Online consultation: Lessons from roll-out of MDR-TB services

Citizen News Service (CNS), a partner of the Stop TB Partnership, and the global Stop-TB eForum along with partners are hosting an online consultation to document community perspectives and learn lessons on what worked and what didn’t in rolling out MDR-TB services in different countries/ contexts. These lessons are very important, especially experiences of affected communities, we believe, and must not be missed. These lessons should inform the ongoing and future planned roll-out (and scale up) of MDR-TB services at all levels.
GUIDING QUESTIONS
* Please share your experiences and perspectives of what works and what doesn’t work in your local settings where MDR-TB related services are available? 
* What are the key lessons from this experience, that must be taken into account before scaling up the MDR-TB services any further for enhanced public health outcomes?

RATIONALE
Despite about half a million new MDR-TB cases every year, MDR-TB related services have been limited to very fortunate few with large number of people who need care remaining unreached. Unless required measures are urgently taken to reduce new MDR-TB infection rate, and standard MDR-TB related care is made available and accessible to all those who are in need, a humungous pandemic will continue to brew.

It is acutely important to learn lessons on what worked and what didn’t in rolling out MDR-TB services which currently reach a very small fraction of people who need care for MDR-TB. These lessons must inform the ongoing roll-out and accelerate scale up of MDR-TB services in different countries and contexts, to enhance positive public health outcomes.

TIMELINE:
The online consultation is open for three weeks (Wednesday, 17th October 2012 to Wednesday, 7th November 2012), after which a SUMMARY REPORT will be published by CNS and partners.

HOW TO PARTICIPATE?
Have your say by:
- Joining the new Stop-TB eForum by sending an email to: stop-tb-subscribe@yahoogroups.com or stoptb@citizen-news.org
- Becoming an organizational PARTNER of this online consultation - to be a partner organization, send an email to: stopTB@citizen-news.org
- EMAIL us your comments, perspectives and experiences at: stopTB@citizen-news.org
- Go online at CNS blog: www.citizen-news.org and publish your comments real time!
- Skype us and we will record your statement (skype id: bobbyramakant ). To schedule skype appointment, email: stopTB@citizen-news.org
- Tweet us! use #tag: #MDRTB
- Have your say on our CNS Facebook page!
- Call us and record your statement! (+91-98390-73355)

WHAT WILL HAPPEN TO THE SUMMARY REPORT?
The summary of this online consultation will feed into the issue brief which the onsite CNS team at the 43rd Union World Conference on Lung Health (Kuala Lumpur, Malaysia) will use to provide issue-based coverage. The CNS team members and partners will also raise key issues highlighted by this consultation process at this conference in appropriate sessions. The summary report will be distributed at this conference, and also be disseminated to national TB programmes of 27 high burden MDR-TB countries identified by the Stop TB Partnership, and through other channels such as Stop-TB eForum, CNS syndicate, other networks and social media platforms.

BACKGROUND
There were about 650,000 cases of multidrug-resistant tuberculosis (MDR-TB) present in the world in 2010. Annually, about 440,000 fall ill with MDR-TB and 150,000 die due to this form of TB. India has an estimated annual incidence of 99,000 cases of MDR-TB (which is second only to China with about 100,000 cases). Out of these only 3610 cases had been initiated on category IV treatment till 2010 under the DOTS Plus program.

TARGETS
Scaling up MDR-TB control and treatment services is critical to achieving the goal of zero TB deaths (and HIV deaths) and new infections, the MDR-TB related targets of the revised Global Plan to Stop TB (2011-2015) and national TB programmes such as the Revised National TB Control Programme (RNTCP - DOTS Plus targets).

LEARN BEFORE WE SCALE UP
We can only effectively scale up the roll out of MDR-TB services, if we learn well from the experience of rolling out MDR-TB services in the past years, in different settings and for different key populations and contexts.

REFERENCE DOCUMENTS
Stop TB Strategy
Global Plan to Stop TB: 2011-2015
WHO Global Tuberculosis Control Report 2012
WHO Global Tuberculosis Control Report 2011
Whole Is Greater Than Sum Of Its Parts: CNS report 2011
RNTCP Annual TB Report 2011
MDR-TB Planning Toolkit (WHO and PATH) 2012
Hearing the unheard voices: Saving children from tuberculosis (CNS Report 2012)

30 comments:

  1. Dear Stop-TB members,

    We will be grateful if you and your team members can send us responses to the below questions in context of existing MDR-TB related services.

    - Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?

    - How far is the nearest DST Lab from your place?

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?

    - Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviours of healthcare providers?

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?

    Kind regards

    Shobha Shukla
    Citizen News Service (CNS)
    Email: shobha@citizen-news.org

    ReplyDelete
  2. SIR,
    GREETINGS. GIVING MY RESPONSES BELOW:

    - Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region? YES

    - How far is the nearest DST Lab from your place? 230 KMS

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient? 1 WEEK .NOT CRITICAL TO PT

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed? – NO NEED OF PERSONAL VISIT - RESULT GIVEN BY E MAIL

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own? -REFERRED FROM HEALTH FACILITY TROUGH TU

    - Is it more difficult to diagnose extra-pulmonary MDR-TB? – NO EXPERIENCE SO FAR

    - Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviours of healthcare providers?

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?

