That then is the challenge this World Tuberculosis Day. With the threat of drug-resistant strains of TB now a certain reality, how does the nation ensure that it can prevent the danse macabre of the Mycobacterium tuberculosis? While drugs are integral, spreading awareness about the need to stick to drug regimens and continue with the full course of the treatment is surely the road to take.
The World Health Organisation defines Multi-Drug Resistant TB (MDR-TB) as resistance to at least two of the first line drugs used: rifampicin and isoniazid. It is, by and large, caused when patients default on treatment, though it is also known to be caused by spontaneous mutation of the bacteria as well. The world is also concerned now about XDR-TB or eXtensively Drug Resistant TB, a subset of MDR-TB also resistant to fluoroquinolones and one of the three injectibles, Kanamycin, Capreomycin and Amikacin. XDR-TB has been noted as an emerging health threat, especially in countries like India, with a high prevalence of HIV.
Tuberculosis Control India, the wing of the Union Ministry of Health that implements the Revised National Tuberculosis Control Programme (RNTCP), indicates that MDR-TB levels in the country are about three per cent in new cases and 12-17 per cent in re-treatment cases. A 2004 WHO Global TB Control Study in India notched MDR-TB at 4.1 percent of the total estimated number of cases of new and previously treated TB cases.
TBC points out that low percentage figures are not a source of comfort. In India it translates into large absolute numbers. L.S. Chauhan, Deputy Director General (TB), Central TB Division, in a paper in the Indian Journal of Tuberculosis, 2008, “Drug Resistant TB-RNTCP Response”, says WHO estimates that there are over 4,00,000 cases of MDR-TB every year across the world, with estimated deaths of over 1,00,000. China, India and the Russian Federation contribute to a majority of this case burden, with India itself contributing 80,000 cases every year.
He also goes on to diagnose the problem: “This is mainly due to under-investment in basic TB control, poor management of anti-TB drugs and transmission of drug-resistant strains. MDR-TB is more difficult and costly to treat than drug susceptible TB, but recent work has shown that it is feasible and cost-efective even in settings of very limited resource.”
Poorly-treated patients can develop drug resistance and potentially incurable forms of TB. Though drug resistant tuberculosis has frequently been encountered in India and its presence has been known virtually from the time anti-tubercular drugs were introduced, it was only recently that the government launched a programme to take on the challenge of MDR-TB. DOTS Plus was the answer. DOTS Plus would ride on the achievement of its predecessor DOTS, that is being used nationwide to treat TB.
According to TBC, the diagnosis and treatment of MDR-TB cases are complex, and therefore RNTCP has developed national guidelines based on the WHO guidelines. As per the DOTS Plus strategy the diagnosis of MDR-TB will be made at the Intermediate Reference Laboratories (IRLs) accredited to perform culture and Drug Sensitivity Testing (DST).
After diagnosis, the treatment of MDR-TB patients is assigned to certain DOTS Plus sites, established in tertiary care centres (like Medical Colleges and speciality hospitals). Hopefully, there will be at least one in each State. The Cat IV regimen of treatment, prescribed for MDR-TB will be given daily, under Directly Observed Treatment at the centre during a short period of in-patient care. Follow-up action will be initiated to deliver the drugs through DOTS again, making it available through DOTS providers directly to the patient.
At the end of 2008, the DOTS Plus services were available in seven States: Gujarat, Maharashtra, Andhra Pradesh, Haryana Delhi, Kerala and West Bengal. Tamil Nadu joined this group in January 2009, after the IRL was set up at the Tuberculosis Research Centre late last year. According to TBC, the plan is to make DOTS Plus services available in all States by 2010.
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