India’s TB treatment inadequate raising risk of drug resistance

By Dr. Ananya Mandal, MDMar 26 2012

India suffers from inadequate government-run tuberculosis (TB) treatment programs and a lack of regulation of the sale of drugs against TB. This has led to the rise in number of drug-resistant cases that are difficult to treat, health activists said Friday.

India adds an estimated 99,000 cases of drug-resistant TB every year, but only a tiny fraction of those infected receive the proper drugs to treat the stubborn disease through the government-funded program. Saturday marks World Tuberculosis Day. An estimated 20 percent of the world’s multi-drug-resistant cases are found in India, which is home to a quarter of all types of tuberculosis cases worldwide.

The original form of the disease can be easily cured by taking antibiotics for six to nine months. But if that treatment is interrupted or the dose is cut, the bacteria battle back by mutating into a tougher strain that can no longer be killed by standard drugs, making it harder and more expensive to treat. The easy availability of TB drugs in the private market and the casual over-the-counter sale of antibiotics is fuelling the development of drug resistance, Piero Gandini, head of Doctors Without Borders in India, said in a statement. “There is an urgent need for regulatory control of sale and administration of TB drugs in the private sector,” he said.

Dr Paul Nunn, head of the WHO's global TB response team, is leading the efforts against multi-drug resistant TB (MDR-TB). Nunn said that, while TB is preventable and curable, a combination of bad management and misdiagnosis was leaving pharmaceutical companies struggling to keep up. Meanwhile, the disease kills millions every year. “It occurs basically when the health system screws up,” said Nunn.

If a tuberculosis case is found to be resistant to the two most powerful drugs, the patient is classified as having multi-drug-resistant TB. An even worse classification of TB — one the WHO accepts — is extensively drug-resistant TB, a form of the disease that was first reported in 2006 and is virtually resistant to all drugs.

“Treating TB requires a carefully followed regime of medication over six months. In places where health services are fragmented or underfunded, or patients poor and health professionals ill-trained, that treatment can fall short, which can in turn lead to patients developing drug-resistant strains. It's been estimated that an undiagnosed TB-infected person can infect 10 others a year. There's a vicious circle, because when new drugs come out they are expensive, so there is no demand. Without the volume of demand, the cost will not come down. If we can't tackle this, we are going to finish up with a lot more people being diagnosed with multi-drug resistant strains. We've already lost the battle in places such as the former Soviet Union, and so we need a huge expansion of effort, especially in places like India and China.” He added, “In some areas we have probably already lost the battle. Globally, it is still just 5% of the total number of TB cases, but with sloppy management of treatment we are moving towards an accelerating problem.”

The organization and other health groups also said India’s TB control program provides treatment to patients only on alternate days. They argue it increases the risk that patients, most of whom are poor daily wage labourers, will miss doses, another factor responsible for drug-resistant strains of TB. Patients also increasingly turn to private doctors who often do not understand how to properly treat TB or the risks of increasing drug resistance by prescribing the wrong drugs.

In January, Indian doctors reported the country’s first cases that appeared to be “totally drug resistant,” a long-feared and virtually untreatable form of the killer lung disease. The Indian hospital that saw the initial cases tested a dozen medicines and none of them worked.

TB was once the biggest killer in Britain, but cases are now concentrated in London and among people not born in the UK. Provisional figures from the Health Protection Agency showed there were 9,042 new cases in 2011, compared with 8,587 in 2010. But Professor Ibrahim Abubakar, head of the TB section at the HPA, cautioned, “Despite the observed increase in TB cases in 2011, this provisional data should be interpreted with caution, because numbers are likely to change due to late notifications and de-notification of cases. It is therefore too early to determine whether this is a return to the upward trend of cases seen in the past two decades in the UK. TB continues to disproportionately affect those in hard to reach and vulnerable groups, particularly migrants, so it is crucial that we have specific strategies in place to address this.”

Aaron Oxley, of Results UK, said, “Thanks to sustained efforts from the Global Fund, TB cases have been in decline, but with the current lack of resources there is scope for severe backsliding on the progress we have made. This is disappointing and worrying news as we have a real chance of seeing an end to TB in our lifetime.”