Maes S. became sick the first time with pulmonary tuberculosis in 1991. Tuberculum bacilli were identified in his sputum under the microscope, and he received a full standard treatment course for 8 months. After this course his sputum was clear of bacilli.
In 1996, most probably due to re-infection, he became sick again. The treatment he needed, and started, was interrupted because he could not afford the money to travel to the doctor every day to receive his drugs. This time his sputum did not become clear, he was categorized as a so-called ‘failure’.
Retrospectively it is very likely that he was already resistant to at least some of the standard anti-TB drugs at this time. But in 1996, MDR-TB was not known in Cambodia and no techniques existed there to detect drug-resistant TB.
He became severely sick again in 1997 and started again on standard-treatment - but the treatment failed again and was eventually stopped.
In August 2006, Maes began to cough up blood and his weight had dropped to 46 kg. He was sent to a hospital in the capital, Phnom Penh. Although by this time the problem of MDR-TB was widely known, the necessary diagnostic techniques were so expensive that it was far beyond Maes' financial means to afford the tests.
So, instead of being put on an treatment of drugs to tackle MDR-TB, he only received some drugs to alleviate the symptoms, but nothing specific against TB. After 4 months in hospital, he was sent home to his province.
Towards the end of 2006, he was introduced to the MSF team, working at the reference hospital in the capital of his home province. The team suspected MDR-TB and sent sputum samples to a private laboratory in Phnom Penh.
They also sent a sample to the Supra-national reference laboratory (SNRL) in Antwerp, Belgium for culture and drug sensitivity testing (DST), knowing that it would take up to three months before the results would be available.
In this particular case the delay was even worse: For both samples the presence of TB could not be determined, because they were contaminated with other bugs, a frequent problem with TB culture.
A third attempt in May 2007 finally delivered the results: Maes was suffering from multidrug-resistant tuberculosis, resistant to three of the five standard anti-TB-drugs including to the two most powerful ones: rifampicin and isoniazid.
His treatment finally started on 18th July 2007, after an almost nine-month delay since his first visit to the MSF programme, ten years since he was suspected of being infected with MDR-TB and fully 15 years since his initial diagnosis with TB.
Maes was lucky as he was in fairly good clinical condition and not suffering from any co-infections, in particular not from HIV. For patients with HIV, a 9-month or even 3-month delay until treatment starts is far too long and will often be deadly. Every day counts.
Maes was also lucky to find an organisation that could pay for the costs of the diagnosis and treatment. Most countries would need to send samples to outside laboratories as they do not have the capacity yet to diagnose MDR-TB. But transport of these potentially dangerous samples of Mycobacterium tuberculosis is very expensive. For example, it's calculated that to send samples from Kenya to Antwerp costs around 300 Euros per patient, money which is not simply not available to most national health providers in developing countries.
New diagnostic tools that are cheap, easy-to-handle and logistically suitable for resource poor settings, are desperately needed in order to drastically scale up TB diagnostics and treatment.