What is a preventable and easily treatable disease is now threatening to overwhelm India with growing drug resistant forms, rising treatment costs and greater suffering
Tuberculosis is a disease of antiquity that claims nearly 1,000 lives every day in India. There are serious challenges that continue to exist in the TB landscape. One of these is drug resistance to anti-TB drugs. Though drug resistant TB has been in existence for long, it has lethal forms that continue to emerge and threaten to undermine the extensive work undertaken to prevent and control the spread of TB.
Drug resistant TB is a man-made problem, the result of treatment mismanagement due to which the TB bacteria develops resistance to the two or more most commonly used drugs in the current four-drug (or first-line) regimen, leading to multidrug-resistant TB (MDR-TB). In some cases, this mismanagement can transform itself into extensively drug resistant TB (XDR TB), where the bacteria do not respond to even second line drugs. This poses a serious threat to global TB control. To make matters worse, an advanced form of drug resistance has been reported recently in India. It is known as extremely drug resistant TB (XXDR-TB). In this form of the disease, none of the known TB drugs or their combinations work.
A study
The reasons for the rise in drug resistance are many. In most instances, detection of the disease is delayed due to the non-availability of good diagnostic laboratories and patients receiving treatment with non-standardised and arbitrary drug regimens of questionable quality. There is continuous use of incorrect diagnostics like serological tests for detecting TB which are utilised in the private sector. Though the World Health Organisation (WHO) has recommended the ban on the use of these tests, $15 billion is being spent annually in India on these. A recent study carried out by the All India Institute of Medical Sciences (AIIMS) concludes that serological tests can detect the disease only in a quarter of TB patients while three-fourths will be wrongly diagnosed as non-TB cases, even if they are smear positive. In other words, most who have the disease will be diagnosed as healthy, and most healthy persons will be diagnosed as TB infected patients, if serology alone is relied upon.
Although drug resistant TB in India has been reported frequently during the last four decades, the available information from here is incomplete. Most patients are not notified to the Revised National Tuberculosis Control Programme (RNTCP) and many treatment outcomes remain unknown. Recently, the Central TB Division (CTD) has taken a policy decision to make it mandatory to notify all TB cases — a positive step.
Treatment costs
MDR-TB can only be treated with second line drugs which are very expensive. The treatment course is very long and expensive. It is vital to have mechanisms of appropriate regimen and ensuring access to quality assured drugs. Self-prescription of anti-TB drugs promotes drug resistance. This is made worse by the lack of regulation in accessing these drugs. Treatment of MDR TB commences after detection, a process that takes many months when conventional methods are used. As a result, patients with MDR- or XDR TB continue to spread the infection to others. Drugs used to treat MDR- and XDR TB are toxic and expensive when compared to those used in the treatment of basic TB. While a course of standard TB drugs costs approximately Rs.1,000, MDR-TB drugs can cost more than Rs.1 lakh. XDR-TB treatment is far more expensive. The need of the hour is not only detecting drug resistant strains early, but also initiating measures for optimising disease management and care so that each patient is diagnosed quickly and treated appropriately.
The RNTCP has had some important successes including targeting an 85 per cent cure rate and 90 per cent diagnostic coverage. As the monthly monitoring of providing treatment under Directly Observed Treatment, Short course (DOTS) is done, its effectiveness needs to be enhanced.
In many instances the national programme has faltered in diagnosing and treating drug resistant TB. In India, the RNTCP provides treatment to TB patients on alternate days, instead of daily treatment.
This poses a higher risk for patients to miss doses, another key factor leading to the creation of drug resistant strains of TB. The TB programme should create treatment protocols that are simple to adhere to and are supported by treatment counselling.
Importance of private sector
The engagement of the private sector has remained unsuccessful by the government. This is worrying as close to 50 per cent of a TB patient’s first point of diagnosis and treatment is the private sector. Many physicians in the private sector and some in the public sector do not follow international norms of treatment. The engagement of hospitals is also vital to curb the emergence and spread of drug-resistant TB.
The prevention of drug resistant TB relies heavily on the effectiveness with which control efforts will succeed to treat TB patients in both the public and the private sectors. The programme cannot rest on its success; it must take a multi-pronged approach to TB control. If not, India must prepare itself to address growing drug resistance, rising treatment costs and extreme human suffering from what is a preventable and easily treatable disease.
(Dr. Sarman Singh is Faculty-in-charge, Microbiology, Department of Laboratory Medicine, AIIMS, New Delhi. The views expressed are personal.)