    Dr.P.S.Sarma
    SMLS TRUST - STOP TB PARTNER

    ReplyDelete
  3. Excerpt from CNS Interview with Professor (Dr) Surya Kant, KGMC
    -------------------------------------------

    Professor (Dr) Surya Kant, Head of the Pulmonary Medicine Department at King George’s Medical University calls MDR-TB an iatrogenic problem. In his opinion, “Most of the times it is we doctors who are responsible for creating multidrug-resistance in society. If doctors are not educating the patients then how can we blame the patients that they have defaulted from the treatment? Patients do not know the consequences of defaulting from the treatment. It is the doctors’ community that has to educate and motivate the patient.”

    ReplyDelete
  4. 4. Excerpt from CNS Interview with Dr Anthony Harries, The Union
    ---------------------------------------------

    Dr Anthony Harries, Senior Advisor at International Union Against Tuberculosis and Lung Disease (The Union), "The way the global TB Control programme works in Africa, India and China, we do not do a sputum culture at the beginning of TB treatment, even though the patient may be having MDR TB. It is only when the 1st line of treatment fails that we do the test for MDR TB. So we pick up the correct diagnosis far too late and by then a lot of patients are already dead and/ or the infection has been transmitted to many others."

    ReplyDelete
  5. There is no drug-sensitivity testing (DST) laboratory (lab) in my area/region. The nearest DST lab is 72 kilometers from my place.

    It usually takes about eight (8) weeks for the DST test results to be known. With the G-Xpert which is 72 km away it takes 2 days.

    The patient has to visit the centre four (4) times before his/her MDR-TB positive status is confirmed.

    Patients are referred from other health facilities and private clinics.

    Yes it is more difficult to diagnose extrapulmonary MDR-TB. It takes nine (9) months for diagnosis and treatment to start in areas where there is no G-Xpert.

    I do not think healthcare providers consider MDR-TB patients as equal partners with dignity.

    TB POSTING A PUNISHMENT FOR SOME HEALTHCARE PROVIDERS
    Healthcare workers dealing with TB are considered to be difficult nurses deployed from other departments as a punishment. They then have to learn from the job. Let TB healthcare workers be trained specifically for TB and retained. Let us employ them through competency and interest and then retain them.

    EARLY DIAGNOSE AND TREAT
    G-Xpert is still based far .Collection and transportation of specimens need to be made efficient and results conveyed to the patients by phone to avoid many trips to the facility . Preliminary test used to be too expensive and the cost was being borne by the patients which took time. With the introduction of G-Expert the time is short for diagnosis but the commencement of treatments will still take longer because of the other tests like Liver function test and the thyroid function test. These tests are not available at the government facilities and the patients not only pay in private clinics but also have to travel long distances to seek that service. As they look for which asset to sell to pay for the tests ,the mycobacterium eat their lungs.

    Peter N Owiti
    Wote Youth Development Projects
    Makueni, Kenya
    Email: pngola@yahoo.com

    ReplyDelete
  6. There is no DST lab in my area. The nearest DST lab is at least 250 km away. Even healthcare providers keep doing hit and trial treatment instead of confirming first whether there is drug resistance or not. Drug sensitivity testing profiling must be done BEFORE a patient is put on treatment - and time delays have to be worked upon to make the DST quick and efficient, and as close as possible to TB clinics.

    MDR-TB patient is supposed to feel grateful for the treatment she/ he is receiving, and under the weight of this supposed gratitude the patient must not complain about side effects. The reality is grim as side effects, even if the doctor thinks these are 'routine', are very severe and debilitating at times. We surely need to address this equation and since MDR-TB patient has to receive care on daily basis for a longer duration, they must be more engaged in the programme itself.

    Amir Siddiqui, Pakistan

    ReplyDelete
  7. I completed my TB treatment in Ballia district successfully two years back. Got a recurrence last year and did treatment in private first, then when it didn’t work, went to the government DOTS Centre. The treatment didn’t work so went to Varanasi, and then to Lucknow and now keeping fingers crossed that I get well soon and this treatment for drug-resistant TB works.

    I want to ask why is there no DST lab in my area? Why I have to travel for hundreds of kilometres and waste months feeling sick in confusion whether the treatment will work or not? Why cannot doctors find out first whether a medicine will work on me or not?

    U Bishwanath

    ReplyDelete
  8. Comment from Le T Thu, Viet Nam

    I am thankful to Hanoi Hospital for Lung - survived MDR-TB, began treatment in 2011. My question is - why treatment has to be so difficult, with severe side-effects that don’t allow me to work normally, and so long up to or more than 2 years?

    ReplyDelete
  9. Mahendra Patwar, MDR-TB patient from Delhi
    --------------------------------

    Rail thin in a checked beige shirt, Mahendra Patwar waits in line at the Shastri Park chest clinic in north-east Delhi to take his daily dose of tuberculosis (TB) medication. The line curls out into a small courtyard, women and men covering their noses and mouths with bits of cloth.

    This is a familiar scene for Patwar, who has been battling TB for nearly eight years. First diagnosed with the disease at 20, Patwar was prescribed daily treatment for six months, and declared cured.

    But three-and-a-half years later, he started coughing again and losing weight. The second time, he was given a higher dosage of treatment for eight months. Then, when it came back again two years later, another four months of medicines.

    Finally, he was diagnosed with multi-drug resistant tuberculosis (MDR-TB)—a persistent strain that does not respond to the two most powerful first-line drugs—isoniazid and rifampicin. While normal tuberculosis can be cured by first-line drugs within six months, MDR-TB requires stronger, more toxic treatment that lasts for between two and three years.

