Elize Pietersen and colleagues (April 5, p 1230) show the very poor outcomes for treatment of extensively drug-resistant (XDR) tuberculosis in South Africa. The study suggests that large numbers of patients, for whom treatment was ineffective, pose a risk of ongoing community transmission. Although we support the provision of community-based care minimising transmission risk after treatment failure, we would also like to put these numbers into context. More than 1500 XDR tuberculosis cases are diagnosed in South Africa annually, likely representing a fraction of the actual burden. In view of that less than half of people diagnosed receive treatment, the combination of undiagnosed and untreated XDR-tuberculosis poses a much larger risk in our communities than the small number of patients discharged with treatment failure Pietersen and colleagues describe.
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