agents
used in treatment of patients who have resistant
tuberculosis. They are available for both intramus-
cular and intravenous administration. All three are
administered at 15 mg/kg/day (maximum, 1.0 g/day).
Sensitivity tests have shown incomplete cross-
resistance between amikacin and capreomycin but
complete cross-resistance between amikacin and
kanamycin [48]. Adverse effects most commonly
associated with the use of these drugs are ototoxicity
and nephrotoxicity. Patients receiving these medica-
tions should have regular audiograms, vestibular and
Romberg testing, and monitoring of renal function.
Treatment guidelines
Tuberculosis treatment guidelines for the United
States have been prepared by and endorsed by the
American Thoracic Society, the Infectious Diseases
Society of America, and the Centers for Disease
Control and Prevention. These regimens are, for the
most part, evidence based. These guidelines rate
treatments according to the strength of the evidence
supporting their use, using a system developed by the
277
Box 1. Infectious Diseases Society of
America/United States Public Health
Service rating system for treatment
recommendations based on quality of
evidence
Strength of the recommendation
A. Preferred; should generally be
offered
B. Alternative; acceptable to offer
C. Offer when preferred or alternative
regimens cannot be given
D. Should generally not be offered
E. Should never be offered
Quality of evidence supporting the
recommendation
I. At least one properly randomized
trial with clinical end points
II. Clinical trials that either were not
randomized or were conducted in
other populations
III. Expert opinion
From Gross PA, Barrett TL, Dellinger EP,
et al. Purpose of quality standards for in-
fectious diseases. Infectious Diseases So-
ciety of America. Clin Infect Dis 1994;18:
421; with permission.
United States Public Health Service and the Infec-
tious Diseases Society of America (Box 1) [6].
The guidelines recommend four regimens for
treating persons with drug-susceptible tuberculosis
[6]. These regimens contain recommendations for
regimen modification under circumstances deter-
mined by a combination of hematologic, microbio-
logic, clinical, and radiographic findings [6]. Each
regimen has an initial intensive phase of 2 months
followed by several options for the continuation
phase of 4 or 7 months’ duration. These regimens,
together with the number of doses specified by the
regimen, are described in Table 1. The initial phases
are denoted by a number (1, 2, 3, or 4), and the con-
tinuation phases associated with the initial phase are
denoted by the number of the initial phase plus a letter
designation for the continuation phase (a, b, or c).
The continuation phase can be given daily, two
times per week, or three times per week with iso-
 278
Table 1
Drug regimens for culture-positive pulmonary tuberculosis caused by drug-susceptible organisms
Ratinga
Initial phase Continuation phase Range of total doses (evidence)b
Regimen Drugs Interval and dosesc (minimal duration) Regimen Drugs Interval and dosesc,d (minimal duration) (minimal duration) HIV HIV+
1 INH 7 d/wk for 56 doses (8 wk) or 5 d/wk 1a INH/RIF 7 d/wk for 128 doses (18 wk) or 182 – 130 (26 wk) A (I) A (II)
RIF for 40 doses (8 wk)e 5 d/wk for 90 doses (18 wk)c
PZA 1b INH/RIF 2/wk for 36 doses (18 wk) 92 – 76 (26 wk) A (I) A (II)f
EMB 1cg INH/RPT 1/wk for 18 doses (18 wk) 74 – 68 (26 wk) B (I) E (I)
2 INH 7 d/wk for 14 doses (2 wk), then 2a INH/RIF 2/wk for 36 doses (18 wk) 62 – 68 (26 wk) A (II) B (II)f
RIF 2/wk for 12 doses (6 wk) or 5 d/wk 2bg INH/RPT 1/wk for 18 doses (18 wk) 44 – 40 (26 wk) B (I) E (I)
PZA for 10 doses (2 wk)e then 2/wk for
EMB 12 doses (8 wk)

sahbazian
3 INH 3/wk for 24 doses (8 wk) 3a INH/RIF 3/wk for 54 doses (18 wk) 78 (26 wk) B (I) B (II)
RIF
PZA
EMB

&
4 INH 7 d/wk for 56 doses (8 wk) or 5 d/wk 4a INH/RIF 7 d/wk for 217 doses (31 wk) or 273 – 195 (39 wk) C (I) C (II)

weis
RIF for 40 doses (8 wk)e 5 d/wk for 156 doses (31 wk)c
EMB 4b INH/RIF 2/wk for 62 doses (31 wk) 118 – 102 (39 wk) C (I) C (II)
Abbreviations: EMB, Ethambutol; HIV , HIV-negative; HIV+, HIV-positive; INH, isoniazid; PZA, pyrazinamide; RIF, rifampin; RPT, rifapentine.
a
Definitions of evidence ratings: A, preferred; B, acceptable alternative; C, offer when A and B cannot be given; E, should never be given.
b
Definitions of evidence ratings: I, randomized clinical trial; II, data from clinical trials that were not randomized or were conducted in other populations; III, expert opinion.
c
When directly observed therapy is used, drugs may be given 5 d/wk and the necessary number of doses adjuated accordingly. Although there are no studies that compare five
with seven daily doses, extensive experience indicates this would be an effective practice.
d
Patients with cavitation on initial chest radiograph and positive cultures at completion of 2 months of therapy should receive a 7-month (31 wk; either 217 doses [7/wk] or 62 doses
[2/wk]) continuation phase.
e
Five d/wk administration is always given by DOT. Rating for 5 d/wk regimens is A III.
f
Not recommended for HIV-infected patients with CD4+ cell counts <100 cells/ml.
g
Options 1c and 2b should be used only in HIV-negative patients who have negative sputum smears at the time of completion of 2 months of therapy and who do not have cavitation
on initial chest radiograph (see text). For patients started on this regimen and found to have a positive culture from 2-month specimen, treatment should be extended an extra 3 months.
From American Thoracic Society, Centers for Disease Control and Prevention, and Infectious Diseases Society of America. Treatment of tuberculosis. MMWR Recomm Rep 2003;
52(RR-11):3.
 treatment of active tuberculosis
niazid and rifampin. It can also be given, more con-
veniently for patients and staff, once weekly using
isoniazid and rifapentine in patients with tuberculo-
sis without cavitation on the chest radiograph. This
group is estimated to represent 40% of persons with
tuberculosis in the United States [3]. Persons who
have cavitation on the initial or follow-up chest
radiograph or who are culture positive at the end
of initial phase of therapy (usually completed after
2 months) have an unacceptably high risk of treat-
ment failure [3,6]. For these patients, the continuation
phase should be extended for an additional 3 months
[6]. It is critically important to have sputum cultures
at the time of completion of the initial phase of treat-
ment to identify patients at increased risk of relapse.
The treatment of tuberculosis in persons with HIV
is discussed elsewhere in this issue.
Treatment of tuberculosis may be delayed for
many reasons. The current treatment guidelines de-
fined completion of adequate therapy by the number
of doses ingested as well as by the duration of
treatment administration [6]. The minimum goal for
adequate therapy is delivery of the full number of
doses in no more than 150% of the expected delivery
duration [6].
Special situations
Central nervous system tuberculosis is one of the
most devastating presentations of human tuberculo-
sis. Disability and death occur despite antitubercu-
losis therapy [49]. The best antimicrobial agents for
the treatment of central nervous system tuberculosis
have not been validated by well-designed, random-
ized, clinical trials. Isoniazid and pyrazinamide pene-
trate the meninges in all stages of inflammation.
Rifampin, ethambutol, and aminoglycosides pene-
trate the blood – brain barrier in the presence of men-
ingeal inflammation but poorly in its absence. The
use of glucocorticoids in an attempt to reduce mor-
tality and morbidity has been controversial [50].
Recently, a large trial of dexamethasone adjunct
therapy for persons 14 years of age and older with
tuberculous meningitis has clarified the role of glu-
cocorticoids [51]. Dexamethasone treatment was
started as soon as possible after starting antituber-
culosis treatment. Patients were stratified by Glasgow
Coma Scale and given intravenous dexamethasone
for 4 weeks for severe disease and for 2 weeks for
mild disease. Subsequently, all patients were given
tapering doses of dexamethasone orally for an addi-
tional 4 weeks. Dexamethasone adjunctive treatment
improved survival. Adverse and severe adverse events
were reduced significantly in the dexamethasone-
279
therapy group. There was no demonstrable improve-
ment in the broader prespecified combined end points
of death or severe disability after 9 months [52].
There have been many reports of an increased risk
of tuberculosis in patients receiving tumor necrosis
factor- alpha (TNF-a) antagonists [53,54]. These
agents, which include infliximab, etanercept, and
adalimumab, are used for the treatment of an ex-
panding group of diseases and work by blocking
TNF-a; an inflammatory cytokine. TNF-a is ex-
pressed by activating macrophages, T cells, and other
immune cells and is an important part of the host
response against M. tuberculosis and other intra-
cellular organisms. Current expert opinion on this
emerging problem in tuberculosis treatment is that
the TNF-a antagonist should be discontinued if
tuberculosis develops during TNF-a antagonist ther-
apy. The optimal time for resuming TNF-a antagonist
therapy is undetermined. It is recommended that
TNF-a antagonist therapy be withheld at least until
treatment with the tuberculosis regimen has been
started, and the patient’s condition has improved [54].
Tuberculosis occurring in pregnancy is a danger to
the pregnant woman and her child, and treatment
should not be delayed because of the pregnancy. In-
fants born to women with untreated tuberculosis may
be of lower birth weight than those born to women
without tuberculosis and can acquire congenital
tuberculosis [55 – 57]. Of the first-line medications,
pyrazinamide is not recommended for general use in
pregnant women in the United States because of
insufficient data to determine safety. Aminoglyco-
sides should not be used to treat tuberculosis in preg-
nancy, because they are associated with birth defects
[6]. There is little information about the safety of
second-line antituberculosis drugs during pregnancy.
The recommended initial treatment regimen in preg-
nancy should consist of isoniazid, rifampin, and
ethambutol [6]. If the organism is confirmed to be
susceptible to isoniazid and rifampin, the ethambutol
may be discontinued and isoniazid and rifampin con-
tinued for a minimum of 9 months [6]. It is recom-
mended that pregnant women receiving isoniazid also
be given pyridoxine (25 mg/day) [6]. Breastfeeding
should not be discouraged for women being treated
with first-line agents, because the small concentra-
tions of these drugs in breast milk do not produce
toxic effects in the nursing infant [58].
Renal insufficiency increases the risk for devel-
oping tuberculosis, and treatment of the two con-
ditions concurrently is a complex and common
situation. Isoniazid and rifampin are metabolized in
the liver, and dosages need not be changed in persons
with chronic renal failure [59 – 61]. Metabolites of
280 sahbazian
pyrazinamide are excreted renally and can accumu-
late in patients with renal insufficiency [61]. Approxi-
mately 80% of ethambutol is cleared by the kidneys,
so ethambutol may accumulate in patients with renal
insufficiency [59,61]. Reducing the dosage may avoid
toxicity, but the peak serum concentrations achieved
may be too low to be effective. Therefore increasing
the dosing interval is recommended [60]. For patients
undergoing hemodialysis, administering all drugs for
tuberculosis after dialysis is a way to facilitate di-
rectly observed treatment and simultaneously to
avoid removal of drugs such as pyrazinamide [6].
To avoid toxicity, it is important to monitor serum
drug concentrations in persons with renal failure who
are taking aminoglycosides, cycloserine, or etham-
butol [60]. Data are unavailable for the effect of
peritoneal dialysis on the clearance of antitubercu-
losis drugs.
The challenges facing patients with tuberculosis
and underlying liver disease are great. Clinicians
must choose antituberculosis agents that, with a few
exceptions, are metabolized by the liver and can po-
tentially cause additional liver damage [62 – 64]. This
damage can be life threatening for a person with
marginal hepatic function [62 – 65]. Hepatic dysfunc-
tion can also alter absorption and distribution of
drugs that are metabolized or excreted by the liver
[65]. In the setting of severe liver disease, it is
reasonable to include fewer hepatotoxic medications
and to extend the period of treatment [6,65]. This
change can be accomplished using a single hepato-
toxic drug, generally rifampin, in combination with
ethambutol, a quinolone, and an aminoglycoside.
Isoniazid can be substituted for rifampin, if rifampin
cannot be given [6]. For these complicated patients,
expert opinion should be obtained [6].
Summary
Insights gained from studies done by the TBTC
have resulted in major changes in the recommenda-
tions for drug therapy of tuberculosis in HIV-infected
and noninfected individuals [1 – 5]. Although the
goals for the treatment of tuberculosis remain the
same, these advances require that tuberculosis drug
therapy now be more individualized. Treatment regi-
mens are based on a patient’s risk profile based on a
combination of hematologic, microbiologic, clinical,
and radiographic findings [6]. Although they are
more complicated than the previous guidelines, they
allow treatment to be refined so that it can be ex-
tended in patients at high risk for treatment failure
and allow shorter, more convenient treatment regi-
& weis
mens in patients who can be identified as being at
very low risk for failure [2].
Acknowledgments
The authors acknowledge Thaddeus Miller’s work
in editing this article.
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 Clin Chest Med 26 (2005) 313 – 326

Treatment of Latent Tuberculosis Infection: Challenges

and Prospects
Kelly E. Dooley, MD, MPHa, Timothy R. Sterling, MDb,*
a
Department of Medicine, Providence Portland Medical Center, 4805 NE Glissan Street, Portland, OR 97213, USA
b
Division of Infectious Diseases, Department of Medicine and Center for Health Services Research,
Vanderbilt University Medical Center, A4103 Medical Center North, 1161 21st Avenue South, Nashville, TN 37232, USA

