Multidrug resistant TB (MDR TB) is a form of TB that has developed resistance to both rifampicin and isoniazid, the two drugs that are considered the backbone of TB treatment. The most important driving factor for the propagation of MDR TB is incomplete or inadequate treatment. The WHO estimates that in 2014, there were 480,000 cases of MDR TB worldwide, accounting for about 5% of all TB cases. Of these, only 123,000 were reported, and 111,000 received treatment (1). The threat of MDR TB in India is persistent and growing. Along with China and Russia, India is a high-burden country for MDR TB. Together, these countries made up over 50% of the world’s cases in 2014. In India alone, there are an estimated 99,000 cases per year (2).
This week, we visited Sivananda Rehabilitation Center, a medical facility that focuses on treatment of both leprosy and TB. For TB treatment, it’s one of the centers that implements DOTS, or Directly Observed Treatment Short Course. This is an initiative by the Indian government’s Revised National Tuberculosis Program (RNTCP) to create a nationally standardized treatment plan for TB. It’s based on WHO recommendations, and its goal is to ensure that patients complete the course of their TB treatment correctly and in its entirety.
The first part of TB treatment is called the intensive phase and generally lasts for two months depending on whether or not follow-up smears are positive. During this period, patients are required to attend a clinic such as Sivananda to be observed taking their medications. The dosing is intermittent, which means that medications are administered every other day and that patients have to go to clinic only three times per week. After the intensive phase, patients enter the continuation phase of treatment. This typically lasts for four to five months. Patients attend clinic only once weekly. At this visit, they take their first dose of medications for the week, and they are given the rest of their week’s doses in neatly packaged boxes. The medications themselves are placed in daily packets with specific instructions about how to take them, and the patient must demonstrate an empty box before getting their next one. Ashas, or community health workers, are also an important part of the DOTS program, and their main responsibility is to reach out to patients who are struggling with compliance or who live in rural areas.
Success rates of the RNTP’s DOTS are pretty good and have achieved the global targets of an 85% cure rate and 70% detection rate (3). If this is the case, then why is it that MDR is continues to be such a growing health threat in India? There are no good studies that directly answer this question. One of the concerns, though, is that it stems from poor compliance and inadequate treatment in the private sector. In a study done in Mumbai in 2010 investigating TB treatment in the private sector, only 6 of the 106 practitioners interviewed wrote a correct regimen. Among these 106 regimens, there were 63 different variations (3). There’s also data showing that compliance in the private sector is pretty poor, with one study reporting a dismal 59% (4).
A solid portion of patients in India receive their care from private medical practitioners. If TB resistance is stemming at least in part from inadequate treatment by these providers, then it seems like this is an appropriate place to intervene. However, in India, I don’t think this is so simple. There are 1.3 billion people in this country, many of them live in rural areas, and 40% of them have latent or active TB. Resources are limited in the medical setting, and there is a dearth of medical providers. There is supposed to be 1 Ashna for every 1000 patients. At Sivananda, we learned that in their district, there is only 1 per 10,000 because of insufficient staff. While there has certainly been a strong effort to fight TB in India, the propagation of resistance is a real concern without a great solution. For now, MDR TB will remain. And while it may not quite be a Rajinikanth, it’s certainly a force to be reckoned with.
2. Rajendra Prasad, et al. The Indian Journal of Chest Diseases & Allied Sciences. 2014; Vol.56. 237-246.
3. Udwadia ZF, Pinto LM, Uplekar MW. Tuberculosis Management by Private Practitioners in Mumbai, India: Has Anything Changed in Two Decades? Pai M, ed. PLoS ONE. 2010;5(8):e12023. doi:10.1371/journal.pone.0012023.
4. Uplekar, M. et al. Int J Tuberc Lung Dis. 1998 Apr;2(4):324-9.