Multidrug-resistant tuberculosis (MDR-TB) has been reported in countries all over the world, but the first report of totally drug-resistant TB (TDR-TB), which is resistant beyond extensively drug-resistant tuberculosis (XDR-TB) that is still susceptible to some second-line drugs, came from Italy in 2007.
The Centers for Disease Control and Prevention (CDC) reports of culture-confirmed cases from Italy and Germany (2003-2006) indicate susceptibility testing was of high quality, according to the World Health Organization (WHO) guidelines, which require retesting at WHO reference laboratories. In a total of 2,888 culture-positive TB cases from the two countries, which included susceptibility testing for first- and second-line drugs, 126 were MDR-TB cases while 11 were XDR-TB. Seventy-four of the MDR-TB patients were treated, and all XDR patients received re-treatment. Patients were greater than 45 years old and stratified by immigrant status, the primary factor affecting increased mortality. Lack of infection control was the primary concern for mismanagement in Western Europe, where new drugs and diagnostic tests are badly needed.
TB epidemic in an Italian school
In the 1990s the decreasing incidence of TB also resulted in a loss of expert diagnostics, along with infection control management and staffing. Evident by 2008 were more than 4,000 new cases annually, nearly 50% occurring in immigrant populations. However, cases in children had been uncommon until a kindergarten/primary school in central Italy reported an outbreak after a breakdown in the TB control program, reflective of increased transmission in that area. When the first case of a kindergartener was reported, an investigation found 35% of her classmates in the same class and associated primary schools tested positive for TB.
After screening with tuberculin tests and/or chest x-ray, children under five years old without active disease were prescribed isoniazid for six months. Screening included 851 persons, 96% of whom were born in Italy. Initially, 53 of 383 children tested positive with the TB skin (Mantoux) test (TST). Nineteen children had active TB and 43 had latent infection. None of the active cases were identified in the school staff or in contacts of children with positive TST results.