It is estimated that one third of the global popu-
lation, or 2 billion people, are infected with Myco-
bacterium tuberculosis [1]. Among infected persons,
approximately 10% progress to the clinically im-
portant (and infectious) stage of active tuberculosis
over their lifetime [2,3]. The risk is higher in persons
with concomitant HIV infection (>20%), evidence of
old healed tuberculosis on chest radiograph (>20%),
or recent M. tuberculosis infection (10% to 20%) [4].
In most infected persons, the host immune response
contains the replication of M. tuberculosis and pre-
vents the development of disease [5]. Among infected
persons who develop active disease, progression
occurs either shortly after initial infection (progres-
sive primary disease) or subsequent to the initial
infection, when there is a breakdown in the host im-
mune response. A person is at greatest risk of pro-
gressing to active disease during the first 2 years
after infection with M. tuberculosis [2]. In addition
to HIV infection and recent M. tuberculosis infec-
tion, other risk factors for progression to active tu-
berculosis include silicosis, diabetes mellitus, chronic
renal failure, malnutrition, weight loss, leukemia, lym-
phoma, cancer of the head, neck, and lung, gastrec-
tomy, and jejunoileal bypass surgery [6].
Diagnosis of latent Mycobacterium tuberculosis
infection
As discussed elsewhere in this issue, the diagno-
sis of latent M. tuberculosis infection relies primarily
on the tuberculin skin test, an intradermal test that
utilizes purified protein derivative (PPD). Because
the mycobacterial proteins in PPD are not specific for
M. tuberculosis, persons infected with other myco-
bacteria (eg, environmental mycobacteria such as
M. avium intracellulare and M. bovis, the organism
in the tuberculosis vaccine bacille Calmette-Guerin)
may result in a false-positive test. Conversely, the
tuberculin skin test has low sensitivity, particularly
in immunocompromised persons. Because of these
limitations, the definition of a positive tuberculin
skin test varies according to the person’s risk of
tuberculosis infection and risk of progressing to
active disease if infected (Box 1) [6]. The different
criteria for a positive test increase its sensitivity in
high-risk persons and specificity in low-risk persons.
Indications for treatment of Mycobacterium
tuberculosis infection

All persons with evidence of latent M. tuber-

This work was supported by the National Institutes of
Allergy and Infectious Diseases K23 AI01654 (TRS).
* Corresponding author.
E-mail address: timothy.sterling@vanderbilt.edu
(T.R. Sterling).
culosis infection should be evaluated for the presence
of active disease. The evaluation should include an
assessment of the signs and symptoms of tuberculo-
sis and a chest radiograph; in persons with symptoms
or an abnormal chest radiograph, sputum for acid-

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.003 chestmed.theclinics.com
314 dooley
Box 1. Criteria for a positive tuberculin
skin test based on millimeters of
induration after intradermal placement of
five tuberculin units of purified protein
derivative (Mantoux technique)
5 mm induration
 HIV seropositive
 Recent contact with a culture-
confirmed tuberculosis case
 Fibrotic changes on chest
radiograph consistent with prior
tuberculosis
 Chronic immunosuppression (eg,
prednisone 15 mg/day for at
least 30 days)
10 mm induration
 Immigration from a high-
prevalence country within the last
5 years
 Injection drug use
 Residents and employees of high-
risk settings: prisons, jails, nursing
homes, and other long-term care
facilities, hospitals, residential
facilities for AIDS patients, home-
less shelters
 Mycobacteriology laboratory
personnel
 Persons at increased risk of devel-
oping active tuberculosis: those
with silicosis, diabetes mellitus,
chronic renal failure, leukemia, lym-
phoma, cancer of the head, neck or
lung, weight loss of more than
10% of ideal body weight, gas-
trectomy, jejunoileal bypass
 Children younger than 4 years old
15 mm induration
 Persons with no risk factors for
tuberculosis
From American Thoracic Society; Centers
for Disease Control and Prevention. Tar-
geted tuberculin testing and treatment
of latent tuberculosis infection. Am J
Respir Crit Care Med 2000;161(4):S234;
with permission.
& sterling
fast smear and culture should also be obtained.
Once active disease has been excluded, all persons
at increased risk of progressing to active tuberculo-
sis (see Box 1) should receive treatment for la-
tent infection.
Importance of treatment of Mycobacterium
tuberculosis infection to decrease the global
tuberculosis burden
Most cases of active tuberculosis arise from per-
sons with latent M. tuberculosis infection; treatment
of such persons is therefore necessary to achieve tu-
berculosis elimination. The focus should be on those
persons at high risk of progressing to active disease.
The strategy of targeted tuberculin skin testing among
high-risk groups and treatment of all such persons
with a positive tuberculin skin test is recommended
in the United States [6,7].
Infection with M. tuberculosis is often termed
latent because of the absence of clinical manifes-
tations, the slower replication rate of M. tuberculosis,
and the lower burden of organisms compared with
active disease [8]. Because of the relatively low
burden of organisms, treatment of latent infection
requires fewer drugs than active disease to facilitate
cure and prevent the development of drug resistance.
Use of a single antituberculosis agent is sufficient
for latent infection but not for active disease. As de-
tailed later, treatment of latent M. tuberculosis in-
fection dramatically decreases the risk of developing
active tuberculosis.
Regimens to treat Mycobacterium tuberculosis
infection
Each of the regimens available to treat latent
M. tuberculosis infection is reviewed here, with
emphasis on both the effectiveness and toxicity of
the regimens. The review is limited to studies con-
ducted in adults and published in the English peer-
reviewed literature; studies reported only in abstract
form are not included. The authors are unaware of
studies of the effectiveness of short-course therapy
conducted among children. Because the risk of
active tuberculosis is substantially higher in HIV-
seropositive persons than in HIV-seronegative per-
sons, and because the effectiveness of many regimens
has been assessed separately according to HIV sero-
status, the data are presented separately for HIV-
seropositive and HIV-seronegative persons. Toxicity
of therapy may also differ according to HIV sero-
Table 1
Randomized, controlled trials of isoniazid for the treatment of latent Mycobacterium tuberculosis infection among HIV-seronegative persons
Active TB Reduction
First author/date [reference] Randomization unit Population Follow-up Regimen n/N (%) (%)
United States Public Health Service trials
Mount, 1962 [67] Family Contacts of known active cases 4 years INH 5 mg/kg/d for 1 year 6/1463 (0.41) 54

treatment of latent tuberculosis infection

PPD+ and Placebo 12/1351 (0.89)
Ferebee, 1962 [17] Family Household contacts of new active TB 3 years INH 5 mg/kg/d for 1 year 29/12439 (0.23) 70
39 US communities, PPD+ and Placebo 97/12594 (0.77)
Ferebee, 1963 [68] Ward Mental institutions 5 years INH 5 mg/kg/d for 1 year 35/12884 (0.27) 62
PPD+ and Placebo 89/12326 (0.72)
Comstock, 1967 [69] Household Alaskan Eskimos in Bethel area 6 years INH 5 mg/kg/d for 1 year 58/3047 (1.9) 59
Most not PPD tested Placebo 141/3017 (4.67)
International trials
Chiba, 1963 [70] Household Osaka, Japan 2 years INH 5 mg/kg/d for 1 year 8/1142 (0.7) 30
Household contacts of new active TB 11/1096 (1.0)
Nyboe, 1963 [71] City blocks Suburb of Tunis City 1 year INH (very erratic pill taking) 18/7769 (0.23) 25
Placebo 25/8141 (0.31)
Egsmose, 1965 [72] Household Rural northern Kenya 4 years INH 5 – 10 mg/kg/d for 1 year (1.04) 35
PPD+ contacts of new active cases Placebo (1.6)
DelCastillo, 1965 [73] Household Philippines 2 years INH 8/97 (8.2) 41
Contacts of active cavitary TB Placebo 18/129 (14.0)
Horwitz, 1966 [74] Village Greenland villagers 6 years INH 400 mg 2 /wk for total 52 doses 238/4174 (5.7) 31
Placebo 323/3907 (8.3)
Veening, 1968 [75] Individual Royal Netherlands Navy 4 years INH 600 mg  4 mo, 400 mg  8 mo 2/133 (0.38) 96
New PPD+ after exposure to index case Placebo 12/128 (9.4)
IUAT, 1982 [9] Individual 7 European countries 5 years INH 300 mg/d for 12 weeks 76/6956 (1.1) 21
PPD+ patients with fibrotic lesions INH 300 mg/d for 24 weeks 34/6965 (0.49) 65
INH 300 mg/d for 52 weeks 24/6919 (0.35) 75
Placebo 97/6990 (1.4)
Abbreviations: INH, isoniazid; IUAT, International Union Against Tuberculosis; PPD, purified protein derivative; TB, tuberculosis.

315
316 dooley
status, so tolerability data are also presented accord-
ing to HIV serostatus. Recommended doses of
specific drugs have been published previously [6].
Isoniazid
Effectiveness
HIV-seronegative persons
Isoniazid is the best-studied regimen for the
treatment of latent M. tuberculosis infection. More
than 20 randomized, controlled trials have been con-
ducted, which together enrolled more than 100,000
persons. Most of these studies were conducted in the
1950s and 1960s and therefore enrolled only HIV-
seronegative persons. These trials are summarized
in Table 1.
Most of the studies assessed the effectiveness
of 12 months of isoniazid versus placebo. The trial
conducted by the International Union Against Tuber-
culosis (IUAT) assessed 3 versus 6 versus 12 months
of therapy and found that 6 months of isoniazid
was less effective (65%) than 12 months (75%) [9].
George Comstock [10] subsequently performed an
analysis of previously conducted clinical trials and
found that 6 months of isoniazid provided insuffi-
cient protection; 9 to 10 months of isoniazid seemed
to provide optimal protection. Based on these find-
ings, the American Thoracic Society (ATS), Centers
for Disease Control and Prevention (CDC), and In-
fectious Diseases Society of America (IDSA) guide-
lines recommend 9 months of isoniazid [6]. A
9-month regimen of isoniazid has never been com-
pared with a 6- or 12-month course of isoniazid in a
clinical trial, however.
HIV-seropositive persons
Isoniazid effectiveness has also been studied in
HIV-seropositive persons, although not as extensively
as in HIV-seronegative persons. The randomized,
controlled trials of treatment of latent M. tuberculo-
sis infection in HIV-infected persons are summarized
in Table 2, and the randomized, placebo-controlled
trials of isoniazid are summarized in Table 3. Among
tuberculin skin-test – positive persons, isoniazid is
clearly more effective than placebo in preventing tu-
berculosis; this finding has been confirmed in a meta-
analysis [11]. Isoniazid has been associated with
improved survival in some studies [12 – 14], but not
in all [11,15,16]. Although there has not been a
direct comparison of 6 versus 9 versus 12 months
of isoniazid, 6 months seems to be less effective
than 12 months. Based on the rationale used for
& sterling
HIV-seronegative persons, and to ensure uniformity
of recommendations, the ATS/CDC/IDSA guide-
lines recommend 9 months of isoniazid for HIV-
seropositive persons [6]. Although HIV-infected
persons are at increased risk of having a negative
tuberculin skin test, particularly with advanced im-
munosuppression, isoniazid is not substantially more
effective than placebo in preventing tuberculosis
in such persons, and therefore is not recommended
(Table 3) [11].
Toxicity
HIV-seronegative persons
In the initial studies of isoniazid, drug discon-
tinuation rates were low and did not differ from rates
among persons receiving placebo [17]. Subsequent
studies, however, have noted higher rates of drug
discontinuation, as summarized in Tables 4 and 5.
Few of these studies have been placebo-controlled.
Isoniazid can cause elevated hepatic transaminases
[18], but these liver function abnormalities are often
transient and are not representative of clinically
significant hepatitis. In studies in which serum trans-
aminases were monitored regularly regardless of
symptoms, 10% to 22% of participants had at least
one elevated transaminase level during the course
of therapy [19 – 25]. Rates of clinically significant
hepatitis are lower. In a surveillance study of the US
Public Health Service, 236 of 13,838 persons (1.7%)
who received isoniazid developed hepatitis. When
considering only those persons in whom the hepatitis
was probably or possibly related to isoniazid, the rate
was 174 in 13,838 (1.3%) [26]. Hepatitis risk
increased with age and concomitant alcohol con-
sumption. In another study, a 7-year survey from one
public health clinic, 11 of 11,141 patients (0.10%)
who started isoniazid developed hepatotoxicity [27].
Isoniazid-associated hepatotoxicity can be fatal,
and the risk of death increases with age. It is
estimated that the hepatotoxicity-associated case-
fatality rate per 10,000 persons initiating isoniazid
treatment is 0 for ages 20 to 34 years, 2 for ages 35 to
49 years, and 4 for ages 50 to 64 years [24,26,28,29].
Although never tested in a trial, rates of hepato-
toxicity may be lower when there is regular monitor-
ing of signs and symptoms of hepatitis [27,28]. In
the United States it is currently recommended that
patients receiving isoniazid undergo monthly clinical
assessments for adverse effects. They should also be
evaluated whenever symptoms develop. Patients
should be educated regarding the signs and symptoms
of hepatotoxicity and instructed to discontinue the
medicine and seek clinical evaluation if symptoms
Table 2
Randomized, controlled trials of treatment of latent Mycobacterium tuberculosis infection among HIV-seropositive persons
Mean
First author/date [reference] Trial type Population Regimens N follow-up Compliance/follow-up
INH versus placebo trials
Pape, 1993 [12] Randomized Haiti INH 300 mg/d for 12 months 118 33 months No loss to follow-up
Double-blind New HIV
Placebo-controlled diagnosis

treatment of latent tuberculosis infection

PPD+ or
Hawken, 1997 [76] Block-randomized Kenya INH 300 mg/d for 6 months 684 20 months 70% follow-up
Double-blind PPD+ or
Placebo-controlled
Gordin, 1997 [77] Randomized US, mostly NYC INH 300 mg/d for 6 months 517 33 months 63% completed therapy; 6% INH
Double-blind Anergic patients and 7% placebo lost to follow-up
Placebo-controlled
Fitzgerald, 2001 [78] Randomized Haiti INH 300 mg/d for 12 months 237 2.5 years 77% followed to death or
Blinding unclear PPD study end
Placebo-controlled
Multiregimen trials
Whalen, 1997 [15] Block-randomized Uganda PPD+: INH 300 mg/d for 6 months or 2018 15 months 75% urine tests and 80% – 89%
Double-blind (1) PPD+ INH 300 mg/d and RIF 600 mg/d for completed the trials
Placebo-controlled 3 months or INH 300 mg/d, RIF 600 mg/d,
and PZA 2000 mg/d for 3 months
(2) Anergic Anergic: INH 300 mg/d for 6 months 718
Mwinga, 1998 [41] Block-randomized Zambia INH 900 mg 2 /wk for 6 months or RIF 1053 1.8 years 81% placebo, 66% INH, and 75%
Double-blind 600 mg and PZA 3500 mg 2 /wk for RIF/PZA were >80% compliant
Placebo-controlled 3 months
Gordin, 2000 [36] Randomized US, Mexico, INH 300 mg/d for 12 months or RIF 600 mg 1583 37 months 80% RIF/PZA and 69% INH
Open-label Haiti, Brazil and PZA 20 mg/kg/d for 2 months completed therapy
No placebo arm PPD+
Halsey, 1998 [40] Randomized Haiti INH 600 – 800 mg 2 /wk for 6 months or 750 2.5 years 55% INH and 74% RIF/PZA had
Unmasked PPD+ RIF 450 – 600 mg and PZA 1500 – 2000 mg >80% compliance
Partly supervised 2 /wk for 2 months (weight-based)
No placebo arm
Abbreviations: INH, isoniazid; PPD, purified protein derivative; PZA, pyrazinamide; RIF, rifampin.