    Patwar began MDR-TB treatment several months ago, involving a daily regimen of pills and an injection. Due to the severe side effects—nausea, loss of appetite, ringing in his ears and severe joint pains—Patwar has been unable to work. He spends his days whiling away time in front of the TV, waiting for his next trip to the clinic.
    Patwar represents one of the “easy” MDR-TB cases: He has a permanent address in Delhi, and rarely misses a dose. Despite his commitment to treatment, the efficacy is only about 50%, according to S.K Arora, Delhi’s State TB control officer.

    But thousands of other patients are starting treatment and stopping before its completion, or not getting treated at all. Migrant workers in particular have emerged as a critical group in the battle against MDR-TB, as they are at higher risk of contracting the strain of TB, but are among the least likely to complete treatment.

    “The spread of MDR-TB is a grave public health risk that needs to be taken very seriously,” said Dennis Falzon, a specialist with the Stop TB programme at the World Health Organization (WHO) in Geneva. “Drug-resistant tuberculosis is a man-made phenomenon. It’s due primarily to improper treatment of TB. If TB is treated improperly or inconsistently, drug-resistant strains emerge—once they emerge, they can spread to other people.”

    Written by Malia Politzer in July 2012, published in Live Mint, online at: http://www.livemint.com/Politics/bsWjPBLT7E6xbIVlbylkiJ/Fighting-drugresistant-TB-chinks-in-Indias-armour.html

    ReplyDelete
  10. Comment from Owen Mulenga, Zambia
    -------------------

    In Kafue district 45km south of Lusaka, Zambia, we don't have drug-sensitivity laboratory ,in most cases we depend on results and information from the main lab in Chelstone 25km from Lusaka city.

    Therefore from Kafue to DSL labs is close to 70 kilometers.

    Mostly it takes 2 visits for a patient to be confirmed his/ her MDR-TB status .

    Because MDR-TB lab is the government institution most patients are referred from the government health facilities and a few from private doctors.

    It is very difficult to diagnose MDR-TB here because we only have one MDR-TB lab which is ever under pressure of work due to the number of clinics it serves. Also it is done when a patient has undergone 6 month of DOTS for normal TB treatment it's when the second sputum test is done ,it is if there still the presence of TB bacilli then it is recommended for MDR-TB test to be done samples are taken to the MDR-TB lab in Chelstone lab and the results can take some days to come.

    The behaviour of healthcare providers towards MDR-TB patients may not be very good mostly because of the setup of our health centre which are poorly ventilated and lack of proper infection-control or safety tools for healthcare providers for them not to be infected with the disease which is very contagious.

    The change which is needed in order for MDR-TB to be diagnosed early is to establish MDR-TB labs in many districts in the province so that MDR-TB can be diagnosed before the patient is put DOTS of normal pulmonary TB after failing it's when MDR-TB is considered and it may be too late for the patient.

    Due to the distance from Kafue to the MDR-TB lab in Chelstone and the pressure of work on lab technicians who serves a number of clinics it takes a week and some days for the results to come.

    Owen Mulenga, Zambia
    Email: owenmulenga@gmail.com

    ReplyDelete
  11. Santosh Kumar, MDR-TB patient from Bihar
    -------------------------------------

    Santosh Kumar is a migrant from Bihar, who has been undergoing treatment for MDR-TB for nearly four months. He sits in a dusty plastic chair in a sunny two-bedroom home he shares with his wife and two children. Although Kumar knows life would be easier in Bihar where he could stay with his parents, there are NO government DOTS-Plus centres that provide free MDR-TB medication near his village. So he has decided to remain in DELHI (1000+km away) with his family until his treatment is complete. “I cannot afford the medication in Bihar,” he said. “They tell me this is the last chance I have to survive.”

    Written by Malia Politzer in July 2012, published in Live Mint, online at: http://www.livemint.com/Politics/bsWjPBLT7E6xbIVlbylkiJ/Fighting-drugresistant-TB-chinks-in-Indias-armour.html

    ReplyDelete
  12. Anonymous
    --------------------

    I am receiving MDR-TB treatment in Zambia and had to go to the lab two times. The lab is 145 km away from my place and it took about 14 days for the results to come.

    My question is why cannot we complain about problems (side effects) we face of treatment to doctors - it is not waste of time of doctors as side effects are one reason why people may interrupt treatment. Also why are patients of MDR-TB not counseled and briefed clearly on side-effects? Who can do this better than someone undergoing MDR-TB treatment or has finished MDR-TB treatment?

    ReplyDelete
  13. Comment from Jitendra Dwivedi, Gorakhpur, India
    --------------------

    Lot of research and experience already exists on why people develop drug-resistance to anti-TB drugs. We need to do diagnosis, treatment of drug-susceptible forms of TB so well that drug resistance doesn’t occur.

    ReplyDelete
  14. 14. Comment from Dr Y Ganesh, India
    --------------------------

    One of the ways to control MDR-TB and bring down numbers of new infections of MDR-TB is to strengthen DOTS - unless we plug the leak how will we ever be able to control MDR-TB?

    ReplyDelete
  15. Comment from Dr Muherman Harun, Indonesia
    ------------------------------------

    We have drug-sensitivity testing (DST) laboratory (lab) in our area/region. It had been called once the WHO Collaborative center for Tuberculosis.

