Tuberculosis re-emerges as a major threat as new drug-resistant strains develop because of mismanagement of the disease

At the beginning of the year, doctors at Mumbai’s P.D. Hinduja National Hospital and Medical Research Centre reported that they had 12 patients infected with TDR-TB, or totally drug-resistant tuberculosis, a condition in which the TB bacilli is resistant to all first- and second-line drugs used in the conventional treatment of the disease. Panic ensued, forcing the Union Health Ministry to step in. It examined the patients’ records and declared that the term TDR was misleading, especially since the World Health Organisation (WHO) had not endorsed it. The patients, the Ministry concluded, had XDR-TB, or extensively drug-resistant TB.

There was outrage among physicians and they called it a knee-jerk reaction, but the government had its way. The term TDR is no longer used. In the meantime, four of the 12 patients died; the number of patients now under treatment at Hinduja is 15. An argument about terminology is futile when TB, a dangerous and contagious disease, long believed to be under control, is actually rampant and seemingly out of control.

News of the cases first appeared in December 2011 in a report published in the journal Clinical Infectious Diseases. Its authors, Drs. Zarir Udwadia, Rohit Amale, Kanchan Ajbani and Camilla Rodrigues of Hinduja Hospital, reported the discovery and treatment of four cases of drug-resistant TB since October 2011. Later, eight more patients were diagnosed with the disease at Hinduja. Logically, there may be many other cases in the State and the country that go undetected since facilities to identify the strain are not easily available.

The plan to house the four Hinduja patients in a sanatorium near Sangli never took off. “They were offered the option of isolation,” said Udwadia, “but to the best of my knowledge they did not take it. They continue to live and be treated in the community.” Of the 15 patients under his care, he said, “Despite popular misconceptions, TDR is not synonymous with ‘Totally Doomed’. Several of these patients are doing well on complicated regimens involving ‘salvage' drugs. Surgery is being increasingly offered as well, especially if the disease is restricted to one lung.”

In response to an invitation from Thorax, the United Kingdom's premier journal of respiratory medicine, Udwadia wrote an editorial to put things in perspective: “These 12 patients, sadly, hold a mirror to the way MDR-TB [multi-drug-resistant TB] is mismanaged in India. The typical patient had failed both standard short course chemotherapy... and then category 2 treatment, a single standardised retreatment regimen… in the public sector. They then turned, in desperation, to multiple private practitioners whose inappropriate prescriptions only served to further amplify resistance till the micro-organisms were finally resistant to all first-line… and second-line drugs tested by us at the Hinduja Hospital and Research Centre, Mumbai.

“The 12 patients (mean age 32 years, six men), had seen an average of four doctors, and received a mean of 9.33 drugs for an average duration of 26 months prior to being labelled TDR-TB by us. What treatment options can we offer the damned? As Paul Farmer said: ‘Our mission must be to treat the sick, not just the sick who can pay. Our mission must be to treat TB regardless of resistance pattern.’ With the very limited treatment options available, we started each patient on a salvage regimen of four new drugs. In addition, aggressive surgery (pneumonectomy) was offered to two patients despite the bilateral nature of their disease. Three patients succumbed to their disease within a few months of being labelled TDR-TB.”

Source :      2012/7/21

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