317
318 dooley & sterling

Table 3
Results of randomized, controlled trials of isoniazid for the treatment of latent Mycobacterium tuberculosis infection among
HIV-seropositive persons
Rx n/N Control n/N 95% Confidence
First author/date [reference] (%) INH (%) placebo RR interval Reduction (%)
PPD positive
Pape, 1993 [12] 2/38 (5.2) 6/25 (24.0) 0.22 0.05, 1.00 78
Hawken, 1997 [76] 5/67 (7.5) 8/69 (11.6) 0.64 0.22, 1.87 36
Whalen, 1997 [15] 7/536 (1.3) 21/464 (4.5) 0.29 0.12, 0.67 71
PPD+ cohort
Mwinga, 1998 [41] 6/101 (5.9) 11/60 (18.3) 0.32 0.13, 0.83 68
PPD negative
Gordin, 1997 [77] 4/260 (1.5) 6/257 (2.3) 0.66 0.19, 2.31 34
Fitzgerald, 2001 [78] 6/126 (4.8) 4/111 (3.6) 1.32 0.38, 4.56 32
Hawken, 1997 [76] 11/235 (4.7) 8/224 (3.6) 1.31 0.54, 3.20 31
Pape, 1993 [12] 2/20 (10.0) 5/35 (14.3) 0.70 0.15, 3.28 30
Whalen, 1997 [15] 9/395 (2.3) 10/323 (3.1) 0.74 0.30, 1.79 26
anergic cohort
Mwinga, 1998 [41] 27/351 (7.7) 17/166 (10.2) 0.75 0.42, 1.34 25
Results are presented according to the tuberculin skin test status of study patients.
Abbreviations: INH, isoniazid; PPD, purified protein derivative; RR, relative risk.

occur. Routine laboratory monitoring is recommended Hepatitis C virus and isoniazid-associated

for persons with abnormal baseline liver function hepatotoxicity
tests, persons at increased risk of hepatotoxicity Hepatitis C virus (HCV) infection has been as-
(eg, HIV infection, liver disease, alcoholism, preg- sociated with an increased risk of hepatotoxicity
nancy), and persons who develop symptoms while among persons receiving combination antitubercu-
on therapy. [6] losis therapy for active disease, particularly HIV-
Isoniazid can also cause peripheral neuropathy, infected persons [32]. HCV infection is common in
but the risk is lower with concomitant use of vitamin injection drug users [33], who are also at high risk of
B6 (pyridoxine) [30,31]. progressing to active tuberculosis if latently infected
with M. tuberculosis. Two studies have assessed the
HIV-seropositive persons risk of isoniazid-associated hepatotoxicity in per-
The rates of isoniazid-associated toxicity requir- sons with underlying HCV. In a study of 146 injec-
ing drug discontinuation in HIV-seropositive per- tion drug users with M. tuberculosis infection and
sons are summarized in Table 5. Although the data normal baseline hepatic transaminases, 138 were
are not as extensive as in HIV-seronegative per- HCV seropositive; 32 (22%) developed hepatic trans-
sons, isoniazid is generally well tolerated in this pa- aminases levels more than three times the upper
tient population. limit of normal, and 11 (8%) required drug discon-
tinuation [34]. These rates are comparable to those
Table 4 reported in populations with lower HCV seropreva-
Toxicity of isoniazid for treatment of latent Mycobacterium lence (see preceding discussion and Table 5). In a
tuberculosis infection in HIV-seronegative patients second study of 415 drug users, of the 214 that
Toxicity requiring discontinuation were HCV-antibody – positive, 16 (7.5%) developed
First author/date of therapy hepatotoxicity (defined as drug discontinuation in
[reference] INH n/N (%) Placebo n/N (%) the setting of hepatic transaminase elevation more
than five times the upper limit of normal in the
Scharer, 1969 [18] 2/90 (2.2) No placebo arm
Byrd, 1972 [22] 16/160 (10) No placebo arm presence of symptoms or as transaminase elevation
Bailey, 1973 [79] 18/427 (7.3) No placebo arm alone on two occasions at least 1 week apart) [35].
Byrd, 1977 [80] 10/120 (8.3) 1/60 (1.7) On multivariate analysis, HCV infection was not
Byrd, 1979 [24] 64/1000 (6.4) No placebo arm independently associated with hepatotoxicity. Both
Stuart, 1999 [25] 26/83 (31.3) No placebo arm studies suggest that isoniazid is safe in persons with
Toxicity is defined as adverse events resulting in discon- HCV infection and is not associated with signifi-
tinuation of therapy. cantly higher rates of hepatotoxicity than in persons
Abbreviation: INH, isoniazid. without HCV.
 treatment of latent tuberculosis infection 319

Table 5
Toxicity of isoniazid for treatment of latent Mycobacterium tuberculosis infection in HIV-seropositive patients
Toxicity requiring discontinuation of therapy 95% Confidence
First author/date [reference] INH n/N (%) Placebo n/N (%) RR interval
Pape, 1993 [12] 0/58(0) 0/60 (0) 0
Gordin, 1997 [77] 24/260 (9.2) 24/257 (9.3) 0.99 0.58, 1.69
Hawken, 1997 [76] 11/342 (3.2) 5/342 (1.5) 2.2 0.77, 6.26
Whalen, 1997 [15] PPD+ 3/536 (0.6) 1/464 (0.2) 2.60 0.27, 24.88
Anergic 0/395 0/323 0
Mwinga, 1998 [41] 26/703 (3.7) 3/350 (0.9) 4.31 1.32, 14.16
Toxicity is defined as adverse events resulting in discontinuation of therapy.
Abbreviations: INH, isoniazid; PPD, purified protein derivative; RR, relative risk.

Although the efficacy of isoniazid in preventing HIV-seropositive persons

tuberculosis exceeds 90% among persons who adhere
to therapy [9], the effectiveness of isoniazid is lower
because of low rates of adherence to the long duration
of therapy. This problem of adherence has led to the
assessment of regimens that require a shorter course
of treatment. These regimens are summarized here.
Rifampin plus pyrazinamide for 2 months
Effectiveness
The effectiveness of the 2-month rifampin plus
pyrazinamide regimen has been studied entirely in
HIV-seropositive persons. Because the risk of tuber-
culosis without treatment of latent infection is sub-
stantially higher in HIV-seropositive persons than in
HIV-seronegative persons, much smaller sample sizes
were required to study effectiveness in the former.
The results of the studies are summarized in Table 6.
In the largest of the studies, the effectiveness of daily
rifampin plus pyrazinamide for 2 months was nearly
identical to 12 months of daily isoniazid [36].

Among available short-course regimens for the Toxicity

treatment of latent M. tuberculosis infection, the
regimen with the shortest duration, and therefore
the greatest potential for improved adherence, is the
2-month regimen of rifampin plus pyrazinamide.
HIV-seronegative persons
Effectiveness of rifampin plus pyrazinamide has
not been studied in HIV-seronegative persons.
Because of high rates of hepatotoxicity in tolera-
bility studies (see later discussion), it is unlikely
that effectiveness will ever be studied in HIV-
seronegative persons.
HIV-seronegative persons
After the effectiveness and tolerability of
2 months of rifampin plus pyrazinamide were dem-
onstrated in HIV-seropositive adults, the regimen was
recommended in the United States for both HIV-
seropositive and -seronegative adults [6]. Shortly
thereafter, however, there were reports of severe
hepatotoxicity and death among persons treated with
this regimen [37,38]. When such cases continued to
be reported, the CDC began collecting retrospective
surveillance data on the number of persons treated

Table 6
Randomized, controlled trials of the effectiveness of pyrazinamide plus rifampin for the treatment of latent Mycobacterium
tuberculosis infection in HIV-seropositive persons
Control n/N 95% Confidence
First author/date [reference] Rx n/N (%) RIF/PZA (%) INH RR interval Reduction (%)
PPD positive
Gordin, 2000 [36] 28/791 (3.5) 29/792 (3.7) 0.97 0.58, 1.61 3
Halsey, 1998 [40] 19/380 (5.0) 14/370 (3.8) 1.32 0.67, 2.56 32
Mwinga, 1998 [41] 2/49 (4.1) 4/52 (7.7) 0.53 0.10, 2.77 47
PPD negative
Mwinga, 1998 [41] 13/173 (7.5) 14/178 (7.9) 0.96 0.46, 1.96 4
Results are presented according to the tuberculin skin test status of study patients.
Abbreviations: INH, isoniazid; PPD, purified protein derivative; PZA, pyrazinamide; RIF, rifampin; RR, relative risk.
320 dooley & sterling

Table 7
Toxicity of rifampin plus pyrazinamide for treatment of latent Mycobacterium tuberculosis infection in HIV-seronegative patients
Toxicity requiring discontinuation Hepatotoxicity requiring discontinuation
of therapy of therapy
First author/date [reference] RIF/PZA n/N (%) INH n/N (%) RR RIF/PZA n/N (%) INH n/N (%) RR
a
Bock, 2001 [58] 13/168 (7.7) No INH arm 1/168 (0.6) No INH arm
a
Chaisson, 2002 [81] 12/589 (2.0) No INH arm 10/589 (1.7) No INH arm
Jasmer, 2002 [60] 28/307 (9.1) 8/282 (2.8) 3.21 12/207 (5.8) 2/204 (1.0) 5.91
a
Lee, 2002 [82] 26/148 (17.6) No INH arm 11/148(7.4) No INH arm
a
McNeill, 2003 [83] 14/110 (12.7) 5/114 (4.4) 2.90
a
Stout, 2003 [84] 8/114 (7.0) No INH arm 6/114 (5.3) No INH arm
Van Hest, 2004 [85] 14/166 (8.4) 17/528 (3.2) 2.62 14/166 (8.4) 18/528 (3.4) 2.47
Toxicity is defined as adverse events resulting in discontinuation of therapy.
Abbreviations: INH, isoniazid; PZA, pyrazinamide; RIF, rifampin; RR, relative risk.
a
In these studies, the patient population was predominantly HIV-seronegative, with a small minority of HIV-
seropositive patients.

with this regimen so that the risk of toxicity could
be determined [39]. Data were collected for persons
initiating therapy between January 2000 and June
2002 and reported to CDC by June 6, 2003. Of the
7737 persons reported to have started rifampin plus
pyrazinamide treatment during the survey period, 204
persons developed aspartate aminotransferase con-
centrations more than five times the upper limit of
normal (2.6/100 treatment initiations), and an addi-
tional 146 patients discontinued therapy because of
symptoms of hepatitis (1.9/100 treatment initiations).
There were 48 cases of severe hepatotoxicity (de-
fined as resulting in hospitalization or death); 11 pa-
tients died. The estimated rate of death caused by
hepatotoxicity was 0.9 per 1000 treatment initiations
[39]. The estimates were limited because data were
obtained retrospectively, and the risk associated with
isoniazid was not determined concurrently. Nonethe-
less, the risk of severe hepatotoxicity and death
seemed to be approximately 10 times greater than
the risk associated with isoniazid, and it was there-
fore recommended that rifampin plus pyrazinamide
should generally not be offered for treatment of
latent tuberculosis infection [39]. The toxicity data
from clinical trials are summarized in Table 7.
HIV-seropositive persons
The regimen was very well tolerated in all of the
clinical trials conducted among HIV-seropositive
persons (Table 8) [36,40,41], even upon repeat analy-
sis specifically addressing hepatotoxicity [42]. Be-
cause of the relatively small sample sizes of the
studies, and an event rate of severe hepatotoxicity of
approximately 1 per 1000, it is possible that such
serious events were not detected in these studies. The
CDC therefore recommends that rifampin plus
pyrazinamide should generally not be offered, regard-
less of HIV serostatus [39].
Isoniazid plus rifampin for 3 months
Effectiveness
There are few studies of isoniazid plus rifampin
for the treatment of latent M. tuberculosis infection.
In the only study among HIV-seronegative adults,
the efficacy among adherent patients of 3 months of
isoniazid plus rifampin was 41% [43]. Among HIV-
seropositive adults, the regimen was 59% effective in