    The nearest DST Lab is about 4 km from the main center. There are 4 peripheral centers which are 15 km from the main center. Twice a week the sputum specimens were collected at the main center and taken to the laboratory.

    Alas, this collecting system started over 29 years ago is recently halted due to reportedly, lack of personnel and funds. Without doubt this will add to the (esp. financial) burden of the patients. God forgive.

    - For the test results to be known it would take 3 hours for direct sputum smear. Nowadays patients had to return next day. For culture tests it takes 2 months and another 2 - 4 weeks for sensitivity tests. Now the patients have to collect the results by themselves, previously it was coordinated by the main center.

    HOW CRITICAL IS THIS TIME GAP FOR THE PATIENT?
    The sensible doctor should be able to cope with the existing situation and different condition(s)

    He would do culture and sensitivity tests at the start of treatment if confronted by serious (or previously) treated lung TB. Depending on the size and nature of the lung lesion and severity of disease, he will decide whether 1 or 3 sputum smears are examined and whether or not sensitivity tests are needed. Thirty years ago, when examination were not of high cost, culture and sensitivity tests were routine for any new patient.

    - HOW MANY TIMES DOES THE PATIENT HAVE TO VISIT THE CENTRE BEFORE HIS/HER MDR-TB POSITIVE STATUS IS CONFIRMED?

    First time presentation of sputum.

    Second time get sputum smear result

    3rd Culture test result

    4th or more visits to get the ultimate sensitivity tests results.

    - ARE THE PATIENTS REFERRED TO THE CENTRE FROM SOME OTHER GOVERNMENT HEALTHCARE FACILITY, PRIVATE DOCTOR, PATIENT COMES ON OWN?

    Sputum examination is still not popular practice, due to the supposedly long
    time needed to get culture/sensitivity tests results. There are no patients
    who present themselves for sputum examination. The laboratory staff would
    obviously reject their request

    - IS IT MORE DIFFICULT TO DIAGNOSE EXTRA-PULMONARY MDR-TB?

    A trained doctor can diagnose scrofuloderma discerning from 'normal cervical lymphglands in children. Only rare or doubtful cases are sent to the PA specialist Children or young adults with radiological fluid in lungs can be diagnosed as follows: As a rule 1 or two month treatment with anti TB drugs and corticosteroids will show a sharp decrease of fluid. No PA test is necessary, nor pleural puncture. or hospitalization.

    - DO YOU THINK HEALTHCARE PROVIDERS CONSIDER MDR-TB PATIENTS AS EQUAL PARTNERS WITH DIGNITY? Most easily. MDR patients cough a lot. Are emaciated and have lost interest to improve self-image.

    WHAT CHANGES CAN BE BROUGHT IN ATTITUDES AND BEHAVIOURS OF HEALTHCARE PROVIDERS?

    To regularly emphasize that every patient has a human dignity, which we should respect, irrespective of religion, conviction, gender, socioeconomic status culture and education.

    - WHAT CHANGES SHOULD BE BROUGHT TO DIAGNOSE MDR-TB EARLY AND TO BEGIN MDR-TB STANDARD TREATMENT AS EARLY AS POSSIBLE?

    Have a decent and reliable bacteriological lab. Reduce the cost of bacterial examination It should be made free

    The number of tests should be increased according to the number of TB drugs used

    Start treatment only if all drugs are available throughout the treatment period. Patient and nearest kin are thoroughly, and consistently motivated. Any constraint to complete satisfactory treatment be solved satisfactorily.

    Kind regards

    Dr Muherman Harun, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  16. Op-Ed written by Dr Madhukar Pai
    -----------------------------------

    TRAINING GUNS ON TUBERCULOSIS
    Dr Madhukar Pai
    The Tribune, India
    29 October 2012
    *************************

    THE RISE OF MULTIDRUG-RESISTANT TB IN THE RECENT PAST IN INDIA IS WORRYING. THE GOVERNMENT, AND BOTH THE PUBLIC AND PRIVATE SECTORS, MUST WORK TOGETHER TO CHECK THE SPREAD OF THIS NEW THREAT

    Tuberculosis (TB) is one of India's oldest and perhaps most neglected public health challenges. The perception among the majority is that we are not at risk of being infected by TB. This assumption is deeply flawed.

    TB is caused by bacteria that spread from person to person through air. We are all exposed and vulnerable to it at all times. Chronic cough (for more than two weeks) and fever are the most important symptoms of the disease. When a person with TB coughs, the bacteria get ejected into the air. These get inhaled by someone else who then becomes infected. Now, with the rise of drug-resistant TB, the disease has become more complicated to control and difficult to treat.

    In most cases, TB is curable. However, it requires several antibiotics simultaneously and long-term treatment for cure. Patients must take at least six months of medication without interruption. If the medicine course is not completed, the bacteria can become resistant to the first-line treatment drugs. This usually happens when patients do not complete their full course of treatment; when doctors prescribe some wrong treatment, the incorrect dose, or length of time for taking the drugs; when the supply of drugs is not continuous; or when poor quality drugs are used.

