India steps up TB fight as fears of drug-resistant strains mount
By Simon Denyer,
MUMBAI — The discovery of an almost untreatable form of tuberculosis in India has set off alarm bells around the world and helped spur a dramatic expansion of government efforts to battle the killer lung disease.
For the past decade, a nationwide tuberculosis program involving millions of health workers and volunteers has made slow but significant progress in battling the disease in India and has been hailed as a public-health success story. But any sense of complacency was dispelled in December when a doctor in Mumbai, Zarir Udwadia, discovered a strain of the disease that did not respond to any of the 12 frontline drugs. He declared a handful of patients at his chest clinic in Mumbai to be suffering from “totally drug-resistant TB.”
Some 130 years after the discovery of the tuberculosis bacteria, and more than 60 years after the discovery of antibiotic treatment, “we have managed by a combination of complacency and incompetence to allow this bacillus to mutate into a virtually untreatable form,” he wrote in the journal of the Asian Pacific Society of Respirology.
His findings made national headlines and won him government condemnation for “spreading panic” and “spoiling the country’s reputation.”
The government, however, recently announced a fourfold increase in the budget to fight tuberculosis in its next five-year plan, the expansion of a nationwide network of costly labs capable of detecting drug-resistant strains of the disease, and the first concerted effort to bring on board India’s poorly regulated private health-care sector.
“The government is taking a very ambitious approach of universal access,” said Ashok Kumar, director of the national TB program. “We aim to detect all TB cases as early as possible and see everyone takes their treatment early and completes it. It needs a lot of effort.”
About 2 million Indians have the disease diagnosed every year, and about 1,000 die of tuberculosis every day.
But the highest mortality rates are found within an estimated 100,000 Indians who suffer from “multi-drug-resistant” strains of the disease, so called because patients do not respond to the two most powerful drugs available.
Months of treatment are needed to eradicate tuberculosis from a patient’s system, and failure to complete the course, or take the right drugs, often allows the bacillus to mutate into drug-resistant strains.
Diagnosis of these strains can be done only in sophisticated laboratories, and treatment, at up to $2,000 per person, costs 200 times what it costs for regular patients.
For that reason, the government has until now virtually ignored patients with drug-resistant strains, with potentially disastrous consequences.
“The problem of drug-resistant tuberculosis is one that the authorities have often tended to gloss over because they have always been more focused on dealing with the huge problem of drug-sensitive TB,” Udwadia said. “We have failed this group of patients, the multi-drug-resistant TB patients. We don’t have the funds to diagnose them correctly. Once we’ve diagnosed them, we don’t treat them correctly. And we pass it off as public-health realpolitik.”
Home to 1 in 5 patients
At its height two centuries ago, tuberculosis — or consumption, as it was then known — killed one in four Europeans, many in the urban slums of the Industrial Revolution, and consigned millions to slow deaths in sanitariums.
The disease was almost wiped out in the West after the development of the antibiotic streptomycin in the 1940s, but it remained a major killer in poorer countries.
In the 21st century, tuberculosis is again on the advance in Africa, dealing out death hand in hand with HIV/AIDS, but it is in gradual retreat elsewhere.
Nevertheless, India is home to more than 1.2 billion people, and its sheer scale, its poverty and its shaky health-care system mean tuberculosis remains a significant concern here. One in six of the world’s population lives in India, and one in five of global tuberculosis patients are found here.
For the past two decades, India has slowly come to grips with regular strains of TB under a World Health Organization program known as DOTS, or Directly Observed Treatment Short Course, in which patients are given free drugs but have to take them three times a week, in the presence of a health worker or volunteer, for at least two months.
It involved a monumental effort — perhaps bettered only by the country’s successful program to eradicate polio — but India now meets global targets by detecting more than 70 percent of TB cases and curing more than 85 percent of those detected.
Udwadia calls that program a “triumph” but says India’s health-care system, in which doctors often lack basic training and pharmacists dispense almost any drug without prescription, allowed drug resistance to grow.
In the past year, he has identified 15 patients with “totally drug-resistant TB,” all people who have seen multiple doctors, have taken multiple drugs but have never had the disease properly diagnosed or treated. Five have died.
The government, he said, has “moved up a gear” in the race against TB, although he worries it is “too late and too little.”
Despite his findings and the discovery of similar strains in Italy and Iran in recent years, the World Health Organization says there is not enough proof to justify the label “totally drug-resistant.” In any case, there are several new drugs and vaccines in advanced stages of clinical trials.
‘It will grow’
Although drug-resistant TB can be transmitted from patient to patient, regular strains of TB still dominate. Just 2 percent of new TB cases in India are found to be multi-drug-resistant; the majority of cases are in patients where the disease has recurred after unsatisfactory treatment.
Perhaps spurred by Udwadia, the government made it mandatory in May for private-sector physicians to report every case they detect. More than 60 laboratories are being established to test for drug-resistant strains, while controls over pharmacies are being discussed.
The problem of drug resistance “is manageable, but it is growing,” said the World Health Organization’s Indian representative, Nata Menabde. “And if you don’t introduce some controls over use of antimicrobials [drugs] and don’t get people into right treatment regimens, it will grow.”
In Mumbai, 35-year-old Owais Sheikh first came down with TB in 1991 and then fell ill with TB and HIV in 2008. A series of costly and unsatisfactory treatments followed until he found himself under Udwadia’s care.
In a simple one-room house in a Mumbai slum, he said he is gradually feeling better since an operation to remove a lung in December. But he speaks quietly in case neighbors learn of his disease.
“If they come to know, there will be a change in their attitude,” he said, with his wife, Musarat, sitting nervously at his side. “This place is rented, and the owners will tell me to leave.”