Table 8
Toxicity of rifampin plus pyrazinamide for treatment of latent Mycobacterium tuberculosis infection in HIV-seropositive patients
Toxicity leading to discontinuation of therapy 95% Confidence
First author/date [reference] RIF/PZA n/N (%) INH n/N (%) RR interval
Halsey, 1998 [40] 0/380 (0) 0/370 (0)
Mwinga, 1998 [41] 14/351 (4.0) 12/352 (3.4) 1.17 0.55, 2.50
Gordin, 2000 [36,42] 75/791 (9.5) 48/792 (6.1) 1.56 1.09, 2.22
Narita, 2003 [86] 5/135 (3.7) 0/25 (0)
Toxicity is defined as adverse events resulting in discontinuation of therapy.
Abbreviations: INH, isoniazid; PZA, pyrazinamide; RIF, rifampin; RR, relative risk.
 treatment of latent tuberculosis infection
preventing tuberculosis [15]. Extensive programmatic
experience with the regimen among children in Great
Britain suggests its effectiveness, but there are no
clinical trial data [44]. In the United States, this
regimen is not among the recommended treatment
regimens, perhaps because of the limited available
data [6].
Toxicity
The regimen has been well tolerated, although
relatively few studies have been conducted to date.
In the study among HIV-seronegative adults, 8 of
167 persons (5%) discontinued therapy because of
adverse drug reaction [43]; the rate among HIV-
seropositive adults was 13 of 556 (2.3%) [15]. In a
pooled analysis of 6105 persons who received iso-
niazid plus rifampin, 156 (2.5%) developed hepati-
tis [45].
Rifampin for 4 months
Effectiveness
Among persons who are intolerant of isoniazid,
or among close contacts of tuberculosis cases in
which the isolate of M. tuberculosis is resistant to
isoniazid, rifampin can be used to treat latent
M. tuberculosis infection. There are, however, only
limited data from randomized clinical trials and
uncontrolled observational studies regarding the
effectiveness and tolerability of the regimen. Given
the importance of rifampin in the treatment of ac-
tive tuberculosis, it is particularly important to
exclude active disease before treating for latent
M. tuberculosis infection, because treatment of un-
diagnosed active tuberculosis with rifampin mono-
therapy will lead to rifampin resistance.
HIV-seronegative persons
The only randomized trial to evaluate the effec-
tiveness of rifampin was conducted in Hong Kong
among persons with latent M. tuberculosis infection
and silicosis. Among all persons initiating therapy,
20 of 165 (12.1%) randomly assigned to receive
rifampin for 3 months developed tuberculosis, com-
pared with 36 of 159 persons (22.6%) who received
placebo, for an effectiveness of 46% [43]. Among
persons who completed the 5-year study, rates were
17 of 103 (17%) and 34 of 99 (34%), respectively, for
321
an effectiveness of 50% [43]. In an observational
study among homeless persons with documented
tuberculin skin-test conversion during an epidemic of
tuberculosis resistant to isoniazid and streptomycin,
49 persons received rifampin. The average duration
of therapy was 6.4 months. None of the 49 persons
developed tuberculosis, compared with 6 of 71 per-
sons (8.6%) who received no therapy [46]. In a
study of 157 tuberculin skin-test – positive adolescent
close contacts of persons with isoniazid-resistant
tuberculosis, all were treated with a 6-month course
of rifampin; none developed tuberculosis during the
2-year evaluation period [47]. Although the effective-
ness of 4 months of rifampin has never been studied,
it is the currently recommended duration in the ATS/
CDC/IDSA guidelines [6].
HIV-seropositive persons
There are no studies of the effectiveness of
rifampin for the treatment of latent M. tuberculosis
infection among HIV-seropositive persons. Because
of the lack of studies, and because active disease is
more difficult to exclude in persons with HIV, one
should use rifampin in this patient population with
much caution, if at all.
Toxicity
HIV-seronegative persons
Although data on the tolerability of rifampin are
limited, it seems to be well tolerated. In the ran-
domized trial conducted in Hong Kong, 6 of 172 pa-
tients (3.5%) discontinued therapy during the study
because of adverse drug reaction. None of these
patients developed hepatotoxicity [43]. In the study
among homeless persons in Boston, 7 of 49 persons
(14%) developed adverse effects requiring discon-
tinuation of therapy, but there were no reports of
hepatotoxicity [46]. Of the 157 adolescents who
received rifampin, 18 (11.5%) interrupted therapy
temporarily, and 2 (1.3%) permanently discontinued
therapy [47]. In a recent study of persons randomly
assigned to receive either 4 months of rifampin or
9 months of isoniazid, 2 of 58 persons (3%) re-
ceiving rifampin developed adverse events requiring
permanent drug discontinuation; none developed
hepatitis [48].
HIV-seropositive persons
There are no data on the safety of this regimen in
HIV-seropositive persons.
322 dooley
Special situations
Pregnant/breastfeeding women
Pregnancy does not increase the risk of progres-
sion from latent infection to active disease. Because
of the morbidity associated with tuberculosis in the
pregnant mother and neonate, treatment of latent
M. tuberculosis infection is recommended for preg-
nant women at high risk of progression to active
disease (ie, those with recent M. tuberculosis
infection or with coinfection with M. tuberculosis
and HIV) [6]. Given the proven effectiveness of
isoniazid and its safety in pregnancy, it is the pre-
ferred regimen. Because of the low levels of iso-
niazid in breast milk, its use is not contraindicated
in breastfeeding women.
Children
The only treatment regimen that has been exten-
sively studied in children is isoniazid. Isoniazid may
be more effective in children than in adults, with a
reported effectiveness of 70% to 90% [49,50]. Be-
cause the effectiveness of short-course regimens
has not been studied in children, such regimens are
not recommended by the ATS/CDC/IDSA [6].
Contacts of persons with drug-resistant tuberculosis
If persons are infected with a strain of M. tu-
berculosis that is resistant to rifampin but suscep-
tible to isoniazid, isoniazid is effective for treatment.
For persons exposed to a case of tuberculosis resis-
tant to isoniazid, treatment with rifampin is recom-
mended, as discussed previously [6]. The optimal
treatment is unknown for persons with evidence of
latent M. tuberculosis infection who have been ex-
posed to multidrug-resistant tuberculosis (MDR-TB),
defined as resistance to at least isoniazid plus ri-
fampin. No clinical studies have assessed the effec-
tiveness of specific regimens, and such studies will
probably never be conducted because of the diffi-
culty in enrolling a sufficient sample size. Recom-
mended regimens include a fluoroquinolone plus
pyrazinamide or ethambutol plus pyrazinamide [51].
The optimal duration of these regimens is unknown,
although 6 to 12 months is recommended. They
often are poorly tolerated [52].
Tumor necrosis factor-alpha antagonists
Drugs that block the inflammatory cytokine tu-
mor necrosis factor-alpha (TNF-a), such as inflixi-
& sterling
mab, etanercept, and adalimumab, are used to treat
autoimmune diseases such as rheumatoid arthritis and
Crohn’s disease. Use of these drugs increases the risk
of progressing from latent M. tuberculosis infection
to active disease in persons with either remote or
recent M. tuberculosis infection [53 – 55]. Before
initiating the use of a TNF-a antagonist, patients
should be evaluated for latent M. tuberculosis in-
fection and, if symptomatic, for active tuberculosis. In
immunocompromised persons, induration of 5 mm
or greater is considered a positive tuberculin skin test
(see Box 1). Treatment of latent infection may be
considered in persons with an induration of less than
5 mm if epidemiologic and clinical circumstances
suggest recent M. tuberculosis infection [54,55].
Treatment for latent M. tuberculosis infection should
be initiated (and preferably completed) before start-
ing treatment with the TNF-a antagonist [55].
Difficulties and challenges of treatment of latent
Mycobacterium tuberculosis infection
Low rates of treatment initiation
Not all persons who are eligible for treatment
of latent tuberculosis infection initiate therapy. In a
study of close contacts of smear-positive pulmonary
tuberculosis cases, 95 HIV-infected persons were
eligible for treatment of latent infection; of these,
only 30 (32%) initiated therapy [56]. In another study
of close contacts of tuberculosis cases, of the
630 persons with newly documented positive tuber-
culin skin tests (all of whom were eligible for ther-
apy), treatment was recommended in 447 (71%),
and was started in only 398 (63%) [57]. Efforts must
be made to improve the use of treatment of latent
infection, particularly in those at highest risk of pro-
gression to active disease, such as HIV-infected
persons and close contacts.
Low treatment-completion rates
Among persons who start therapy, treatment-
completion rates are low. In the second study of
close contacts mentioned previously, 203 of 398 per-
sons starting therapy (51%) completed it; 203 of
630 of those eligible for therapy (32%) completed it
[57]. In a study of isoniazid treatment of latent in-
fection in an inner-city population, 84 of 409 persons
eligible for therapy (21%) completed it [58]. Low
treatment-completion rates can result in continued
transmission of M. tuberculosis and additional cases
[59]. The low completion rates may result from a lack
 treatment of latent tuberculosis infection
of understanding on the part of the patient of the
importance of treatment, the absence of symptoms
related to tuberculosis, the toxicity of the regimen,
and the prolonged duration of therapy. Even if
toxicity is relatively mild and infrequent, patients
may be less likely to tolerate adverse effects because
they do not have symptomatic tuberculosis disease.
Shorter treatment duration may improve completion
rates [36,40], but this result has not been noted
uniformly [60]. Education of the patient regarding the
importance of such therapy is extremely important.
Direct observation of treatment of latent infection can
improve adherence [61,62] but is often not feasible
for tuberculosis treatment programs because of its
high cost.
Monitoring for toxicity
As discussed previously, the potentially severe
toxicity associated with the treatment of latent
M. tuberculosis infection necessitates monitoring,
particularly in persons at increased risk for toxic-
ity. Routine monitoring for symptoms of toxicity is
recommended. Monitoring of laboratory tests (eg, he-
patic transaminases) to prevent toxicity, or at least
identify toxicity in its early stages, is a reasonable
approach in persons at high risk for toxicity, although
the utility of such a strategy (and the optimal
monitoring strategy) has never been assessed in a
clinical trial.
Logistical difficulties in implementing treatment of
latent tuberculosis infection
Treatment of latent M. tuberculosis infection has
been a cornerstone of efforts to control tuberculosis
in the United States for the past several decades. This
approach has been possible because of the relatively
low number of tuberculosis cases and available pub-
lic health resources in the United States. In areas of
the world where tuberculosis case rates are substan-
tially higher and resources are more limited, treat-
ment of latent M. tuberculosis infection is limited;
the focus in these countries is to identify and treat
cases of active tuberculosis.
Prospects for improvements in the treatment of
latent Mycobacterium tuberculosis infection
There is clearly a need for safe and effective short-
course treatment of latent M. tuberculosis infection.
Studies are underway to assess the tolerability and
effectiveness of once-weekly isoniazid plus rifapen-
323
tine for 3 months. A study assessing the tolerability
of this regimen has recently completed enrollment in
Brazil, and data analysis is underway. A compari-
son of isoniazid plus rifapentine versus the standard
regimen of daily isoniazid is underway in South
Africa and in a multinational study being conducted
by the Tuberculosis Trials Consortium of the CDC
(US Public Health Service Study 26). If effective
and well-tolerated, isoniazid plus rifapentine would
provide a relatively simple short-course regimen for
the treatment of latent tuberculosis infection, which
could improve treatment completion rates.
Data from the mouse model of tuberculosis, which
has correlated closely with human tuberculosis
[63,64], have demonstrated that moxifloxacin, a
newer fluoroquinolone, has excellent activity against
M. tuberculosis. This drug may allow shorter and
more effective treatment of active tuberculosis [65,66]
and may be effective for the treatment of latent tuber-
culosis infection. Additional studies are warranted.
The Tuberculosis Epidemiologic Studies Consor-
tium of the CDC has launched a large study of the
treatment of latent tuberculosis infection in the United
States (Task Order 13), including an assessment of
the regimens used and the factors associated with
acceptance of, adherence to, and tolerability of cur-
rent treatment regimens. A better understanding of
these factors will allow the development of in-
terventions to improve the treatment of latent
M. tuberculosis infection in the United States and
throughout the world.
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 Clin Chest Med 26 (2005) 295 – 312

Tuberculosis in Children
Kristina Feja, MD, MPH, Lisa Saiman, MD, MPH*
Department of Pediatrics, College of Physicians and Surgeons, Columbia University, 622 West 168th Street,
PH4West, New York, NY 10032, USA

Tuberculosis (TB) accounts for significant mor-
bidity and mortality in children and adolescents
worldwide, with the majority of cases of latent TB in-
fection (LTBI) and disease occurring in developing
countries. Pediatric TB, or childhood TB, defined
by the World Health Organization (WHO) and Cen-
ters for Disease Control and Prevention (CDC) as TB
in children less than 15 years of age, presents health
care providers with unique challenges. In contrast to
adults and older adolescents, the clinical manifesta-
tions of TB disease in children are usually related to
primary tuberculosis. Diagnostic and therapeutic chal-
lenges arise because children have less specific signs
and symptoms of disease, have fewer positive myco-
bacterial cultures, are at increased risk for progres-
sion of disease once infected, and are at an increased
risk of disseminated disease.
Pediatric TB is considered a sentinel event
reflecting recent transmission from an undiagnosed
infectious source case in the community. Performing
contact investigations in adults with infectious TB to
detect other cases of TB or LTBI is an important
means of diagnosing or preventing TB in children.
Public health efforts vary according to country and
available resources. Developed countries focus on
identification and treatment of LTBI as well as active
disease. Children who have LTBI represent the res-
ervoir for future disease. In resource-poor countries,
identification and treatment of TB disease, using the
strategy of directly observed therapy (DOT), if avail-
able, are the primary public health efforts. This article
* Corresponding author.
E-mail address: LS5@columbia.edu (L. Saiman).
examines aspects of TB epidemiology, pathogenesis,
clinical presentations, diagnosis, treatment, and pub-
lic health issues unique to children.
Epidemiology of childhood tuberculosis
The knowledge of the global epidemiology of TB
in children is somewhat limited. In 1990, approxi-
mately 7,500,000 TB cases occurred worldwide, of
which 650,000 occurred in children [1]. In 2002, the
WHO estimated that 8,800,000 TB cases occurred
worldwide, based on data from 209 countries with an
estimated mean case rate of 145 per 100,000 popu-
lation (range, 2 – 1067 cases) [2]. Although estimates,
these numbers can be particularly useful when assess-
ing the effectiveness of TB control programs.
Currently, the WHO reports only acid-fast bacillus
(AFB) smear – positive cases stratified by age. There-
fore, age-specific estimates of all cases (smear-
negative and smear-positive) are unavailable. Data
from the WHO reflecting 2002 regional notification
rates of smear-positive cases among children ranged
from 0 per 100,000 persons in Europe to 6 per
100,000 in Africa and 43 and 45 per 100,000 in
South Africa and Zambia, respectively [2]. Reporting
only AFB smear – positive cases potentially has a
huge impact on accurate estimates of pediatric cases,
because young children have lower organism burdens
than adults and adolescents, and they are less likely
to be AFB smear – positive. Approximately 95% of
children less than 12 years of age are AFB smear –
negative [3]. Other challenges in accurately estimating
the burden of TB in children include the difficulties
establishing a definitive diagnosis, the increased

