World TB Day (March 24) calls for awareness of the global epidemic of tuberculosis and efforts to eliminate the disease. On the occasion, The Hindu takes a look at the Kerala scenario, especially against the backdrop of the State reporting the highest level of basic TB treatment failure in the country at 6 per cent.

High prevalence of diabetes in the community and improper treatment and follow-up of standard tuberculosis treatment (basic TB treatment under the Renewed National Tuberculosis Control Programme) have been fuelling drug-resistant tuberculosis in the State.

Kerala has been reporting high levels of failure of standard TB treatment using first-line drugs primarily because of the increasing prevalence of diabetes, public health professionals point out.

“Kerala has reported the highest level of basic TB treatment failure in the country at six per cent. Our basic case detection rate stands at 68 per cent, while our cure rate is 84 per cent, which is lower than RNTCP standards. Diabetes and poly drug resistance are the primary reasons for failed TB treatment, leading to a high incidence of drug-resistant TB,” a senior Health official says.

In a survey conducted some eight months ago by the International Union Against TB and Lung Diseases among 630 TB patients in 20 TB units in the State, 44 per cent of the patients were found to be having diabetes.

The State has so far enrolled 382 patients with multi-drug-resistant TB (MDR TB) under its DOTS Plus treatment regimen with second-line TB drugs. Among these MDR TB patients, the prevalence of diabetes is 60 per cent, which has been sorely affecting the treatment outcome, Health officials say.

Cure rate

The treatment period for MDR TB is two years. The current cure rate for MDR TB in the State is 48 per cent. The death rate is 20 per cent, default rate, 20 per cent, while the status of the rest is unknown as they could not be followed up. The pattern is said to be the same in DOTS Plus sites elsewhere also.

Sunil Kumar, Director, State TB Training and Demonstration Cell, says that the State has been systematically screening all the TB patients registered under RNTCP for diabetes for the past two years.

“We are screening TB patients for diabetes, but the diabetes treatment and regular blood sugar monitoring is outside the purview of RNTCP programme. Other than HIV, no other co-morbidities have been receiving any attention as far as TB treatment is concerned. Our treatment outcome is poor because the TB patients are on different drug regimens for their co-morbidities and this affects the therapeutic level of TB drugs in the blood stream,” he says.

Those with diabetes are at least two or three times at higher risk of developing TB because of their lowered immune status. Diabetes medications could interact with TB drugs and complicate glycemic control.

No studies have yet been conducted in Kerala on drug resistance, drug interactions or the synergistic effects of TB drugs and other medications that TB patients might need to take for co-morbidities like diabetes or hypertension.

In order to prevent the epidemic of diabetes from affecting TB control activities, the general health system's non-communicable diseases control programme should be coordinated with the RNTCP, says Dr. Sunil Kumar.

Antibiotics

Apart from diabetes, another reason for TB treatment failure in Kerala is said to be antibiotic resistance, particularly the resistance to quinolone group of drugs.

“Flouroquinolones are broad spectrum antibiotics and a very indispensable group of drugs for treating MDR TB. But chest physicians here have been routinely prescribing quinolones for all upper respiratory infections, leading to high levels of drug resistance. Studies conducted in Gujarat and Maharashtra have indicated quinolone resistance levels among 40 per cent of the patients and it could be even higher in Kerala,” a chest physician in the city says.

“Strengthening basic TB case detection and control through RNTCP is the key to reducing the emergence of drug resistant TB. Private sector doctors have their own reasons for opposing the national programme, but right now we do not have another option to tackle a public health challenge like TB. We need more private sector participation in RNTCP because varied drug regimens and improper follow up will only create more drug resistant cases in the community,” says R. V. Asokan, national coordinator (TB), Indian Medical Association.