    MULTIDRUG-RESISTANT TB
    -------------------------
    The rise of multidrug-resistant (MDR) TB in the recent past in India is worrying. MDR-TB is resistant to isoniazid and rifampicin, two of the most important and commonly-used first-line antibiotics used to treat TB. The MDR TB requires extensive treatment (two years or longer) with multiple drugs, and outcomes are usually poor. Treatment of drug-resistant TB is also very expensive because of the high cost of second-line drugs...

    TO READ THE FULL ARTICLE, GO Online at: http://www.tribuneindia.com/2012/20121029/edit.htm#6

    ReplyDelete
  17. Experiences shared by Payel Bhattacharya, MDR-TB patient from Delhi
    -------------------------------

    32 years old Payal Bhattacharya, who lives in Delhi, suffers from an extremely rare genetic disorder known as Von Hippel-Lindau (VHL) syndrome which results in the formation of multiple benign or malignant tumours in different body organs. Recently Payal spoke to CNS on phone regarding her added problem of drug resistant TB.
    “I have been on tuberculosis medication for more than two years. I am a VHL patient and have undergone several surgeries because of this disorder. After one such surgery I started losing weight very rapidly and was then detected with TB in 2009. For the first three months I was on rifampicin and combutol, but later on I was found to be resistant to these 1st line drugs. Even after taking streptomycin injections for 8 months, my condition did not improve. I was then put on some other drugs, along with streptomycin. But still I did not respond to treatment. My lymph gland was affected, whose biopsy, done after 8 months into taking MDR TB treatment, gave a positive result. I was referred to Dr Guleria of AIIMS who prescribed claribid which gave some relief to me. But I am still not cured. I will complete two years of treatment on 24th October under my present doctor and then go for a whole body MRI as advised by him to determine the future course of action.

    I suffer from severe side effects of drugs. I am getting pigmentation of the skin and I cannot walk without a walker. I am under a lot of pain. I also get seizers (fits). Despite all my problems, I am continuing with my medication. I seem to be resistant to all antibiotics and would like pharma companies to get some feedback on this. There is need for better drugs for TB too which have lesser side effects. Through our (MDR TB patients) experiences they should develop better antibiotics. In these two years medicines have really damaged my life.

    I would like the government to do something concrete for people living with TB. Mere words are not enough. There should be some actual action. MDR TB Patients need support. Very few people can really connect to patients like us. It is pathetic that we have to pay for all our medicines, doctors’ fees, diagnostic tests. Yes, my genetic disorder is very rare, but TB is very common in India. So there should be some funding mechanism for a patient like me who has to be dependent on her younger brother and manage with great difficulty to pay huge monthly bills of over Rs 35,000 for treatment.”

    (Payel Bhattacharya told this to CNS on phone - transcribed and edited by Shobha Shukla - CNS)

    ReplyDelete
  18. Dear Stop-TB members,

    We will be grateful if you and your team members can send us responses to the
    below questions in context of existing MDR-TB related services.

    MDR-TB TREATMENT
    - What is the treatment duration?
    - What is the cost per month?
    - Do the medicines have any side effects and is the patient well informed about them?
    - Are there any special nutritional needs or dietary constraints during treatment? Did the healthcare provider brief the patients on them?
    - What are the treatment outcomes? Are they different from extrapulmonary MDR-TB? What factors affect treatment outcome?
    - Is appropriate counseling and treatment literacy given to the patient and family members or caretakers before and during treatment?
    - What infection control methods is the patient told to follow? What infection control measures are in place in healthcare settings?

    MDR-TB PREVENTION
    - What are the main causes leading to an escalation of MDR-TB cases?
    - What is being done to reduce its occurrence? What needs to be done more?
    - How can we initiate and improve general literacy on TB in the population and will it impact TB control efforts?

    Shobha Shukla
    Citizen News Service - CNS
    Email: shobha@citizen-news.org

    ReplyDelete
  19. Crisp and pointed observations, Dr Pai. As a WHO Consultant with [Revised National Tuberculosis Control Programme] RNTCP in India some time back, I would grapple with these issues in my field visits with a question on the patients' lips, why don't the doctors think collectively on how to treat TB?

    Why are the private doctors avoiding government guidelines for the treatment?

    Thanks

    Suvpat (on blog)
    *********************

    [Mods note: The above comment refers to an article written by Dr Madhukar Pai, available online at: http://www.citizen-news.org/2012/10/preventing-epidemic-of-drug-resistant.html . Thanks]
    *********************

    ReplyDelete
  20. Dear Stop-TB members and Prof. Madhukar Pai,

    I am very interested in the contagiousness of MDR or XDR TB.

    In your personal opinion and experience, is MDR or XDR TB a very contagious
    disease?

    Can it appear in the same household of the infectious patient?

    MDR or XDR TB may (if remain untreated) transmit the infection or eventually
    cause the disease in same house hold contacts.

    Would those contacts then produce the same MDR or XDR TB bacilli (with the
    same sensitivity tests?) Would such situation prove the true infectiousness
    of the MDR XDR TB?

    Perhaps you would like to comment? Thank you in advance,

    Sincerely,

    Dr Muherman Harun
    Jakarta, Indonesia
    Email: muhermanharun@gmail.com

    ReplyDelete
  21. Patient name-Nizamuddin
    Age/Sex-35 yrs/M
    Address- Tikona Park, Delhi

    -Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?
    Ans: No

    - How far is the nearest DST Lab from your place?
    Ans: 8-10 km

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?
    Ans: 3-4weeks.Yes it is critical

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?
    Ans: 5-6 times

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?
    Ans: Don’t know

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?
    Ans: Yes

    -Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviour of healthcare providers?
    Ans: Yes. Talk politely with patients and give medicines easily to the patients.