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.02.010 chestmed.theclinics.com
296
prevalence of extrapulmonary disease, the lack of a
standard clinical case definition, and the generally
lower public health priority given to childhood TB
compared with adult TB in many countries [3].
Nelson and Wells [3] reviewed recent epidemio-
logic studies and surveillance data describing trends
in the global burden of TB in children. Childhood TB
accounted for only 2% to 7% of TB cases in
developed countries, compared with 15% to 40% of
cases in developing countries. This difference may be
explained partially by an older population structure in
developed countries. Case rates in children seem to
be increasing in Africa, countries of the former Soviet
Union, and some countries in Europe, the Middle
East, and South America such as Sweden, England,
Wales, Greenland, Austria, Denmark, Israel, and
Brazil. Possible reasons for this trend include
increasing immigration of children or families born
in countries with high case rates of TB, worsening
economic conditions, rising HIV infection rates, and a
weakening public health infrastructure [3,4]. Con-
versely, Turkey and Peru have experienced a decline
in case rates among children. In Peru, the decline in
case rates has been attributed to the institution of an
aggressive DOT short-course program. Nelson and
Wells [3,4], however, cited several limitations of
these epidemiologic data which included possible
reporting bias because countries with smaller TB
burdens may be less likely to report cases and some
studies included only hospitalized patients. Compar-
ing rates across countries may not be feasible because
of variations in case definition, case finding, and
contact investigation protocols.
The epidemiology of TB in the United States has
undergone substantial changes during the past 20
years. After decades of decline, the United States
20
15
10
0
1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003
<15 15-24
Age Group (years)
Fig. 1. Tuberculosis case rates (per 100,000) by age group in the United States from 1993 to 2003. (From Centers for Disease
Control and Prevention. 2003 Surveillance slide sets. Available at: http://www.cdc.gov/nchstp/tb/pubs/slidesets/surv/surv2003/
default.htm. Accessed March 14, 2005.)
feja & saiman
experienced an increase in TB case rates in the late
1980s and early 1990s with case rates of pediatric TB
increasing from 2.4 cases per 100,000 persons (1261
cases) in 1985 to 3.1 cases per 100,000 (1708 cases)
in 1992 [5]. The cause of this resurgence was
multifactorial. Contributing factors included the
HIV epidemic, the dismantling of national TB control
programs, the increased immigration of persons from
countries with a high prevalence of TB, and, perhaps,
improved reporting [6]. Happily, since 1993, there
has been a steady decline of TB in the United States.
Nelson et al [7] recently reviewed the epidemiology
of 11,480 cases of childhood TB reported in the
United States between 1993 and 2001 and reported
that the number of childhood TB cases declined by
44%, from 1663 cases in 1993 to 931 cases in 2001,
with a respective 48% decline in incidence rates from
2.9 to 1.5 cases per 100,000 persons (Fig. 1). This
decline, however, is less pronounced than that seen in
adults (Fig. 1). Seventy percent of all cases of
pediatric TB occurred in eight states: California,
Texas, New York, Illinois, Georgia, Florida, New Jer-
sey, and Pennsylvania, and most cases presented in
urban areas with populations greater than 2,500,000.
In the United States, a disproportionate burden of
cases is seen among younger children, racial and
ethnic minorities, and those who are foreign-born
(Figs. 2, 3). In 2001, case rates per 100,000 persons
were 2.8, 1.0, and 0.9 in children less than 5 years of
age, 5 to 9 years of age, and 10 to 14 years of age,
respectively. From 1993 to 2001, 74% of pediatric
TB cases occurred in Hispanic and non-Hispanic
blacks and approximately 30% occurred in foreign-
born children [7]. Approximately two thirds of
foreign-born children with pediatric TB were born
in the following countries: Mexico (39.8%), the Phil-
25-44 45-64 65+
 tuberculosis in children 297

800

Pediatric TB Cases
700
600
500
400
300
200
100
0
90

91

92

94

96

97

99

01
93

95

98

00

02
19

19

19

19

19

19

19

20
19

19

19

20

20
Year
White, non-Hispanic Black, non-Hispanic
Hispanic American Indian/Alaskan Native
Asian/Pacific Islander

Fig. 2. Pediatric tuberculosis cases by race and ethnicity from 1990 to 2002. (From Centers for Disease Control and Prevention.)

ippines (8.9%), Vietnam (5.7%), Somalia (4.4%),
Russia and the former countries of the Soviet Union
(3.5%), and Haiti (3.3%). Approximately 60% of
foreign-born cases were reported from three states:
California (38.5%; n = 1070), New York (11.4%;
n = 317), and Texas (8.9%; n = 247) [7].
Risk factors for latent tuberculosis infection and
progression to tuberculosis disease
Several recent studies have assessed the risk
factors for LTBI among children in the United States.
Risk factors varied somewhat from study to study but
generally included close contact with a TB case, birth
in a country with high prevalence of TB, travel to or a
household visitor from a high-prevalence country, a
family member with LTBI, contact with a high-risk
adult (eg, an adult who is infected with HIV/AIDS,
homeless, incarcerated, or a user of illicit drug) and
age greater than 11 years of age [8 – 11].
Approximately one third of the world’s population
is infected with Mycobacterium tuberculosis. Most
infected persons do not progress to disease. In the
absence of treatment for LTBI, 5% to 10% of
immunologically normal adults develop TB disease
during their lifetimes, and half of the risk occurs in
the first 2 to 3 years after infection [12]. Infected
children have a comparatively higher risk of pro-
gression to active disease: 43% of infants less than
1 year of age, 24% of children 1 to 5 years old, and
15% of those 11 to 15 years old develop TB disease if
not treated for LTBI [6]. Factors that increase the risk
of progression from infection to disease usually affect

