Discovery of a deadly form of TB in a Mumbai hospital underscores mismanagement
TB turns invincible
In December last, when doctors at Hinduja Hospital in Mumbai raised the alarm over a deadly form of tuberculosis, the Union health ministry was quick to refute the claim. In its press release on January 17, the ministry said the term “totally drug resistant TB” is “misleading”; it is neither recognised by the national programme for TB control nor by WHO. But WHO has received reports of a similar strain of TB bacteria before: first from Italy in 2007 and then from Iran in 2009. With India becoming the third country to have raised the concern, it has now convened a meeting of global TB experts in March to discuss whether the strain should be called totally drug resistant (TDR), or be clubbed under the existing category of extensively drug-resistant TB (XDR-TB), given that advanced drugs are in the making and that it is not possible to test TB bacteria against every possible drug and concentration.
Calling the new TB strain as XDR or TDR, however, does not take away the seriousness of the issue that the Hinduja researchers have highlighted. Inappropriate and irrational treatment is amplifying the resistance of TB bacteria, which have grown resistant to the first-line treatment, and are mutating into difficult-to-cure forms like XDR-TB and TDR-TB, the researchers noted in the study published in Clinical Infectious Diseases on December 21. While they blame the private healthcare sector for abusing precious anti-TB drugs by prescribing irrationally, several public health experts also find fault with the Revised Natio¬nal TB Control Programme (RNTCP).
DOTS fails to cope with mutating TB
It is not clear when India saw its first case of drug-resistant TB, though health experts say its presence has been known from the time anti-TB drugs were introduced about two decades ago. Initially, it was resistant to first-line drugs, including the powerful isoniazid and rifampicin, and hence named multi-drug resistant TB (MDR-TB). To control its spread, India started scaling up DOTS programme, a WHO recommended strategy under RNTCP, to DOTS-Plus in 2006.
By then decades of neglect had made the bacteria stubborn. That year, soon after WHO brought into notice XDR-TB, resistant to second-line treatment as well, India reported its first case of the disease. Hinduja Hospital was the first to report the case. In absence of a universal regime, the only ways to treat a XDR-TB patient are surgery and drugs not tried before. Eight of 10 patients succumb to the illness.
RNTCP did not grow at the pace at which the TB bacteria developed resistance, says Sarabjit Chadha of the International Union Against Tuberculosis and Lung Diseases. He blames the mutation of TB bacteria on insufficient diagnostic facilities. Ideally, doctors should do a drug susceptibility test (DST) before treating a patient who has failed to respond to the first-line therapy or is a dropout and could have developed resistance to certain drugs. The six-week-long test helps doctors decide on the right regime. But in India DST is done only after patients fail to respond to the second-line therapy and develop difficult-to-treat forms like XDR-TB, Chadha adds. RNTCP has just 27 labs, of which four are equipped to test drug resistance in an XDR-TB patient.
“The faster the drug-resistant TB cases are identified, the quicker their treatment can start,” says Jayant Banavaliker of Rajan Babu Institute for Pulmonary Medicine and Tuberculosis run by Delhi’s municipal corporation. “Delay in treatment can amplify resistance.”
Discontinuation of treatment is known as the primary reason for developing drug resistance. But it is not easy to complete second-line therapy, admits Joanna Laomirska of Medicines Sans Frontiers (MSF) India. Patients have to take strong drugs and injections for months. Many suffer from pain in the abdomen and vomiting. Some even commit suicide, she adds, suggesting that DOTS-plus should have provision for counselling the patients.
MAKING OF A STUBBORN TB
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