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?
    Ans: Culture reports should be available earlier, investigation should be done properly and all required investigations should be done.

    ReplyDelete
  22. Patient name-Gajraj
    Age/Sex-36 yrs/M
    Address- Shahdara, Delhi

    -Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?
    Ans: No

    - How far is the nearest DST Lab from your place?
    Ans: 8 km away

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?
    Ans: 2-3 weeks. Yes it is critical

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?
    Ans: 2-3 times

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?
    Ans: Yes, from other government healthcare facility, private doctor.

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?
    Ans: No

    -Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviour of healthcare providers?
    Ans: Yes. Talk politely with patients and explain about medicines to them.

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?
    Ans: Culture reports should be available quickly i.e. atleast 1 month. Last report should be arrive on time.

    ReplyDelete
  23. Patient name-Gopal
    Age/Sex-43 yrs/M
    Address- Ashok Nagar, Delhi

    -Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?
    Ans: No

    - How far is the nearest DST Lab from your place?
    Ans: far away

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?
    Ans: 2-3 weeks. Not critical

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?
    Ans: 2 times

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?
    Ans: Yes, from other government healthcare facility, private doctor, patient comes on own too.

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?
    Ans: Yes, more difficult to diagnose lump.

    -Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviour of healthcare providers?
    Ans: Yes. Behave nicely with patients and give them respect

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?
    Ans: Long lines to be avoided at the centres and reports available quickly without facing any problem.

    ReplyDelete
  24. Patient name-Om Prakash
    Age/Sex-23 yrs/M
    Address- Nandnagri, Delhi

    -Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?
    Ans: No

    - How far is the nearest DST Lab from your place?
    Ans: 10 km

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?
    Ans: 2-3 weeks. Yes critical

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?
    Ans: 2-3 times

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?
    Ans: Don’t know

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?
    Ans: No

    -Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviour of healthcare providers?
    Ans: No. Talk politely with patients

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?
    Ans: Don’t know

    ReplyDelete
  25. Patient name-Karim
    Age/Sex-17 yrs/M
    Address- Ajit Nagar, Delhi

    -Is there any drug-sensitivity testing (DST) laboratory (lab) in your area/region?
    Ans: No

    - How far is the nearest DST Lab from your place?
    Ans: 7-8 km

    - How much time does it normally take for the test results to be known? How critical is this time gap for the patient?
    Ans: 2-3 weeks. Very critical

    - How many times does the patient have to visit the centre before his/her MDR-TB positive status is confirmed?
    Ans: 6-7 times

    - Are the patients referred to the centre from some other government healthcare facility, private doctor, patient comes on own?
    Ans: Yes, from other government healthcare facility, private doctor, patient comes on own too.

    - Is it more difficult to diagnose extra-pulmonary MDR-TB?
    Ans: Yes

    -Do you think healthcare providers consider MDR-TB patients as equal partners with dignity? What changes can be brought in attitudes and behaviour of healthcare providers?
    Ans: Yes. Talk politely with patients and not to get angry or misbehave with them.

    - What changes should be brought to diagnose MDR-TB early and to begin MDR-TB standard treatment as early as possible?
    Ans: Investigations should be done on time and there shouldn’t be repetitive visits.

    ReplyDelete
  26. THE KILL PILLS: Lab test in Tamil Nadu rates 7 % drugs as 'substandard'
    Pushpa Narayan, The Times of India
    August 23, 2012
    ***************************

    IN THE PAST YEAR, PARVATHY, A DOTS PROVIDER, HAS FOUND SEVERAL EMPTY CAPSULES OF RIFAMPICIN

    Every time, Parvathy Chandrasekar doles out antibiotics to tuberculosis patients under the government's DOTS (directly observed treatment short course) programme, she opens the capsules and closes them. "You never know," she says, "if the capsules are empty or have the drug inside."

    In the past year, Parvathy, a DOTS provider, has found several empty capsules of rifampicin. She made this check a routine since last October, when she accidentally pressed open one of the rifampicin capsules and found it empty. The Kodumal designated microscopy centre in Trichy replaced the drugs.

    TB, caused by Mycobacterium tuberculosis, can be fatal, but is curable with a cocktail of antibiotics. Rifampicin is among this combination of first-line drugs that include ethambutol, isoniazid and pyrazinamide. "It is a serious concern. It could slow down cure or even make the patient resistant to the bacteria. We made a complaint to the district health officials, but it wasn't investigated," said Gnana Sekar, who works with Annai Trust.

    State drugs controller Dr G Selvaraj says he is concerned not only about rifampicin,but a variety of drugs that are found to be substandard. In the last five years, his office has found drugs for diabetes, high blood pressure and heart diseases to be of inferior quality. Vitamin tablets, steroids and cough syrups have also been found to be useless.

    "Not all of them are harmful, but many of them may not yield the desired results because many do not have the prescribed strength of the active ingredient," said Dr G Selvaraj. And that can be dangerous.

    In 2012, more than 4,110 drugs were tested by the state drug testing laboratory. It found 284 (nearly 7%) were "not of standard quality." Earlier this year, samples of a steroid, prednisone, taken from the government supply, had 'nil' content of the active ingredient. The drug is administered for respiratory disorder and pain relief.