1400
Pediatric TB Cases

1200
1000
800
600
400
200
0
90

91

92

93

94

95

96

97

98

99

00

01

02
19

19

19

19

19

19

19

19

19

19

20

20

20

Year
Foreign-born U.S.-born

Fig. 3. Pediatric tuberculosis cases by birth country from 1990 to 2002. (From Centers for Disease Control and Prevention.)
298 feja
the immune system and include immunosuppressive
therapy, HIV coinfection, malnutrition, medical con-
ditions (eg, renal and liver failure, diabetes mellitus,
or cancer), TB infection within the past 2 years, age
of 4 years or younger, or intercurrent viral infections
such as measles [6,12,13].
Pathogenesis
The pathogenesis of pediatric TB is largely similar
to that described for adults and older adolescents, but
subtle differences in pathogenesis can lead to differ-
ences in clinical presentations. As in adults, more
than 98% of infections in children occur when
M. tuberculosis bacilli enter the lungs through
aerosolized droplets expelled when an infectious
adult coughs, sneezes, or sings [6]. Other less
common portals of entry include the gastrointestinal
tract, the skin, mucous membranes, and conjunctiva.
When inhalation is the route of infection, the
organisms multiply in alveolar macrophages, thus
creating a small area of inflammatory reaction known
as the primary focus [14]. Early in infection, tubercle
bacilli may also spread to the regional lymph nodes
or disseminate through the bloodstream. The pri-
mary focus, regional lymph nodes, and adjoining
lymphatics are collectively known as the primary
tuberculous complex. The pathology of the primary
complex is the same, regardless of the site of
infection. Cellular immunity develops, usually 2 to
12 weeks after infection, and manifests as delayed
hypersensitivity to tuberculin, that is, a positive
tuberculin skin test (TST). At this time, the primary
focus becomes encapsulated, and perifocal inflamma-
tion increases and manifests as a granuloma, which
may be visible on chest radiograph. Radiographic
evidence of perifocal infiltration is most common in
younger children [13]. In most cases, cellular immu-
nity controls the spread of infection. The pathologic
events associated with this process include caseous
necrosis, fibrosis, and healing of the primary complex
components with or without calcification. The extent
of calcification depends on the relative degree of
necrosis and caseation [13] and occurs sooner after
infection in infants. Although this sequence of events
occurs in LTBI [14], the resolution of infection may
not be complete, and viable M. tuberculosis may
persist for many years, potentially reactivating and
causing TB disease months to years later.
Primary tuberculosis, defined as disease progres-
sion of any part of the primary complex, is most
common in younger children. Disease from a primary
pulmonary source may extend to the adjacent lung
& saiman
or disseminate further. Progression within the lung,
pulmonary primary disease, is the most common
manifestation of primary TB and presents as enlarge-
ment of the affected regional lymph nodes. The
primary focus may be smaller and may not be
visualized radiographically. Lymphadenopathy may
lead to further spread of disease by partial or com-
plete bronchial obstruction, by erosion of the bron-
chial wall resulting in endobronchitis, or by external
compression of the bronchus resulting in segmental
lesions caused by localized hyperinflation and atel-
ectasis of the adjacent lung tissue.
Local progression in the lung may also occur from
the primary focus, particularly if the majority of
bacilli remain within this component of the primary
complex. In young children, the primary focus
generally continues to grow even after the develop-
ment of cellular immunity and may caseate centrally,
liquefy, and empty into the bronchi resulting in
further spread [13]. This phenomenon is known as
progressive pulmonary primary tuberculosis.
Progression of disease beyond the lungs occurs
more frequently in younger children [13]. Younger
children are more likely to have involvement of distal
lymph nodes such as the mediastinal nodes, which
may also compress or invade bronchi, blood vessels,
or lymphatics. Occasionally disease progression oc-
curs by local spread to the pleural space, mediasti-
num, esophagus, or pericardium. Progression to these
sites most often occurs through the bloodstream,
however. Mycobacteria disseminated by the blood-
stream can cause extrapulmonary disease (eg, super-
ficial lymphadenopathy generally of the cervical
nodes, miliary TB, meningitis, or osteoarticular
TB). Meningitis develops when caseating lesions on
the cerebral cortex invade the meninges and dissemi-
nate into the subarachnoid space. Tuberculomas, a
less frequent manifestation of central nervous system
disease, form when caseous foci within the brain
enlarge and become encapsulated. Miliary TB occurs
when large numbers of bacilli disseminate through
the bloodstream and cause simultaneous disease in
two or more organs [13].
The pathogenesis of different forms of childhood
TB may be viewed as a continuum in which host
factors play an important role in controlling the extent
of disease. Immunologic control of TB infection is a
function of macrophages and dendritic cells, man-
ifested by a Th1-type T-cell immunity characterized
by strong CD8-positive cell response with production
of interferon gamma by CD4-positive cells. Children
have a relative deficiency of macrophage and
dendritic cell function, however, and, in contrast with
adults, tend to develop Th2-type T-cell responses to
 tuberculosis in children
mycobacterial infection characterized by lack of
CD8-positive cell response and interleukin (IL)-4
and IL-5 production by CD4-positive cells. Addi-
tional research is needed to determine the exact role
of each immune factor in the pathogenesis of TB
disease in children. Such knowledge might facilitate
the development of a more effective vaccine [15].
Clinical and radiographic manifestations of latent
tuberculosis infection and tuberculosis in children
Latent tuberculosis infection
In both adults and children, LTBI is defined as
infection with M. tuberculosis as evidenced by a
positive TST and lack of clinical or radiographic
signs or symptoms of TB disease. Radiographs are
usually normal but may show evidence of healed
primary complex in the form of dense nodules (with
or without calcifications), calcified nonenlarged
regional lymph nodes, or pleural thickening [16,17].
CT scans are generally not indicated in children with
LTBI unless a chest radiograph is equivocal. Lateral
views are particularly useful in detecting hilar
adenopathy, and both frontal and lateral views should
be obtained to assess children for pediatric TB
[18,19].
Tuberculous disease
The clinical presentation of TB disease depends
on the site of infection, bacillary load, patient age,
and host immunity. TB in children often presents
with nonspecific symptoms and may be indolent.
Fig. 4. Bilateral hilar adenopathy in a 16-month-old known
contact of an infectious TB case (posterior-anterior view).
299
Fig. 5. Hilar adenopathy in a 16-month-old known contact
of an infectious TB case (lateral view).
The diagnosis may be delayed as alternative disease
entities are considered. Thus, the diagnosis of TB
requires a high index of suspicion. Children, espe-
cially young children, tend to develop primary dis-
ease or extrapulmonary TB as early complications of
initial infection, whereas these entities are less com-
mon in adults and older adolescents [13]. United
States data from 1993 to 2001 describing 11,480 child-
hood TB cases demonstrated that 76.9% of cases
were pulmonary, 15.5% lymphatic, 2.1% meningeal,
1.1% miliary TB, 1.1% pleural, and 1.4% osteo-
articular [7].
Pulmonary tuberculosis
The most common presenting symptoms of
pulmonary primary TB are cough, fever, wheezing,
decreased appetite, and fatigue [13,20]. Weight loss
and night sweats are far less common than in adults.
Children with pulmonary primary TB may be
asymptomatic despite abnormal radiographic find-
ings; infants are more likely than older children to be
symptomatic [21]. Physical findings may be rela-
tively mild compared with the extent of radiographic
findings and may include rales, wheezing, or de-
creased breath sounds, but respiratory distress is
infrequent [20]. Pediatric patients with TB are usually
not infectious; they lack cavities with a large number
of bacilli, and the relatively weak cough of young
children is not conducive to the airborne transmission
of organisms.
Radiographic manifestations of pulmonary pri-
mary TB include intrathoracic lymphadenopathy
of the hilar, mediastinal, and subcarinal nodes and
parenchymal changes (Figs. 4, 5) [21]. In some
300 feja
Fig. 6. Segmental atelectasis of the right upper lobe with
hyperinflation of right middle and lower lobe caused by ball-
valve effect in an 8-month-old girl demonstrating partial
obstruction of the bronchus intermedius by hilar adenopathy
(anteroposterior view).
patient populations, isolated hilar adenopathy has
increased in frequency during the past 2 decades,
possibly because of more efficient contact investiga-
tions of infectious TB cases and subsequent detection
of disease in children at an earlier stage of illness
[22]. The most common parenchymal findings in-
clude segmental hyperinflation and atelectasis caused
by bronchial obstruction (Fig. 6), alveolar consoli-
dation, interstitial densities, and, occasionally, bron-
chiectasis (Fig. 7) [21].
Fig. 7. CT scan demonstrating partial right lower lobe
consolidation with extensive postobstructive bronchiectasis
in a 13-year-old boy.
& saiman
Fig. 8. CT scan demonstrating bilateral upper lobe cavities
and infiltrates in a 14-year-old girl.
Progressive pulmonary primary TB presents with
weight loss or failure to gain weight, anorexia,
fatigue, low-grade fevers, and intermittent cough.
Rales may persist for days to weeks after the onset of
initial symptoms [13]. Advanced disease may result
in the development of a cavity or endobronchial
spread [13].
Chronic pulmonary TB or adult-type reactivation
disease is seen most commonly in adolescents whose
primary infection occurred after 7 years of age [13].
Like adults, such patients present with fever, weight
loss, a productive cough, hemoptysis, and night
sweats. Radiographic findings include cavitary le-
sions, typically in the upper lobes (Fig. 8). An atlas of
radiographic images of intrathoracic TB disease in
children is available at www.iuatld.org/pdf/iuatld_
atlas.pdf. Recent United States data indicated that,
when compared with younger children, children 10 to
14 years of age had significantly higher rates of
cavitary disease (11.8% versus 3.5%; P< 0.001),
AFB smear – positive sputum (10.3% versus 1.7%;
P< 0.001), and culture-positive sputum (21.3% ver-
sus 4.2 – 5.0%; P< 0.001) [7].
Extrapulmonary tuberculosis
Extrapulmonary TB occurs in 9% to 23% of
pediatric TB cases [7,20,23]. Superficial lymphade-
nitis is the most common site of extrapulmonary TB
followed by pleural, meningeal, osteoarticular, and
miliary TB in varying frequency depending on the
patient population. Superficial lymphadenitis is
responsible for 44% to 67% of cases of extrapulmo-
nary disease [7,20,23], is more common in children
(15.5%) than adults (6.8%) [7], usually affects the
 tuberculosis in children
Fig. 9. CT scan demonstrating right sided cervical lymph-
adenopathy with central necrosis and right jugular vein
thrombosis in a 2-year-old with HIV/AIDS.
anterior cervical and submandibular nodes, and may
be caused by M. bovis (Fig. 9). Superficial lymph-
adenitis usually presents within 6 months of infection
[13] in children with a median age of 31 to 36 months
[20,23]. Firm, nontender or minimally tender en-
larged lymph nodes without generalized symptoms
are the most common presentation [13,23]. As
evidence of the relatively indolent presentation of
this entity, among 48 children diagnosed with super-
ficial TB lymphadenitis, symptoms occurred a
median of 35 days before hospitalization, and 47 of
the 48 had lymph node enlargement as the only
symptom [23]. Concurrent chest radiographic find-
ings were noted in 23 of the 48 patients, however, and
included enlarged hilar lymph nodes (n = 21) and
calcified nodules (n = 2) [23]. In a smaller study,
only 2 of 11 children with cervical TB lymphadeni-
tis had concurrent chest radiograph abnormalities
[20]. In advanced disease, matting of the nodes, ad-
herence to the overlying skin with dark discoloration
of the skin, and subsequent drainage of caseous mate-
rial occur [13]. Cosmetic deformities may result if ade-
quate treatment is not administered.
In the United States, tuberculous pleural effusions
are found in 1.1% to 3.6% of children with active
disease [7,20], accounting for 5% of cases of
extrapulmonary disease [7]. Merino et al [24] found
pleural effusions in 39 of 175 children (22%) less
than 18 years of age with pulmonary TB [24]. Most
cases occur 3 months after primary infection [25] in
older children (mean age, 13.5 years) [24]. The most
common clinical manifestations include fever,
fatigue, respiratory distress, and chest pain. Dimin-
ished breath sounds and dullness to percussion are the
most common physical findings. Radiographic find-
301
ings include unilateral pleural effusion in most cases
and associated parenchymal findings in approxi-
mately half of patients [24]. Prognosis is excellent,
although residual pleural thickening occurs [24].
Miliary and meningeal TB develop after hema-
togenous dissemination of M. tuberculosis, usually
within 3 to 6 months of initial infection [13,25].
Frequently these two entities present together, espe-
cially in children less than 5 years of age [7,26].
Tuberculous meningitis is the most severe complica-
tion of TB disease and in the United States accounts
for 2.1% of pediatric cases and 9.1% of extrapulmo-
nary TB cases [7]. Studies of childhood TB menin-
gitis cite a median age of 17 to 23 months of age in
the United States [20,27] and 30 to 48 months of age
among children presenting in other countries [23,26].
As with other forms of TB, the clinical presentation is
usually indolent, with symptoms present 1 to 4 weeks
before diagnosis [27]. The most common presenting
symptoms are high-grade fever, vomiting, lethargy,
headache, and seizures. Seizures are especially com-
mon in children less than 2 years of age [13,27].
Physical findings include nuchal rigidity, cranial
nerve findings caused by exudates on the cerebral
base leading to obstructive hydrocephalus, and
hemiparesis caused by vascular occlusion. The
clinical course is divided into stages that have both
therapeutic and prognostic significance: stage I
(nonspecific symptoms such as fever, irritability,
headache, sleepiness, or malaise with no focal
neurologic findings), stage II (nonspecific symptoms
with neurologic findings), and stage III (marked
decrease in mental status with neurologic findings)
[13]. Evidence of hydrocephalus detected by CT of
the brain is usually present, whereas parenchymal
disease, such as tuberculoma, is evident only in 20%
to 37% of cases (Fig. 10). In addition, 40% to 86% of
chest radiographs are abnormal [20,26,27]. Risk
factors for poor outcome are associated with stage III
disease at the time of admission, patient age of 3 years
or less, miliary disease, or delay in initiation of treat-
ment [28]. Infants have more rapid disease progres-
sion and poorer outcome than older children [13,23].
Before effective antituberculosis drugs were avail-
able, the mortality rate among children with TB
meningitis was 100%. With effective therapy, the
mortality rate has decreased to less than 10% [26,27].
TB meningitis still causes significant long-term
morbidity such as mental retardation, seizure dis-
orders, and hemiparesis. In a study of 30 children
conducted during the 1980s, 70% were reported to
have major neurologic sequelae [27].
Miliary TB accounts for 1.1% and 4.7% of all
pediatric cases and extrapulmonary cases, respec-
302 feja
Fig. 10. MRI scan demonstrating ring-enhancing lesions
in cerebellum bilaterally in a 13-year-old girl (T1-weighted
coronal postcontrast views).
tively [7]. Miliary TB is similar to TB meningitis in
its pathogenesis, time of onset after infection, in-
dolent presentation, severity, and disproportionate
effect on infants and young children. The median
age of presentation is 6 to 11 months [23,29]. Miliary
TB may occasionally present acutely, but, in most
cases, weeks of fever, cough, weight loss, anorexia,
and malaise are present before diagnosis. Hepato-
splenomegaly and generalized lymphadenopathy
develop in 50% to 70% of cases. Bilateral diffuse
micronodular pulmonary consolidations develop in
90% of cases manifest as respiratory distress, diffuse
rales, or wheezing [29,30]. During the 1980s, the case
fatality rate for miliary TB was 14% among 94 chil-
dren in South Africa [29].
Osteoarticular TB accounts for 1.4% of all cases
of pediatric TB and 5.9% of cases of extrapulmonary
TB in children compared with 2.2% of total cases
in adults [7]. The onset of disease usually occurs 6
to 18 months after primary infection [13]. The me-
dian age of onset was 6 years of age in a case series
of 102 children conducted from 1982 to 1998 [23].
The vertebrae, followed by knee, hip, and elbow, are
the bones most commonly affected. Presenting signs
and symptoms may include localized inflammation,
pain, swelling, fever, and decreased movement and
limited range of motion of the affected bone or
joint [23,30,31]. Radiographic evidence of spondy-
litis, arthritis, and osteomyelitis may occur, and
chest radiograph abnormalities are noted in 50% of
cases [32].
Additional presentations, such as tuberculosis of
the gastrointestinal tract, eyes, genitourinary tract,
& saiman
pericardium, skin, or middle ear, rarely occur in chil-
dren and account for less than 2% of all pediatric TB
cases in the United States [7].
Tuberculosis in newborns
Several unique manifestations of TB disease may
present in neonates either because of intrauterine in-
fection causing congenital disease or postnatal trans-
mission of M. tuberculosis from a mother or other
caregiver with active tuberculosis.
Maternal tuberculosis and impact on infants
The proportion of pregnant women who have
active TB seems to be increasing [33], but there is
no evidence that pregnancy is a risk factor for
progression from LTBI to active disease. Although
the clinical presentations of TB in pregnant women
are similar to those noted in nonpregnant adults,
nonspecific signs such as fatigue and malaise may be
attributed to pregnancy and thus cause a delay in
diagnosis in this population. Increased obstetric
morbidity and neonatal mortality were associated
with delayed treatment [34]. In a case-control study,
infants born to women with pulmonary TB were
significantly more likely to be of low birth weight
(< 2500 g), small for gestation, or premature and had
increased rates of perinatal mortality when compared
with infants born to women without TB of similar
age, parity, and socioeconomic status [35]. Adverse
outcomes were increased with late maternal diag-
nosis, incomplete or irregular treatment, or advanced
pulmonary lesions. Furthermore, pregnant women
with nonlymphatic extrapulmonary TB had higher
rates of antenatal hospitalization, and their infants had
Apgar scores of 6 or lower and low birth weight.
Pregnant women with TB lymphadenitis and their
infants had outcomes similar to those in a healthy
control group [36].
Congenital tuberculosis is a rare entity, with ap-
proximately 300 cases reported in the literature [37].
Infection of the fetus may occur by hematogenous
dissemination through the placenta (50% of cases) or
by aspiration or ingestion of infected amniotic fluid.
The former leads to primary complex formation in
the liver or lungs, whereas the latter leads to primary
disease in the lungs or gastrointestinal tract [37].
Previously, surgery or autopsy was used to diagnose
the site of the primary complex and thereby identify
the mode of transmission. Today, CT findings and the
time course of the development of lesions may be
used to distinguish the modes of transmission [38]. In
1994, Cantwell et al [37] proposed revised criteria for
congenital TB. These criteria include proven tuber-
 tuberculosis in children
culous lesions in the infant, exclusion of postnatal
transmission by thorough contact investigation of
close contacts including health care workers, and one
of the following:
Lesions in the first week of life
Primary complex in the liver or caseating he-
patic granulomas
TB infection of the maternal genital tract or placenta
Congenital TB most often presents in the second
to third week of life and may mimic other congenital
infections such as syphilis, cytomegalovirus, or neo-
natal sepsis. Hepatosplenomegaly, respiratory distress,
fever, lymphadenopathy, and abdominal distention
are the most common signs and symptoms [37]. Most
infants have abnormal chest radiographs, usually
showing a miliary pattern, hilar and mediastinal
lymphadenopathy, or parenchymal infiltrates [33,
37,38], and, less commonly, multiple rim-enhancing
pulmonary nodules with central hypodense areas
[38]. In many cases, infants require mechanical
ventilation. Delayed diagnosis and onset of treatment
contribute to the approximately 40% mortality [37].
Perinatal TB is acquired from postnatal trans-
mission from the mother, adult caregiver, health care
worker, or other infectious source and presents later
than congenital TB. Clinical manifestations may be
similar to those noted in congenital TB. Of 38 South
African infants (including 7 cases of congenital TB)
who were less than 3 months of age when diagnosed
with TB, 87% had cough, 82% had tachypnea, 66%
had hepatomegaly, and 53% had splenomegaly [39].
Other common findings are pneumonia, fever, and
lymphadenopathy [40].
Diagnosis of pediatric latent tuberculosis infection
and tuberculosis
The diagnosis of TB infection or disease rests on
the basic components of history (eg, previous TB or
contact with infectious case, signs, and symptoms),
TST results including the precise millimeters of
induration, chest or other radiographic findings, and
mycobacteriology smear and culture results. LTBI is
relatively simple to diagnose in children. Criteria for
diagnosis are
A positive TST as interpreted based on stratifica-
tion of risk factors (Box 1)
Normal chest radiograph or radiographic signs of
primary complex with granulomas or calcifi-
303
cations in the lung parenchyma, nonenlarged
regional lymph node, or both
The lack of the previously described clinical signs
or symptoms of disease
In recent years, a paradigm shift to targeted
tuberculin skin testing has taken place in the United
States. This concept suggests that children should be
screened for known risk factors for TB, elicited on a
risk factor questionnaire. Only children with one or
more risk factors should be skin tested, thereby
increasing the sensitivity and specificity of the TST
(Box 2).
Current recommendations for screening, diag-
nosis, and treatment of LTBI in children are found
in a consensus document prepared by the Pediatric
Tuberculosis Collaborative Group entitled Targeted
Tuberculin Skin Testing and Treatment of Latent
Tuberculosis Infection in Children and Adoles-
cent [19].
Case definitions for tuberculosis disease
Although AFB smears and culture remain the
cornerstones of diagnosing TB among adults, chil-
dren are often diagnosed clinically based on a
positive TST, clinical and radiographic findings
suggestive of TB, or a history of contact with an
adult with TB [21,41]. Both the WHO and the CDC
employ laboratory-confirmed or clinician-diagnosed
case definitions. In the United States, the laboratory
case definition consists of (1) isolation of M. tuber-
culosis complex (ie, M. tuberculosis, M. bovis, and
M. africanum) from a clinical specimen; (2) demon-
stration of M. tuberculosis from a clinical specimen
using nucleic acid amplification (NAA) test; or
(3) demonstration of AFB from a clinical specimen
when culture is unavailable. In the absence of
laboratory confirmation, the clinical case definition
is fulfilled by all of the following criteria [42]:
1. Positive TST
2. Signs or symptoms of TB disease, such as
abnormal, unstable chest radiograph or clini-
cal evidence of current disease (eg, fever, night
sweats, cough, weight loss, hemoptysis)
3. Treatment with two or more anti-TB drugs
4. A completed diagnostic evaluation
A case will also be reported and counted by the
CDC if the these criteria are not met but a provider
diagnosis is given by a state or local health depart-
ment following a thorough review of the patient’s
medical record. For example, in New York City, the
304 feja
Box 1. Definitions of positive tuberculin skin
test results in children using three cut-off
levels
Induration 5 mm
Children in close contact with known
or suspected contagious cases of
tuberculosis disease
Children suspected to have tuberculosis
disease because of
 Findings on chest radiograph
consistent with active or
previously active tuberculosis
 Clinical evidence of
tuberculosis disease
Children receiving immunosuppressive
therapy or with immunosuppressive
conditions, including HIV infection
Induration 10 mm
Children at increased risk of
disseminated disease:
 Those younger than 4 years of age
 Those with other medical conditions,
including Hodgkin’s disease, lym-
phoma, diabetes mellitus, chronic renal
failure, or malnutrition
Children with increased exposure to tu-
berculosis disease:
 Those born, or whose parents were
born, in high-prevalence regions of
the world
 Those frequently exposed to adults
who are HIV-infected, homeless,
users of illicit drugs, residents of
nursing homes, incarcerated or
institutionalized, or migrant farm
workers
 Those who travel to high-prevalence
regions of the world
Induration 15 mm
Children 4 years of age or older without
any risk factors
From American Academy of Pediatrics. Tu-
berculosis. In: Red book: 2003 report of
the committee on infectious diseases. 25th
edition. Elk Grove (IL): Pickering LK; 2003.
p. 642 – 60; with permission.
& saiman
Box 2. Risk assessment questionnaire
All Risk Assessment Questionnaires should ask
the following questions (adolescents can be asked
these questions directly):
1. Was your child born outside the United
States? If yes, this question would be
followed by where was your child born?
If the child was born in Africa, Asia, Latin
America, or Eastern Europe, a tuberculin
skin test should be placed.
2. Has your child traveled outside the United
States? If yes, this question would be
followed by where did the child travel,
with whom did the child stay, and how
long did the child travel. If the child
stayed with friends or family members in
Africa, Asia, Latin America, or Eastern Eu-
rope, for 1 week or longer, cumulatively,
a tuberculin skin test should be placed.
3. Has your child been exposed to anyone
with TB disease? If yes, this question
should be followed by questions to deter-
mine if the person had TB disease or LTBI,
when the exposure occurred, and the
nature of the contact. If the child’s
exposure to someone with suspected or
known TB disease is confirmed, a tuber-
culin skin test should be placed, and the
local health department should be notified
per local reporting guidelines.
4. Does your child have a close contact with
a person who has a positive TB skin test?
If yes, see question 3 follow-up
questions.
Risk Assessment Questionnaires can in-
clude the following based on local epidemiology
and priorities:
1. Does your child spend time with anyone
who has been in jail (or prison), a shelter,
who uses illegal drugs, or who has HIV?
2. Has your child drunk raw milk or eaten
unpasteurized cheese?
3. Does your child have a household member
who was born outside the United States?
4. Does your child have a household member
who has traveled outside the United
States?
From Pediatric Tuberculosis Collaborative
Group. Targeted tuberculin skin testing and
treatment of latent tuberculosis infection in
children and adolescents. Pediatrics 2004;
114(4):1175 – 201; with permission.
 tuberculosis in children 305

