Dramatic scale-up of programmatic management of drug-resistant TB in India

Despite challenges of health systems and the biggest TB disease burden globally, India has certainly come a long way forward in its response to providing access to standard WHO recommended anti-TB treatment through Directly Observed Treatment Short course (DOTS) to more than 14.2 million (1.42 crores) people across the country. Yet, despite successes TB continues to remain one of the key public health priorities in India.

Drug-resistant TB is one of the concerns and India envisions providing universal access to quality diagnostics and treatment services for all patients with drug-resistant TB in the next five years. India has scaled up its response to drug-resistant TB manifold in the past two years with fully equipped state-of-the-art laboratories and diagnostic services and treatment facilities across the country.

St Stephen's Hospital, Delhi and Indian Public Health Association (IPHA) Delhi Chapter had jointly organized a Continuing Medical Education (CME) programme on multidrug-resistant tuberculosis (MDR-TB) on 4th October 2013.

The Revised National TB Control Programme (RNTCP) has recognized this public health threat and responded in a major way to scale up strengthening of diagnostic and laboratory capacities alongside expanding treatment and care services across the country. By 15th March 2013, diagnostic and treatment capacities for drug-resistant TB were made available in every state of the country. The number of patients who are getting tested for drug-resistant TB and those with the disease who are accessing standard quality-assured drugs has gone up as well with close to 30,000 patients having received care cumulatively.

RNTCP has laid out a well-thought national strategic plan to fight TB and drug-resistant TB for the coming years till 2017. As the programme continues to expand there are major opportunities for improving programme outcomes by evidence-based approaches and innovations in areas such as early case finding, multi-level counselling, social and rehabilitation support, regulating rational drug use, public private partnerships, among others.

This CME presented a comprehensive overview on MDR-TB to a range of healthcare providers, covering the science of preventing, diagnosing, and treating MDR-TB, impact of innovative and community-centric approaches, cured patients’ voices and experiences of those presently seeking care, a global overview of drug-resistant TB, and RNTCP’s response. 

Dr Amod Kumar, Head of Community Health Department at St Stephen's Hospital and key organizer of this CME, said that St Stephen’s Hospital was established in 1885. Even after more than 125 years of its existence the basic ethos of this hospital has not changed and still lies in care and compassion which were the very basis of its foundation. The Community Health Department of St Stephen's Hospital is still as important in today's context as it was back then. It has adopted over 75,000 people in Sundar Nagari area of Delhi, providing them with comprehensive healthcare services through auxiliary nursing midwife (ANM), community health centres, among others. This department has added a special feather in its cap by being the only private hospital that provides Diplomate of National Board (DNB) in Preventive and Social Medicine (PSM). Child to child education programmes, drug de-addiction programmes, self-help groups for women, cooperative societies, rural programmes in 10 villages of Gurgaon are some of the other key activities of this department. It also functions as a mother NGO for the homeless supervising 84 shelters for the homeless and providing care packages to other pockets of the homeless also in order to improve quality of care for the homeless in the city. In addition to the valuable contribution St Stephen’s Hospital’s community health department is making on public health, other super speciality departments have ensured that the hospital continues to provide free and subsidized comprehensive and holistic quality healthcare services to people.

Dr Amod Kumar explained how home-based care model for patients of MDR-TB who are receiving treatment from PMDT sites in Delhi functions. MDR-TB treatment outcomes are significantly better when patients are provided with regular counselling, home care and social support.

Dr VK Ramteke from IPHA Delhi Chapter and a noted surgeon said that a range of public health interventions help significantly in reducing the new case load as well as complement other programmatic aspects of managing drug-resistant TB. He highlighted irrational drug use as one of the contributors to drug resistance and said that health literacy is not only useful for the public but also for other healthcare providers, including doctors.

Dr Vishwa Mohan Katoch, Director-General of ICMR and Secretary DHR said that Government of India's programme has done commendable task in TB control. “We are winning the battle” said Dr Katoch. But at the same time he highlighted enormous challenges that confront India’s effort on TB control. MDR-TB is 100% a manmade disaster. Owing to efforts to raise literacy among healthcare providers on standard anti-TB treatment, most doctors have become aware about the proper treatment regimen. In real life situation that confronts those fighting TB on the frontlines it is not pragmatic to do culture sensitivity for every presumptive TB case. Nevertheless it is no less important to ensure that the patient receives appropriate combination anti-TB therapy. He suggested doing community-wide studies to map drug sensitivities so that appropriate regimens can be rolled out. 51 state-of-the-art laboratories across India are a testimony of the historic progress made on strengthening laboratory capacities in the country. These laboratories with bio-safety level III facilities provide TB and drug susceptibility testing services from different evidence-based and standard diagnostic techniques such as solid and liquid cultures, Line Probe Assays (LPA), Gene Xpert (Cartridge-Based Nucleic Acid Amplification Testing – CB-NAAT). More than 10 such evidence-based tests are currently available with comparable sensitivity and specificity. Some of these such as CB-NAAT does not require BSL-III facilities and can be done by laboratory technicians or other trained staff as well. Data from these laboratories should be analyzed and looked into to further improve programme outcomes.

Dr Katoch strongly recommended that doctors should not replace or add 1 or 2 drugs to a failing regimen-- rather replace regimen by regimen as per the diagnostic and treatment algorithms. Diagnosis of drug-resistant TB and drug susceptibility is not a clinical diagnosis rather a bacteriologic (and laboratory based) one.

Drug resistance is not unique to TB and has posed formidable public health challenge in other disease control programmes too. Leprosy control also had faced serious forms of drug resistance in second half of 20th century. But owing to great work done by the government-led leprosy control programme with support from missionaries and other NGOs such as LEPRA, the rates went down from nearly 25% in 1982 to almost 0% today.

India has done very well on TB and MDR-TB control through RNTCP and services have reached most parts of the country. He recommended that government programme has to lead more and be in control just like what happened in leprosy control which had led to leprosy eradication (prevalence less than 1%).

Dr RP Vashist, former Delhi State Tuberculosis Officer (STO) also reiterated that MDR-TB is a manmade phenomenon. In order to control MDR-TB, we have to strengthen basic TB control component of RNTCP. TB should be treated in a standardized manner with healthcare providers adhering to evidence-based diagnostic and treatment algorithms as per the guidelines.

Bobby Ramakant, Citizen News Service - CNS
October 2013

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