    In March 2009, government hospitals were found to be using spurious antiseptic povidone iodine. The solution, which should be brown, was found to be colourless. The same year, the state government busted a series of spurious drug rackets which collected expired drugs from dump yards to be cleaned and relabelled. The CB-CID is investigation the case.

    At least one-third of cases filed under the Drugs and Cosmetics Act deals with substandard and spurious drugs, sharply reflecting the public health hazards posed by a network of unscrupulous pharmaceutical companies, distributors and retailers. Since April this year, 120 cases have been filed by the state drug control directorate for variousoffences."If thereis an increase in the number of spurious drugs cases in the recent years, it is because the crackdown," said former director of drugs control Dr M Bhaskaran. The health department, which did not have enough drug inspectors till a year ago, now have 150 of them across the state, including 45 in Chennai.

    Experts in the pharma industry say there are still loopholes in the system. For instance, the government does not monitor if expired drugs are safely disposed and the punishment continues to be minimal. Though the department claims that the conviction rate has been 99% in the last two years, the fine amount is less than Rs 1 lakh. Cases of imprisonment have been rare. In 2009, the penalty for manufacture of spurious drugs was increased to a minimum of 10 years—which may extend to a life term — and a minimum fine of Rs 10 lakh or three times the value of the drugs confiscated, whichever is higher.

    Online at: http://articles.timesofindia.indiatimes.com/2012-08-23/india/33340783_1_spurious-drugs-drugs-and-cosmetics-act-rifampicin

    ReplyDelete
  27. Médecins Sans Frontières (MSF) is supporting a community-based treatment program for drug-resistant tuberculosis in HIV-infected patients in a slum setting in Mumbai, India since 2007. Patients are being treated for both diseases on an ambulatory basis, and care and treatment are provided free of charge to all patients.

    We attach here 2 of our recent publications where we report on this community treatment programme: one paper is on the treatment outcomes and the other on the adverse events, which remains one of the major treatment and programmatic challenges.

    MSF Mumbai HIV MDR-TB Outcomes PLoS One 2011 is online at:
    http://www.scribd.com/doc/112142071/3-Msf-Mumbai-Hiv-Mdrtb-Outcomes-Plos-One-2011

    MSF Mumbai HIV MDR-TB treatment adverse events PLoS One 2012 is online at:
    http://www.scribd.com/doc/112141830/6-MSF-Mumbai-HIV-MDRTB-Treatment-Adverse-Events-PLoS-One-2012

    We have just completed a qualitative study on the patients' and providers' experiences with the treatment of the HIV/DR-TB co-infection. We are currently analysing our qualitative data. We would be happy to share these experiences with the group in the future.

    Warm Regards

    Petros Isaakidis
    Medical Epidemiologist, Operational Research Focal Person
    Médecins Sans Frontières OCB, India
    Chandni Bungalow, Union Park, Khar(W)
    400052 Mumbai, India
    Email: MSFOCB-Asia-Epidemio@brussels.msf.org

    ReplyDelete
  28. Comment from Dr Nerges Mistry, The Foundation for Medical Research
    ************

    Disclaimer: The Foundation for medical research does not prescribe second line Anti TB medication. The replies (in green) to the queries below is purely from literature reviewed and the Foundations experience in operational research. Also find attached our 2 publications which have been included in support of our views.

    Thanking you

    Dr Nerges Mistry
    Director and trustee
    The Foundation for Medical Research
    Mumbai, India
    Email: fmr@fmrindia.org
    Website: www.fmrindia.org
    ---------------------------------------

    - What is the MDR-TB treatment duration?
    18-24 months

    - Do the MDR-TB medicines have any side effects and is the patient well informed about them?

    Drug: CYCLOSERINE
    -----------------------
    FREQUENT side effects: Neurological and psychiatric disturbances, including headaches, irritability, sleep disturbances, aggression, and tremors, gum inflammation, pale skin, depression, confusion, dizziness, restlessness, anxiety, nightmares, severe headache, drowsiness.

    OCCASIONAL side effects: Visual changes; skin rash; numbness, tingling or burning in hands and feet; jaundice; eye pain

    RARE side effects: Seizures, suicidal thoughts

    Drug: KANAMYCIN
    -----------------------
    FREQUENT side effects: Pain at injection site, renal failure (usually reversible)

    OCCASIONAL side effects: vestibular and auditory damage-usually irreversible; genetic predisposition possible (check family for aminoglycoside ototoxicity), nephrotoxicity (dose-related to cumulative and peak concentrations, increased risk with renal insufficiency, often irreversible), peripheral neuropathy, rash

    Drug: OFLOXACIN
    -----------------------
    FREQUENT side effects: Generally well- tolerated

    OCCASIONAL side effects: GI intolerance; CNS-headache, malaise, insomnia, restlessness, and dizziness.

    RARE side effects: allergic reactions; diarrhea; photosensitivity; increased LFTs; tendon rupture; peripheral neuropathy.

    Drug: LEVOFLOXACIN
    -----------------------
    FREQUENT side effects: Generally well- tolerated

    OCCASIONAL side effects: GI intolerance; CNS-headache, malaise, insomnia, restlessness, dizziness, allergic reactions, diarrhoea, photosensitivity

    RARE side effects: tendon rupture; QT prolongation; peripheral neuropathy.