provider diagnosis is fulfilled if the patient is being Tuberculin skin testing

treated with two or more anti-TB drugs determined to
be medically justified by the TB Control Surveillance
Unit [43]. In the past decade, only 23.6% of pediatric
cases fulfilled the laboratory case definition, com-
pared with 84.3% of adult cases; 52.6% of pediatric
cases fulfilled the clinical case definition; and 23.0%
were given a provider diagnosis [7]. From 1985 to
1994, 41 states and the District of Columbia reported
provider-diagnosed cases, but not all reporting areas
used the same provider-diagnosis case definition [5].
For example, some states included additional criteria
such as anergy in HIV-infected persons, an epide-
miologic link to a known TB case, or clinical im-
provement on therapy without radiographic follow-up
[5]. These different surveillance definitions can
obviously affect case rates. The accuracy of surveil-
lance data for pediatric TB may be further compro-
mised by incomplete reporting; in a study conducted
in New York City from 1993 to 1995, 20% of cases
identified by an alternative surveillance method,
which included gastric aspirate reports, hospital dis-
charge codes, and physician interviews, were not re-
ported to the health department [43].
A reactive TST, an important component of the
CDC’s clinical case definition, is interpreted as
positive according to the individual patient’s risk
factors (see Box 1). Overall, children with reported
TB disease are more likely to have positive reactions
(89%) than adults (54%) [7]. Approximately 20% of
children with culture-proven TB may have negative
TSTs at diagnosis, however, and about 5% may have
persistently negative TSTs [44]. TST positivity also
depends on the site of disease; for example, only
57.6% of miliary and 54.6% of meningeal cases had
positive TSTs, compared with 90.6% of pulmonary
cases [7]. In contrast, TST results in congenital TB
are always negative but may become positive in 1 to
3 months [33].
Certain factors such as infections, live viral
vaccines, certain medical conditions, drugs, technical
factors, and interpretation bias are associated with
both false-negative and false-positive TST reactions
(Table 1) [19]. Anergy testing with control skin-test
antigens is not routinely recommended by the CDC
[45] and has several limitations. These limitations

Table 1
Factors associated with false-negative or false-positive tuberculin skin test reactions
False-negative reactions False-positive reactions
Infections
Viral illnesses (HIV, measles, varicella) Exposure to nontuberculous mycobacteria
Bacterial (typhoid fever, brucellosis, typhus, leprosy) (eg, M. marinum, M. kansasii)
Early TB infection (< 12 wk)
TB disease (meningitis, miliary, pleural)
Fungal (Blastomycosis)
Live-virus vaccines
Measles Bacille Calmette-Guerin vaccine
Polio
Smallpox
Concomitant medical conditions
Metabolic abnormalities (chronic renal failure) Transfusion with whole blood from donors with
Malignancies (Hodgkin’s disease, lymphoma, leukemia) known positive tuberculin skin test
Sarcoidosis
Poor nutrition
Drugs and technical factors
Corticosteroids, chemotherapy Inexperienced or biased reader
Newborns and children <2 y
Material: poor quality, inadequate dose (1 tuberculin unit),
improper storage (exposure to heat/light), expired
Administration: not injected intradermally, too long in syringe
Reading: inexperienced or biased reader, recording error,
read too early/late
Interpretative
Decreasing mm of induration Increasing mm of induration
From Pediatric Tuberculosis Collaborative Group. Targeted tuberculin skin testing and treatment of latent tuberculosis infection
in children and adolescents. Pediatrics 2004;114(4):1186; with permission.
306 feja
include the lack of standardization of antigens and
poor reproducibility of the delayed-type hypersensi-
tivity reaction [46], lack of association of anergy with
a high risk of progression to TB disease, and no
demonstrable benefit of treatment with empiric iso-
niazid in anergic HIV-infected individuals to prevent
TB disease [47].
Effect of bacille Calmette-Guerin vaccination on
tuberculin skin test results
Bacille Calmette-Guerin (BCG) vaccination is
used in most countries with a high incidence of TB
to prevent the severe forms of TB in young children.
According to the WHO, 161 member states have
BCG vaccination on their immunization schedule,
and global BCG vaccination coverage in 2002 among
infants less than 1 year of age was 81% [48]. Thus, it
is important to understand the potential effects of
BCG vaccine on TST results in previously immu-
nized children who immigrate to developed countries
and undergo targeted tuberculin skin testing. Factors
such as age at BCG immunization (less effect if
vaccinated at birth), time since immunization (less
effect if immunization occurred years before TST),
exposure to nontuberculous mycobacteria (increased
exposure may cause false positive TSTs), prevalence
of LTBI (higher prevalence increases the positive
predictive value of reactive TSTs), and type of
vaccine used (larger number of viable bacilli causes
larger effect) may influence TST results [19].
Children immunized with BCG at birth who were
studied 12 years later and found to have a TST
induration of 10 mm or more had a five- to 48-fold
increased risk of developing TB disease within
4 years [49]. Thus, positive TST reactions in BCG-
vaccinated children from countries with high case
rates of TB are likely be caused by LTBI, not im-
munization. It is recommended that a history of BCG
immunization be ignored when planting, reading, and
interpreting a TST [20].
Smear for acid-fast bacilli and mycobacterial culture
Smear and culture techniques in children are
similar to those in adults, but the types of specimens
and their yield differs. Younger children with
pulmonary TB rarely produce sputum and have a
relatively low organism burden. Thus, first morning
gastric aspirates have traditionally been the best
clinical specimens to obtain in young children with
suspected pulmonary TB. These aspirates may be
positive for M. tuberculosis in 30% to 50% of all
cases [21,50] and in as many as 75% of infants [51].
& saiman
Standardization of gastric aspiration techniques is
critical and has been shown to increase the proportion
of positive cultures [50]. Hospitalization may not be
necessary to obtain gastric aspirate specimens from
children with suspected TB (providing hospitalization
is otherwise not clinically indicated). There was no
significant difference in the yield of outpatient
(37%) and inpatient (48%) gastric aspirates among
80 children [52]. In the United States, the relative
yield of gastric aspirates is not reportable, but recent
epidemiologic studies indicate that only 2.4% and
8.5% of all pediatric cases had smear-positive and
culture-positive gastric aspirates, respectively [7].
To circumvent the low yield of positive cultures
from expectorated sputum and gastric aspirates, Zar
et al [53] successfully performed sputum induction in
142 of 149 children (median age, 9 months; 70%
HIV-infected) in South Africa. After a 2- to 3-hour
fast, pretreatment with inhaled salbutamol was
followed by nebulized 5% sterile saline and chest
physiotherapy. Sputum was then obtained by suction-
ing (90% of children) or expectoration (10% of
children). Induced sputum cultures grew M. tuber-
culosis more frequently (11%; 15 of 142 children)
than gastric aspirates (6%; 9 of 142 children).
Bronchoscopy does not aid significantly in the
diagnosis of pediatric TB; only 4% to 12% of
bronchoalveolar lavage (BAL) cultures were positive
among children with suspected or presumed pulmo-
nary TB [54 – 56]. Furthermore, in the two studies
examining a total of 70 children, the overall yield of
BAL specimens was lower than that of gastric
aspirates (10% – 12% versus 32% – 50%), and 83%
to 100% of children with positive BAL specimens
also had positive gastric aspirates [55,56]. Bronchos-
copy in children may be useful to accurately diagnose
endobronchial disease, however [57]. Cultures from
children with extrapulmonary TB grow M. tuber-
culosis from the affected site in about 50% of cases
[20]. A summary of diagnostic procedures and
findings is found in Table 2. More recent diagnos-
tic techniques include polymerase chain reaction,
NAA, serology tests, and immunoassays based on
detection of cellular responses to specific M. tuber-
culosis antigens.
Treatment of latent tuberculosis infection and
tuberculosis disease
Children with LTBI and TB are treated with the
drugs used for adults, although regimens, side-effect
profiles, and availability of antituberculous drugs in
pediatric doses may differ. Further, recommendations
 tuberculosis in children 307

Table 2
Diagnostic methods for obtaining specimen to assess tubercular disease in children
Site Evaluation Findings
Pulmonary Induced sputum May be AFB smear – negative but culture positive
Gastric aspirates Role of rapid amplification tests is limited, not FDA
Bronchoscopy approved for AFB-smear negative specimens
Central nervous system Lumbar puncture Lymphocytosis, low glucose, high protein
Cerebrospinal fluid Smear usually negative
Culture may be positive
Rapid amplification tests are not FDA approved
Pleural, pericardial, peritoneal Fluid samplea Lymphocytosis, low glucose, high protein
Smear usually negative
Culture may be positive
Adenosine deaminase may be elevated
Adenitis Biopsy Caseous granulomas with AFB on pathology
Culture may be positive
Osteoarticular Joint aspirationa Smear and culture of sediment or biopsy
Bone or synovial biopsy Culture may be positive
Renal Urine sample Smears usually negative
Multiple samples
Abbreviations: AFB, acid-fast bacilli; FDA, Food and Drug Administration.
a
Greater volume and centrifugation increase yield.