Keywords: Tuberculosis, MDR-TB
TB is contagious or infections, communicable from one human to
another. When an individual gets it, does it start out as a normal TB
strain, and then morphs into MDR or XDR? Or does an MDR/XDR propagate
as MDR/XDR to other humans? That clarity is needed before panic level
increases. If MDR/XDR is restricted only to those who are not adhering
to the prescribed antibiotics, then we have less of a public health
concern. The author or another expert on the subject should be asked
to provide this clarification. I remember reading many years ago in
the New England Journal of Medicine that drug resistant strains were
not communicating to another individual as drug resistant, and drug
resistance was limited to the individual.
Tuberculosis is a major public health problem since antiquity.While treating the cases of tuberculosis ,we generally emphasis only the curative part like proving the DOTs treatment.This not the solution to the problems.Public health is a Preventive , promotive and curative health care through organized effort of the community.Country like us , has problems of nutritional deficiencies, hygiene and sanitation, shortage of trained health worker, poverty...etc.Unless we will not focus on these issues ,curative treatment will be not able to eradicate the Disease.There is need to look other aspect of Tuberculosis eradication strategy.Providing nutritional supplement to Tuberculosis Patient along with under observation of trained front line health worker through organized community effort might be helpful.
Self-prescription and arbitrary dosing are the most common sources of drug
resistance. The poor in India often have no access to medical facilities and/or no
money to purchase medicine. In such a case, they are likelier to discontinue a
course of treatment or switch to cheaper counterfeit drugs.
There is also considerable lack of awareness among the educated middle-class
patients, who will often demand antibiotics for the merest trifles like cold (which
incidentally cannot be cured with antibiotics) and then discontinue the course as
soon as symptoms have disappeared.
We in India, with our utterly mismanaged healthcare system are literally digging
out own grave and that of the whole world. At the present rate, we are going to be
exporting all sorts of pestilence, such as drug-resistant TB and MRSA to the entire
world.
Do we care enough to do something about it?
Dr Sarman Singh has voiced the anguish of those engaged in healthcare development. Although Indian RNTCP achieved the MDG of 85% coverage under DOTS in 2008, much before the deadline, unfortunately that has not helped in bringing down the number of TB patients in the country. Looks like, either the 85% coverage algorithm or the information reported under RNTCP is not reliable. Much more needs to be done perhaps on both fronts. I am surprised that despite a very high level of awareness in ICMR about TB being linked to societal factors, there is little operational research to find reasons for the continued epidemic. There is also need for strong govt support to the private sector entrepreneurs engaged in developing cutting edge diagnostics for TB detection. Hopefully some frightful day, the TB epidemic will bring all of us, public and private entities together to fight the scourge of TB.
The best approach to contain TB is to use Ayurvedic treatment and medicines. It is harmless and bacteria do not develop drug resistance. It is cheap and affordable. Instead of this the patients who go to the modern methods of treatment suffer a lot and additionally, it has been seen that they often lead to developement of diabetes, at least in the case of some drugs. The modern treatment is often ineffective due to drug resistance.
Yes, government has taken various measures to check and treat TB infected subjects. There are provisions to isolate the highly infected patients and render treatment which is free of cost. However, there are lots of instances heard about the patients absconding from isolated centers and spreading the infection. This is again a social problem; we know that per statistics the lower economic group is the maximum who get infected. Isolation and long treatment plans will indirectly affect the family of the patient. So we see patients not following the treatment regimens completely.
We will be able to control only if the infected subjects are cooperative enough to control the progression and spread of disease to other population. It is always two ways and patient education about the disease and willing ness to take appropriate treatment is mandatory.
It can be really dangerous, if itz not taken care of
This is in response to Dr Sarman Singh's article titled "Breathing
uneasy over TB". The author presents a simplistic solution that TB can
be prevented, but it is true that in-spite of several decades of fight
against TB through several National TB Programmes, there seems to be
no light at the end of the tunnel. TB is a major public health problem
and kills almost 1000 people every day in India. But control and
eradication seem to be far off dream.
We need to think and reflect, as to what has gone wrong. Have we in
India missed something in understanding the true nature of TB. How is
that countries like USA and several European countries have been able
to address this problem even before the discovery of drugs to treat
TB?
If one examines the history of these countries in achieving success of
conquering the TB scourge is that all of them have systematically
understood the nature of TB, that it is transmitted from animals.
This is the case of failure of public health and its policy. TB and HIV are making a deadly combination. This is a disease which can afflict any one in the society. There are well advances in medicine which can be used to tackle them and it needs to resolution of policy makers to provide free medications and develop adequate training facilities for healthcare personnel. Case managers or some one in health department need to track the TB patients till the completion of the treatment duration and if not it is leading to MDR, XDR TB which is very dangerous to every one in the society. The old saying a stitch in time save nine and it aptly applies to TB management.
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