    Drug: ETHIONAMIDE
    -----------------------
    FREQUENT side effects: Severe GI intolerance (nausea, vomiting, diarrhea, abdominal pain, excessive salivation, metallic taste, stomatitis, anorexia and weight loss). Adverse gastrointestinal effects appear to be dose related, with approximately 50% of patients unable to tolerate 1 gm as a single dose. Gastrointestinal effects may be minimized by decreasing dosage, by changing the time of drug administration, or by the concurrent administration of an anti-emetic agent

    OCCASIONAL side effects: Allergic reactions; Psychotic disturbances (including mental depression), drowsiness, dizziness, restlessness, headache, and postural hypotension. Neurotoxicity (administration of pyridoxine has been recommended to prevent or relieve neurotoxic effects); transient increases in serum bilirubin; reversible hepatitis (2%) with jaundice (1-3%); gynecomastia; menstrual irregularity, arthralgias, leucopenia, hypothyroidism especially when combined with PAS.

    RARE side effects: reports of peripheral neuritis, optic neuritis, diplopia, blurred vision, and a pellagra-like syndrome, reactions including rash, photosensitivity, thrombocytopenia and purpura.

    Drug: PARA AMINO SALICYLIC ACID
    ----------------------
    FREQUENT side effects: GI intolerance (anorexia and diarrhea); hypothyroidism (increased risk with concomitant use of ethionamide).

    OCCASIONAL side effects: hepatitis (0.3-0.5%); allergic reactions; thyroid enlargement; malabsorption syndrome; increased prothrombin time; fever.

    --------------------------
    References: RNTCP, DOTS plus guidelines, CTBD, DGHS

    ReplyDelete
  29. Comment CONTINUED from Dr Nerges Mistry, The Foundation for Medical Research
    ************

    Q- What are the MDR-TB treatment outcomes? Are they different from extrapulmonary MDR-TB? What factors affect treatment outcome?

    A: Standardised treatment outcome definitions are to be used following treatment of an MDR-TB case and are as follows:
    - Cure: An MDR-TB patient who has completed treatment and has been consistently culture negative (with at least 5 consecutive negative results in the last 12 to 15 months). If one follow-up positive culture is reported during the last three quarters, patient will still be considered cured provided this positive culture is followed by at least 3 consecutive negative cultures, taken at least 30 days apart, provided that there is clinical evidence of improvement.

    - Treatment completed: An MDR-TB patient who has completed treatment according to guidelines but does not meet the definition for cure or treatment failure due to lack of bacteriological results.

    - Death: An MDR-TB patient who dies for any reason during the course of MDR-TB treatment

    - Treatment failure: Treatment will be considered to have failed if two or more of the five cultures recorded in the final 12-15 months are positive, or if any of the final three cultures are positive.

    - Treatment default: An MDR-TB patient whose MDR-TB treatment was interrupted for two or more consecutive months for any reasons.

    - Transfer out: An MDR-TB patient who has been transferred to another reporting unit (DOTS Plus site in this case) and for whom the treatment outcome is not known. Till the time the DOTS Plus services are available across the country, the Cat IV patients can be transferred out only to those districts, within or outside the state, where these services are available. If a Cat IV patient moves from one district to another, both of which are covered by the same DOTS Plus site, transfer out will not be required.

    - Treatment stopped due to adverse drug reactions: A patient on MDR-TB treatment who develops severe adverse reactions and could not continue the MDR-TB treatment in spite of the management of the adverse reactions as per the defined protocols and decision has been taken by the DOTS-Plus site committee to stop treatment

    - Treatment stopped due to other reasons: A patient on MDR-TB treatment who could not continue the MDR-TB treatment for any other medical reason (than adverse drug reactions), and a decision has been taken by the DOTS-Plus site committee to stop treatment.

    - Switched to Category V treatment: A Category IV patient who during treatment is identified as an “XDR-TB suspect” and who is found to have XDR-TB on testing by an NRL, who subsequently has had their Category IV treatment stopped and RNTCP Category V treatment initiated.

    - Still on treatment: An MDR-TB patient who, for any reason, is still receiving their RNTCP CAT IV treatment at the time of the submission of the RNTCP DOTS- Plus Treatment Outcome Report.

    ReplyDelete
  30. Comment CONTINUED from Dr Nerges Mistry, The Foundation for Medical Research
    ************

    Q- What infection control methods is the patient told to follow? What infection control measures are in place in healthcare settings?

    A: Patients are inducted on cough etiquettes and are asked to cover their mouths using a paper/cloth mask

    MDR-TB PREVENTION
    Q- What are the main causes leading to an escalation of MDR-TB cases?

    A: Miscategorization of patients at the RNTCP (Atre et al, 2007), Lack of cross ventilation, No fast tracking of patients, high population burden, lack of infection control practices, great delay in diagnosis, lack of regulation of private practitioners (Dholakia et al, 2012).
    ----------------

    Q- What is being done to reduce its occurrence? What needs to be done more?

    A: In Mumbai, each ward is being converted to a TB district (n=24) with 24 district TB officers, making it more manageable and administratively confluent. A large number of laboratories are in the process of being accredited for testing of first line and second line drug susceptibility. Infection control experts are being collaborated with to reduce infectious burdens in health care settings (A FMR collaborative project).

    Population awareness, isolation of patients atleast at the onset of disease to observe for drug reactions and also reduce transmission, more diagnostic laboratories

    ReplyDelete