India: Wrong TB diagnosis, treatment result in 2 deaths every 3 minutes

It's easy to understand why coughing could pass unnoticed in India for tuberculosis (TB) exists on an epic scale here. It remains the country's biggest and most neglected public health problem. But these coughs were noticed because of our description of the first four Indian cases of TB who were resistant to all 12 available drugs.

Unlike MDR (multi-drug resistant) patients, who were resistant to two drugs, and XDR (extensively-drug resistant) patients, who were resistant to four drugs, our patients were TDR (totally resistant) to a total of 12 drugs, leaving them with few options.

The facts speak for themselves: India has the highest TB burden in the world with nearly 30 crore Indians infected, accounting for 21% of the global incidence. It is estimated that TB kills three lakh Indians annually: two deaths every three minutes, a grim statistic that has changed little over the decades.

Patients with MDR-TB have been let down by all stakeholders.

The government TB programme couldn't rapidly diagnose or treat the patients. The diagnosis is impossible without a drug susceptibility test. This test was offered to barely 1% of the estimated number of MDR cases. As a result, patients were diagnosed late or not at all and TB, a disease transmitted by coughing, spread through our crowded communities. It's estimated that a single untreated TB case will infect 10-15 contacts in a year. We, thus, have the makings of a potential epidemic on our hands.

Then even after these patients were diagnosed, the government looked in the other direction and did not have drugs in place to treat them. They went either untreated or even worse, were treated with drugs that the lab reports suggested they were resistant to. In any other country, this would have caused an outcry in the public and medical circles. In India, this was passed off as acceptable public health realpolitik.

Let down by the government medical system, these patients turn to private medical practitioners. Some private practitioners, who are poorly trained, prescribe incorrect drugs in wrong doses which again worsen the disease. Thus, TDR-TB is a sad, but cautionary, tale of how the tools available have been squandered until an almost untreatable form of TB emerged.

After initial panic and then denial, the government finally swung into action and adopted a number of positive measures. This included more funding for TB, the rollout of new tests (the promising automated GeneXpert test which gives a diagnosis of drug resistance in six hours as opposed to six weeks) and more manpower to strengthen the programme. But a lot remains to be done in this country and the fate of global TB control depends on the country's ability to respond to this crisis.

In India, what is urgently needed are better lab facilities, the abandonment of the impotent Cat 2 treatment that the government currently uses to treat patients who fail standard treatment and the expansion of DOTS-Plus (providing appropriate drugs to all with MDR-TB). Public-private partnerships and education of private practitioners need to gain momentum. The need to partner with the private sector, which treats 70% of all TB patients, is critical.

Finally, it's to be hoped that a legislation is passed to ensure only qualified specialists prescribe second-line drugs. India remains the only country in the world where any and every doctor of any specialty can prescribe TB drugs with complete impunity.

All this will take political will and additional funding, but India's MDR-TB patients have been neglected for so long that their claims for justice can no longer be denied. Unless, we do this, we will, by our complacence, be guilty of ignoring an emerging public health epidemic, one that India can ill afford.

Source: The Times of India