An incurable form of tuberculosis has emerged in India, the first-ever occurrence in a country with a massive epidemic and a highly mobile population that can easily spread the disease.
These are patients with tuberculosis that cannot be cured with any combination of the World Health Organization-recommended drugs, either “first line,” the standard treatment, or second-line, the most powerful, toxic and expensive medications. This form of tuberculosis is 100-per-cent fatal, and its emergence here has alarmed public health officials, because India has nearly a fifth of the world’s TB patients but a health system too frail to respond.
Iran reported the first known cases of Totally Drug Resistant Tuberculosis (TDR-TB) in 15 patients in 2009. Then in November, doctors in Mumbai concluded four of their patients had it – and after a series of tests, identified eight more cases, which they describe in an article published in the U.S.-based journal Clinical Infectious Diseases in late December.
Zarir Udwadia, a consultant chest physician at P.D. Hinduja National Hospital and Medical Research Centre in Mumbai and lead author of the article, said he and his colleagues confirmed that these 12 patients had TDR-TB by performing what is called “drug susceptibility testing” in the Hinduja hospital laboratory, which is accredited by both the national TB program and the World Health Organization.
“We have the makings of a potential epidemic,” Dr. Udwadia said.
Already, two Indians die of tuberculosis every three minutes – nearly 1,000 people each day.
The totally resistant strain has emerged because of poor practices by private-sector physicians who often know little about TB but prescribe drugs for patients, many of them slum dwellers, who bounce between them and an efficient but alienating public-health system as their income allows.
In a study on the prescribing practices of private practitioners treating TB, Dr. Udwadia found that only five of 106 prescribed correctly. “Second-line drugs are thrown around like water,” he added, in a way that only serves to breed further drug resistance. A TB patient not properly treated can infect 10 or 20 other people every year, he says.
The Indian government has yet to respond formally to the announcement that TDR-TB has been found here. Blessina Kumar, vice-chair of the global STOP TB campaign of the World Health Organization, said she feared that embarrassed officials from the national TB control program would attempt to deny its existence.
“The emergence of TDR-TB reflects directly on the efficiency of the [national TB]program and the public health system,” she said. “So there will be a reluctance to accept that it has now been found here. But now it is time to put in contingency efforts or it’s going to really blow out of proportion.”
Her concerns seem well-founded. When asked, Ashok Kumar, deputy director-general of India’s national TB program, said “there is nothing abnormal” about the reported cases of TDR-TB, adding, “What new form? What new form is there?”
Echoing Dr. Udwadia’s observations about the lax prescribing standards of private physicians, he said that there was bound to be drug-resistant TB in India, and that it simply had not been mapped until now. But he insisted there is no cause for alarm. “With a large population, it is inevitable some will be resistant,” he said. “I don’t think we need to worry because some news has come from one hospital.”
In the context of India’s disease burden – 2.3 million new cases in 2009 – these 12 are not a big issue, he said. “You have to look at the numbers in context, not just data from this one small corner.”
Ms. Kumar believes TDR-TB likely exists in many other parts of the country; the Mumbai cases were diagnosed because of the high level of skill and care at the Mumbai hospital she said, “and the others just haven’t come to light.”
The national TB program has the right architecture, she said, closely monitoring patients on TB medications, which must be taken daily for as long as a year to guarantee the disease is cured, but poor delivery of services. “On paper it looks like a very good program but when you go … you are treated badly, you are not respected, you are shoved and pushed, no one listens to what you have to say – when anyway you are upset because you have this horrible, stigmatized disease – who would want to go back?”
Patients stop their treatment, or go to private physicians for as long as they can, but run out of money and end up back in the public system – with their drug regimen perilously disjointed. A patient whom Dr. Udwadia saw yesterday has been treated by nine physicians in five years; almost all of the drugs he was prescribed were in incorrect dosages.
Strains of tuberculosis that were resistant to the standard treatments (multi-drug resistant) were first diagnosed in the early 1990s. They are harder to treat than classic TB – which is difficult to diagnose but not complicated to cure – but it is possible.
Then in 2006 doctors in South Africa identified something they called Extremely Drug Resistant TB, which could not be cured with more than half the known treatments; that caused a health panic in a country with a massive HIV epidemic.
Cases of XDR-TB turned up in Mumbai a year later. Yet even XDR-TB can be cured with enough money, skills and time.
The strain Dr. Udwadia and his colleagues found in their lab is different. These patients “are basically no-hopers,” he said bluntly.
India’s TB program has had some victories, rolling out “daily observed treatment” to every part of the vast country. But if patients don’t respond to the standard treatment, “the government throws up its hands” and says it can’t help, Dr. Udwadia said. Less than 1 per cent of the estimated 275,000 MDR-TB patients in India are treated in the public system, he said; the rest are taking the wrong drugs in the private system. “They linger on, infecting 10 or 20 of their contacts every year.”