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| INVITED EDITORIAL |
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| Year : 2016 | Volume
: 4
| Issue : 2 | Page : 41-42 |
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Totally drug resistant-tuberculosis in India: The bad just got worse
Zarir F Udwadia
Department of Pulmonary Medicine, Hinduja Hospital and Research Center, Mumbai, Maharashtra, India
| Date of Web Publication | 10-Jun-2016 |
Correspondence Address:
Zarir F Udwadia
Hinduja Hospital, Veer Savarkar Marg, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2320-8775.183836
How to cite this article:
Udwadia ZF. Totally drug resistant-tuberculosis in India: The bad just got worse. J Assoc Chest Physicians 2016;4:41-2 |
In the early weeks of January 2012, a report of four cases of highly drug resistant (DR) tuberculosis (TB) from Mumbai, India, stirred up a storm.[1] India bears a giant's share of the world's multi DR-TB (MDR-TB) burden, but these cases were different even though they came from a center (Hinduja Hospital and Research Center) which has been reporting on the alarming escalation in DR-TB in Mumbai over the last two decades.[2] All the patients described were resistant to all first (isoniazid, rifampicin, ethambutol, pyrazinamide, and streptomycin) and second line drugs (SLDs) (kanamycin, amikacin, capreomycin, ofloxacin, moxifloxacin, ethionamide, and para-aminosalicylic acid) to which they were tested. That the report came from Mumbai's most reputed Mycobacterial Laboratory, accredited for Drug susceptibility test (DST) by the Revised National TB Control Program and serving as the de facto reference mycobacterial laboratory for the city, added to the veracity of this report. The name chosen by the authors “totally DR” (TDR) TB was seized on by local health authorities, the United Nation and medical and general press although there had been scattered reports of similar cases prior to this.[3],[4]
India has long had the distinction of the highest numbers of DR-TB cases in the world,[5] but how did this extreme form of resistance develop? DR-TB in all its many forms is a man-made problem, and both the public and the private sectors are to blame. For decades the NTP ignored the growing numbers of MDR cases that were being encountered and instead of offering these patients, who had failed standard Cat 1, a drug sensitivity test (DST) and then appropriate SLDs chose to give them instead Cat 2 treatment which, in most cases, served only to amplify resistance. This was an example of what I would describe as public policy paralysis. Private practitioners were equal to blame. India has a huge and unregulated private sector: 70% of hospitals are privately run and 76% of doctors engage in private practice. Fifty percent of practicing doctors are of alternative faiths such as Homeopathy, Ayurveda or Unani. A study we conducted in Dharavi, Asia's most densely populated slum in the heart of Mumbai, showed that only 3% of the doctors practicing there were able to prescribe a correct prescription for a patient with MDR-TB.[6] Without doubt, the poor prescribing practice of Indian PP's fueled the MDR-TB crisis in the country, for DR-TB in all its forms is an iatrogenic disease arising under the selective pressure of poor prescriptions. Finally, the biosocial factors so prevalent in India, have also contributed to the emergence and spread of DR-TB. These include poverty, malnutrition, the huge co-existing diabetes epidemic, the effects of smoking, indoor and outdoor pollution.[7]
Caught between the vortices of an uncaring public system and an unregulated and exploitative Private system the Indian MDR-TB patient struggled to stay afloat. Delays in diagnosis (too few laboratories in private and public sectors) and the erratic treatment doled out by each successive physician resulted in relentless amplification of resistance from MDR to extensively DR (XDR) TB, and then to the inevitable TDR cases we first described in 2012.
Treating these highly resistant patients is a difficult, demanding and expensive proposition. Standard principles, if followed in the setting of our outpatient department based practice, have achieved cure rates of around 70% which compare well with series from across the globe.[8] However, treatment of these patients is laboratory and labor intensive and the importance of individualized therapy, based on reliable DST must be emphasized.
So much remains to be done to prevent the further slide into worsening DR, and these are my suggestions for the future:
- Urgently build laboratory infrastructure, scale up the availability of the Gene Xpert test so that patients with MDR can be diagnosed more early and more accurately
- Determine the extent of the problem by rapidly completing the results of a countrywide and representative TB resistance survey
- Increase the coverage of DOTS-Plus so it is accessible to all patients across the country
- Legislate so only selected and trained PP's can take on the management of these highly demanding cases
- Introduce newer drugs early for the appropriate XDR patients who are therapeutically destitute. It is nothing short of scandalous that bedaquiline and delamanid have both been Food and Drug Administration approved since 2012 but are yet not available in India. Except for an initial Indian report, there is no local experience with these new drugs in the country which most urgently needs to have them available [9]
- Finally, the government needs to prioritize health and ensure that the current global TB funding gap is breached. This funding gap stands at $1.6 billion/year. India's annual NTP budget of $63 million/year is inadequate to support the large numbers of MDR patients who need treatment.
As Jonathan Smith, a professor of philosophy at Yale reminds us “It's not that we can't cure TB, it's that we cannot cure TB for poor people. TDR-TB has been present for decades, but instead of pathological resistance the culprits are apathetic government and nonfunctioning infrastructures that elude accountability. TDR-TB reinforces my claim that TB management should be deemed the largest violation of human rights the global health community has ever seen.”
| References | |  |
| 1. | Udwadia ZF, Amale RA, Ajbani KK, Rodrigues C. Totally drug-resistant tuberculosis in India. Clin Infect Dis 2012;54:579-81.  |
| 2. | Udwadia ZF. India's multidrug-resistant tuberculosis crisis. Ann N Y Acad Sci 2001;953:98-105. |
| 3. | Migliori GB, De Iaco G, Besozzi G, Centis R, Cirillo DM. First tuberculosis cases in Italy resistant to all tested drugs. Euro Surveill 2007;12:1203. |
| 4. | Velayati AA, Masjedi MR, Farnia P, Tabarsi P, Ghanavi J, Ziazarifi AH, et al. Emergence of new forms of totally drug-resistant tuberculosis bacilli: Super extensively drug-resistant tuberculosis or totally drug-resistant strains in Iran. Chest 2009;136:420-5. |
| 5. | WHO Report. Global Tuberculosis. Geneva: World Health Organization; 2014. |
| 6. | Udwadia ZF, Pinto LM, Uplekar MW. Tuberculosis management by private practitioners in Mumbai, India: Has anything changed in two decades? PLoS One 2010;5:e12023. |
| 7. | Ortblad KF, Salomon JA, Bärnighausen T, Atun R. Stopping tuberculosis: A biosocial model for sustainable development. Lancet 2015;386:2354-62. |
| 8. | Udwadia ZF, Moharil G. Multidrug-resistant-tuberculosis treatment in the Indian private sector: Results from a tertiary referral private hospital in Mumbai. Lung India 2014;31:336-41. [ PUBMED]  |
| 9. | Udwadia ZF, Amale RA, Mullerpattan JB. Initial experience of bedaquiline use in a series of drug-resistant tuberculosis patients from India. Int J Tuberc Lung Dis 2014;18:1315-8. |
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