Union response to Lancet Global Health correspondence on shorter all-oral MDR-TB regimens

In response to a recent article published in The Lancet Global Health titled Now is the time for shorter all-oral regimens for multidrug-resistant tuberculosis, Union authors have published the following response.

Authors Dr Riitta Dlodlo, Director of the Department of Tuberculosis (TB) and HIV, Dr Alberto Piubello, Coordinator of the Expanded MDR-TB Programme, Dr Grania Brigden, Deputy Director of the Depatment of TB and HIV, and Dr Paula I Fujiwara, Scientific Director, state:

“We agree with KJ Seung’s and C Hewison’s(1) call to advance all-oral treatment regimens for multidrug-resistant tuberculosis (MDR-TB.)

“However, the efficacy of the all-oral regimen recommended by WHO in 2019(2) is unknown, with no randomised control trial planned.  In our view the results of the STREAM Stage 1 trial – showing the 9-month(3) regimen to be as efficacious as the previous WHO-recommended 20-24-month regimen additionally with accompanying positive programmatic results(4,5) – support the role of the Bangladesh regimen in providing a shorter current MDR-TB treatment when used in accordance with the WHO guidelines.(2)  

“However, the Bangladesh regimen contains an injectable agent with the associated risk of ototoxicity and as such it should be viewed as a stepping-stone that we must move on from.  We support National TB Programmes (NTPs) doing operational research (OR) in all-oral shorter regimens, potentially even as an alternative to implementing a longer regimen, to add to the evidence base in shorter all-oral regimens.  The regimens being researched by NTPs should aim to achieve high cure rates with fewer side effects than the injectable-containing regimens, and avoid any amplification of resistance to key drugs, including those in the new WHO group A classification.  Funders have a vital role in supporting the NTPs to carry out this research and drive forward all oral regimens. 

“We hope ongoing research, including STREAM Stage 2 trial and high quality OR by NTPs into shorter all-oral regimens, will create a new evidence-based paradigm for MDR-TB treatment.”


  1. Seung KJ, Hewison C.  Now is the time for shorter all-oral regimens for multidrug-resistant tuberculosis.  Lancet Glob Health 2019. Published Online April 17, 2019. http://dx.doi.org/10.1016/S2214-109X(19)30186-X
  2. WHO. WHO consolidated guidelines on drug-resistant tuberculosis treatment. 2019. https://www.who.int/tb/publications/2019/consolidated-guidelines-drug-resistant-TBtreatment/en/ (accessed April 24, 2019).
  3. Nunn AJ, Phillips PPJ, Meredith SK, et al. A trial of a shorter regimen for rifampin-resistant tuberculosis. N Engl J Med 2019; 380: 1201–13.
  4. Trebucq A, Schwoebel V, Kashongwe Z, et al.  Treatment outcome with a short multidrug-resistant tuberculosis regimen in nine African countries.  Int J Tuberc Lung Dis 2018; 22(1): 17-25.
  5. Aung KJ, Van Deun A, Declercq E, et al. Successful 9-month Bangladesh regimen for multidrug-resistant tuberculosis among over 500 consecutive patients. Int J Tuberc Lung Dis 2014; 18: 1180-7.