for pediatric regimens and doses from national and gression to disease and disseminated disease. All
international organizations (eg, the British Thoracic infants and children with LTBI and no history
Society, American Thoracic Society, WHO) may of previous treatment for TB should be treated
differ. Nevertheless, the backbone of all recom- with isoniazid for 9 months. When the source
mended regimens for LTBI is isoniazid unless the case has isoniazid-resistant, rifampin-susceptible
child has been exposed to an isoniazid-resistant M. tuberculosis, rifampin is recommended for at least
source case. Although the recommended regimens 6 months [17].
for TB vary somewhat, they generally include two to In young children, especially those less than
four of the following first-line drugs: isoniazid, 4 years of age, with close exposure to an infectious
rifampin, pyrazinamide, and ethambutol. Generally, source case, window prophylaxis is recommended
antituberculosis drugs are well tolerated by children in efforts to initiate preventive therapy early and
and are better tolerated than by adults. potentially prevent progression to active disease [17].
The success of pediatric treatment regimens If the contact investigation demonstrates that a young
depends on using correct doses (Table 3) and com- child’s initial TST shows no induration, and chest
pleting a full course of therapy. Adherence to radiography is normal, treatment with isoniazid (or
treatment is facilitated by the use of child-friendly rifampin, if the source case is known to have an
(eg, good tasting, small volumes) drug formulations isoniazid-resistant, rifampin-susceptible organism) is
and DOT. Treatment should be started promptly recommended to prevent progression to active dis-
in young children when infection or disease is diag- ease. A follow-up TST is performed 12 weeks after
nosed, because they are at increased risk for pro- the last exposure to the infectious source case; if the
induration is less than 5 mm, preventive therapy is
discontinued. If the TST induration is 5 mm or greater
(see Box 1), a full course for LTBI is completed.
Table 3
Choice of treatment regimens in children with TB
Pediatric doses for first-line antituberculous drugs
disease must consider the identification of a source
Dose mg/kg (maximum dose) case and mycobacterial susceptibilities, extent of
First-line drugs Daily Intermittent disease, empiric versus targeted therapy, and local
Isoniazid 10 – 15 (300 mg) 20 – 30 (900 mg) resistance patterns. The lower bacillary load typical
Rifampin 10 – 20 (600 mg) 10 – 20 (600 mg) of primary pulmonary tuberculosis is associated with
Pyrazinamide 15 – 40 (2 g) 50 (2 g) less risk of drug resistance [58]. Therefore, a 6-month
Ethambutol 15 – 25 (1 g) 50 (2.5 g) regimen of isoniazid, rifampin, and pyrazinamide for
308 feja
the first 2 months (daily for at least 2 weeks) followed
by 4 months of isoniazid and rifampin (daily or 2 –
3 times/week) is recommended for children with
drug-susceptible intrathoracic tuberculosis [17]. Chil-
dren with hilar adenopathy and no other evidence of
disease may be treated with 6 months of isoniazid and
rifampin if drug resistance is not a consideration [17].
If reactivation-type cavitary disease is diagnosed, an
adult-type regimen is used that includes ethambutol
in addition to isoniazid, rifampin, and pyrazinamide
during the initial 2 months, until drug susceptibilities
are determined [58]. Ethambutol also should be
added during the first 2 months if isoniazid resistance
is documented or suspected, particularly in regions
with high rates of isoniazid resistance [17].
Most extrapulmonary disease in children can be
treated like pulmonary TB with 6 months of therapy.
TB meningitis, miliary, and severe disseminated
disease require four drugs (isoniazid, rifampin,
pyrazinamide, and ethambutol) used daily for
2 months followed by daily or twice weekly isoniazid
and rifampin for a total of 9 to 12 months [17,58].
Some experts continue all four drugs to complete a
full course if susceptibilities are unknown.
Toxicities of first-line tuberculosis drugs
Isoniazid is generally very well tolerated by
children, but, rarely, hepatic, neurologic, and gastro-
intestinal toxicities may occur. Hepatotoxicity may
manifest as asymptomatic transient elevation of
transaminases (most common) to fulminant hepatitis
and liver failure (very rare). Risk factors for hepatitis,
such as preexisting liver disease, older age, mal-
nutrition, excessive alcohol consumption, and the use
of concomitant hepatotoxic drugs, are less frequently
noted in children [19,58]. Palusci et al [59] performed
a pooled analysis and calculated that 8% of
965 children developed transient abnormalities in
liver function tests, but only 0.4% discontinued iso-
niazid. Fewer than 1% of children receiving isoniazid
may develop adverse effects that include rash,
nausea, vomiting, and diarrhea [60,61], but severe
hepatotoxicity has been reported [59,62,63]. Thus,
before initiating isoniazid therapy, a history should
be obtained for risk factors, side effects with previ-
ous isoniazid, and signs or symptoms of liver dis-
ease [19].
Baseline liver function tests and further testing
during therapy are recommended only in children
with risk factors for hepatitis. Liver function tests
should be obtained in children without risk factors if
signs (scleral icterus, jaundice, brown urine, clay-
colored stools) or symptoms (anorexia, nausea, vomit-
& saiman
ing, malaise, fatigue, abdominal discomfort, or fever)
of liver toxicity develop during treatment [19]. Fur-
thermore, parents and children should be educated
to be alert for signs and symptoms of hepatitis while
the patient is receiving isoniazid.
The use of isoniazid may lead to peripheral neu-
ropathy caused by pyridoxine (vitamin B6) deficiency
from increased excretion. This toxicity manifests as a
tingling sensation of the fingers and toes. This phe-
nomenon is rare in children, although factors such as
diabetes, uremia, a diet deficient in milk and meat,
nutritional deficiencies, symptomatic HIV infection,
alcohol consumption, pregnancy, and breastfeeding
may increase the risk of peripheral neuropathy. Chil-
dren and adolescents with these risk factors should
receive pyridoxine [17].
Additional toxicities of isoniazid include a hy-
persensitivity reaction such as maculopapular or
morbilliform skin rashes, which may necessitate
discontinuation of isoniazid. Isoniazid inhibits the
P450 cytochrome isozymes and may therefore in-
crease serum concentrations of concomitant drugs
such as anticonvulsants [58].
Rifampin may cause adverse effects such as cuta-
neous reactions, gastrointestinal reactions, flulike
syndrome with intermittent therapy, hepatotoxicity
(particularly when paired with isoniazid), and, rarely,
a severe immunologic reaction. In a study of
157 adolescents receiving 6 months of daily rifampin
for treatment of LTBI caused by isoniazid-resistant
M. tuberculosis, 26% reported anorexia, nausea,
fatigue, or rash, but only 1.3% (2/157) required
permanent drug discontinuation [64]. Patients should
be made aware of the probable orange discoloration
of body fluids (eg, urine, sweat, tears) as well as the
need for additional birth control methods in adoles-
cents taking oral contraceptives. Rifampin is a potent
cytochrome P450 enzyme inducer and can decrease
the serum concentration of many drugs, including
oral contraceptives, HIV protease inhibitors, non-
nucleoside reverse transcriptase inhibitors, cortico-
steroids, and phenytoin [58].
Pyrazinamide generally is well tolerated in chil-
dren and rarely causes hepatotoxicity in doses of
30 mg/kg/day or less, although toxicity can be
observed during treatment with multidrug regimens.
Toxicities from pyrazinamide (20 – 25 mg/kg/day)
were evaluated among 114 children (aged 6 months
to 15 years) given 2 months of isoniazid, rifampin,
and pyrazinamide followed by 4 months of isoniazid
and rifampin for pulmonary TB. Adverse effects
during the pyrazinamide treatment phase included
fever (2.6%), gastrointestinal disturbances (4.4%),
and transient asymptomatic elevation of uric acid
 tuberculosis in children
(9.8%). No patients had treatment interrupted [65]. In
another study, liver enzymes were monitored in
43 children receiving isoniazid, rifampin, and pyra-
zinamide [66]. Only 5 (12%) of the 43 developed
transaminase elevations more than twice the upper
limit of normal for age. One child developed jaundice
requiring temporary discontinuation of medications.
Most laboratory abnormalities occurred in the first
2 weeks of treatment and resolved by 14 weeks of
treatment [66]. Despite the rarity of symptomatic
hepatitis, pyrazinamide is not recommended for
pediatric patients with underlying liver disease or
isoniazid-induced hepatotoxicity [17].
Adverse reactions associated with ethambutol
include retrobulbar neuritis, gastrointestinal distur-
bances, and hypersensitivity. Retrobulbar neuritis is
usually a reversible, dose-dependent, and renal
function – dependent phenomenon that manifests as
decreased visual acuity or decreased red-green color
discrimination. Monitoring for these signs and
symptoms is recommended monthly in older children
and adults [17,58]. Past guidelines have advised
against using or have advised caution when using
ethambutol in younger children who cannot verbalize
symptoms of optic neuritis, although two reviews did
not detect visual toxicity in young children [67,68].
Current recommendations of the American Academy
of Pediatrics suggest consideration of the risks and
benefits involved with the use of ethambutol in
younger children [17].
The use of second-line drugs such as cycloserine,
ethionamide, streptomycin, amikacin, kanamycin,
capreomycin, p-aminosalicylic acid, and fluoroquino-
lones should always be reserved for the treat-
ment of multidrug-resistant TB. Consultation with
a pediatric TB specialist is required, because the
associated adverse effects may be greater than
with first-line drugs, because clinical experience
and pharmacokinetic data are more limited in
children than in adults, and because inappropriate
management may lead to life-threatening conse-
quences [58].
Corticosteroids as adjuvant therapy are indicated
when the heightened inflammatory response may
cause further tissue damage. High-dose steroids
should always be used in conjunction with effective
antituberculosis therapy and should be tapered slowly
over weeks to avoid a rebound reaction. Generally,
1 to 2 mg/kg/day of prednisone (maximum, 60 mg/day)
or its equivalent tapered over 6 to 8 weeks is used
[17]. Prospective, randomized trials have shown that
concomitant corticosteroids decreased mortality rates
in children with TB meningitis [69,70] and reduced
neurologic complications, neurologic sequelae [70],
309
and cognitive dysfunction [69]. A prospective, ran-
domized study of 29 children with greater than
50% bronchial obstruction caused by TB found a
more rapid improvement in radiographic and bron-
choscopy findings in children treated with concomi-
tant prednisolone than in those only given anti-TB
medications [71]. Although no randomized trials in
children are available, corticosteroids may be used to
increase reabsorption of pleural and pericardial fluids
and to alleviate alveolocapillary block in severe
miliary disease [17].
Optimal treatment regimens for TB in HIV-
infected children have not yet been established.
Prospective cohort studies have noted higher treat-
ment failures among HIV-infected children receiving
standard short-course therapy when compared with
non – HIV-infected children (29%, 6/21, versus 3%,
5/156; P = 0.0004) [72]. Mortality rates also were
found to be higher in HIV-infected children with
pulmonary TB (41%, 22/58 HIV-positive, versus 7%,
26/459 HIV-negative; P < 0.001) or TB meningitis
(30%, 3/10 HIV-positive, versus 0/30 HIV-negative,
P = 0.01) [73,74]. The American Academy of Pedia-
trics recommends at least 9 months of therapy with
isoniazid, rifampin, pyrazinamide, plus ethambutol
(or an aminoglycoside) for at least 2 months pending
drug-susceptibility results [17]. An expert in pediatric
TB and HIV should be consulted. Rifabutin can be
substituted for rifampin to avoid drug interactions in
children receiving protease inhibitors as part of the
HIV treatment.
It is paramount to ensure successful completion of
therapy. Pediatric formulations are not available for
many antituberculosis drugs, and often pills or cap-
sules must be crushed and mixed with food, fre-
quently resulting in bitter-tasting mixtures. Despite
these barriers, between 1993 and 1999, 90% of
children with TB in the United States completed
therapy [7]. A combination of DOT, parent/patient
education, pediatric formulations, enablers (strategies
to overcome logistic barriers such as funds for
transportation or extended clinic hours), and incen-
tives (strategies to enhance motivation such as
snacks, food coupons, or movie tickets) can increase
completion rates [19]. DOT is recommended for use
in all children with TB disease and multidrug-
resistant LTBI and in children with drug-susceptible
LTBI when resources permit [17,19,58].
Public health aspects of pediatric tuberculosis
As with adults, the public health sector plays an
important role in control of TB in children through a
310 feja
hierarchy of activities that range from identification
and treatment of patients with TB disease to
conducting public health investigations of infectious
source cases and identifying and treating patients
with LTBI [19]. Following recognition of an infec-
tious adult or adolescent case, a contact investigation
is performed to identify exposed persons, including
children and adolescents, and evaluate them for LTBI
or TB disease. Source-case investigations are con-
ducted to identify an infectious adult from whom a
child with active TB may have contracted M. tuber-
culosis. During this process, the close contacts of the
child (including other children) are evaluated for
infection and disease. Last, associate investigations
evaluate household contacts of children with LTBI to
find a potential source of infection and to identify
others with LTBI.
As previously mentioned, younger children with
pulmonary TB are rarely infectious. Therefore, air-
borne isolation is not generally required in a health
care setting. Unique situations have been described,
however, in which transmission may have occurred
from a young child with unrecognized congenital TB
or cavitary TB. Such transmission is associated par-
ticularly with suctioning or respiratory care inter-
ventions [75,76]. More commonly, accompanying
parents, relatives, or health care workers with un-
diagnosed pulmonary TB are the source of nosoco-
mial transmission in pediatric health care settings
[77 – 81]. Infection control measures, therefore,
should focus on adults accompanying the child.
Promptly evaluating of the household contacts of a
child with suspected TB by chest radiograph before
giving visitation rights in the hospital may avoid
health care – associated transmission of TB.
Summary
The epidemiology of pediatric TB continues to be
shaped by risk factors such as age, race, immigration,
poverty, overcrowding, and HIV/AIDS. Once in-
fected, young children have an increased risk of TB
disease and progression to extrapulmonary disease
because of immunologic host factors. The patho-
genesis of disease differs from that in adults, because
primary disease and its complications are more
common in children. This prevalence of primary
disease in turn leads to differences in clinical and
radiographic manifestations in pediatric TB. Diffi-
culties in diagnosing children stem from the low yield
of mycobacteriology cultures and the subsequent
reliance on clinical case definitions. Inadequately
treated TB infection and TB disease in children today
& saiman
are the future source of disease in adults. Therefore,
close collaboration between public health services
and pediatric care providers is needed to ensure suc-
cessful completion of treatment. Future goals should
continue to focus on developing more accurate
epidemiologic data for childhood TB, supporting
TB control programs to decrease morbidity and mor-
tality in children with TB and LTBI, and developing
additional pediatric formulations of antituberculo-
sis drugs.
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 Clin Chest Med 26 (2005) ix – x

Preface
Tuberculosis

Neil W. Schluger, MD
Guest Editor
In 1952, Selman Waksman received the Nobel
Prize for his discovery of streptomycin. In his Nobel
address, Waksman said:
In the treatment of tuberculosis, the more controlled
dosage of streptomycin and the supplementary use of
PAS tended to overcome some of the limitations of
the antibiotic, notably its toxicity and the develop-
ment of bacterial resistance. The recent introduction
of isonicotinic acid hydrazide suggests the possibil-
ity that its combined use with streptomycin will tend
further to control the disease and overcome undesir-
able complications. The conquest of the bGreat
White Plague,Q undreamt of less than 10 years ago,
is now virtually in sight. [1]
That same year, Rene and Jean Dubos, in their still
important and prescient book The White Plague, wrote:
However useful in specialized cases, vaccination,
antimicrobial drug therapy, or other therapeutic
measures cannot possibly solve the social problem
of tuberculosis. . .. It is only through gross errors in
social organization, and mismanagement of individ-
ual life, that tuberculosis could reach the catastrophic
levels that prevailed in Europe and North America
during the nineteenth century, and that still prevail in
Asia and much of Latin America today. [2]
Unfortunately, the Dubos’ assessment proved more
accurate than Waksman’s. Despite great advances in
immunology, microbiology, and drug development,
tuberculosis remains among the great public health
challenges of our time. The failure to reduce tuber-
culosis rates in high-burden countries is not due to
lack of efficacy of drugs in those countries, but rather
the confluence of medical and social factors that fuel
the ongoing tuberculosis epidemic: the coepidemic
of HIV; poverty; lack of a functioning public health
infrastructure; the economics of tuberculosis drug de-
velopment; bureaucratic and doctrinaire approaches
to tuberculosis control; lack of funding to support
basic research aimed at development of new drugs,
diagnostics, and vaccines; and apathy.
The articles in this issue of the Clinics in Chest
Medicine address many of these issues. They have
been written by leaders in the basic science, medical,
and public health communities who have broad per-
spective and expertise in their fields, and who are
engaged in efforts locally and globally to control the
worldwide tuberculosis epidemic.
I would like to dedicate this issue to all patients
who have tuberculosis, in hopes that the information
and knowledge offered within will improve their lives
in a direct and immediate way.
Neil W. Schluger, MD
Division of Pulmonary, Allergy, and
Critical Care Medicine
Columbia University College of
Physicians and Surgeons
PH-8, Room 101
630 West 168th Street
New York, NY 10032, USA
E-mail address: ns311@columbia.edu

0272-5231/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.ccm.2005.03.001 chestmed.theclinics.com
x preface

References 12, 1952]. Available at: http://nobelprize.org/medicine/

laureates/1952/waksman-lecture.html.
[1] Waksman SA. Streptomycin: background, isolation, [2] Dubos R, Dubos J. The white plague. New Brunswick
properties, and utilization [Nobel lecture; December (NJ)7 Rutgers University Press; 1987. p. 224.