India faces totally drug-resistant TB

India faces 'totally drug resistant' TB cases. Copyright: WHO/TDR/Crump

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[NEW DELHI] India’s central health ministry officials currently studying 12 cases of extensively drug-resistant tuberculosis (XDR-TB) that emerged in a Mumbai hospital say they fall short of being totally drug resistant (TDR-TB). 

While admitting that the cases were more serious than extensively drug resistant TB (XDR-TB), the officials told journalists on 18 January in Mumbai that they are best described as ‘extra XDR-TB’.

A report in The Hindu newspaper on 19 January, citing the central health ministry team, said seven of the 12 cases at the P.D. Hinduja National Hospital and Medical Research Centre were responding to treatment. Three others proved fatal and two more were being traced.  

XDR-TB cases are resistant to any of the three second-line drugs, while Multi-Drug Resistant TB (MDR-TB) cases are defined as those that do not respond to at least two of the most potent first-line anti-TB drugs.

A team led by Zarir Udwadia from the Mumbai hospital had reported four cases described as TDR-TB in Clinical Infectious Diseases on 21 December, in which first-line and second-line drugs failed to kill bacteria cultured from patients’ sputum.

Italy reported the first TDR-TB cases in 2007, followed by Iran in 2009.

India has the world’s highest TB burden, accounting for a fifth of cases. The country reports 1.98 million new cases each year, and 280,000 deaths, according to Kuldeep Singh Sachdeva, head of the Revised National TB Control Programme (RNTCP).

"This (Indian) report on TDR-TB in India is worrisome because it is a clear sign that TB is not being correctly diagnosed and managed, especially in the private medical sector where irrational TB management practices are widespread," said Madhukar Pai, associate professor at McGill University’s department of epidemiology and biostatistics, Montreal.

"Furthermore, TB drugs are freely available over-the-counter and poorly regulated," Pai, an expert on TB diagnostics, told SciDev.Net.

Pai said that mismanaged TB was not only bad for patients, but also threatened TB control efforts in India.

However, he said, it was important to engage the vast private health sector and get it to adhere to nationally and internationally recommended guidelines on TB diagnosis and treatment.

Over 50 per cent of all TB cases in India are managed in the private sector, and "without their engagement and contribution, the goal of universal access  cannot be reached," Pai observed.

A statement by the Indian health ministry this week (17 January) rejected use of the term “totally drug resistant”, saying the category was recognised neither by the WHO nor by India’s RNTCP.

WHO defines these cases as XDR-TB and they are managed by national XDR-TB treatment guidelines, the statement said.

WHO recommends against the use of drug susceptibility testing (DST) results for second-line drugs, beyond those used to identify XDR-TB, in guiding treatment.

It said the term ‘totally drug resistant’ was "non-standardised" and "misleading"; testing for resistance beyond XDR-TB was not advocated by WHO and "poor clinical response to treatment has not yet been correlated with diagnosis of drug-resistant TB without laboratory conformation from accredited labs."

Link to the abstract in Clinical Infectious Diseases: