Multi drug resistant tuberculosis (MDR-TB) is to spike in India over the next twenty years, predicts a recent study published in The Lancet. The news puts the World Health Organization’s End TB strategy at risk of failure. It also jeopardises the pledge of the Indian government to end TB in the country by 2025. Unless something is done about improving quality of TB care in the private sector, the situation for India might be worse than the study suggests, according to one global authority, Prof Madhu Pai.
The study estimates that, by 2040, MDR-TB will account for 12.4% of tuberculosis cases in India. This figure will have increased from 7.9% in 2000. India is one of four countries the study expects to have a future increase in burden on MDR-TB. Other countries included are the Philippines, where 8·9% of TB cases are to be predicted to be drug resistant, 32·5% in Russia, and 5·7% in South Africa.
Extensively drug-resistant TB (XDR-TB) will account for 8.9% of TB cases by 2040, compared to just 0.9% in 2000. This is particularly worrying, as a high prevalence of XDR-TB will make eradication efforts almost impossible without the development of new medications.
India will receive 3000 courses of the drug bedaquiline in November this year, courtesy of the United States Agency for International Development (USAID). Though this drug has shown a high efficiency for curing even MDR-TB, as reported previously by Health Issues India, it is used as a last line of defence. This is due to an 11 percent fatality rate of those taking the medication during the human trials. Furthermore, there is the reality that 3,000 courses of bedaquiline will not relieve the lion’s share of India’s MDR-TB burden – with a potential 76,800 cases.
India already accounts for 16 percent of the estimated 480,000 new cases of MDR-TB. This is as well as 27 percent of the world’s 10.4 million new TB cases and 29 percent of its 1.8 million TB deaths. The news that rates of MDR-TB are to increase means the situation is only going to get worse.
The Government of India announced earlier this year that it would eliminate TB from the country by 2025. This has been something of a tall order ever since it was announced in the government’s health budget. Scepticism comes from the high incidence of TB in India, coupled with continued access to healthcare limitations, underfunding of TB control programs and a lack of engagement between public health systems and the private sector. If MDR-TB increases as is anticipated, this constitutes yet another obstacle to realising the objective.
Prof. Madhukar Pai, MD, PhD – the associate director of McGill International TB Centre and a world leader in TB research – has provided exclusive comments to Health Issues India discussing his professional view of the situation:
“The CDC modeling study shows that MDR and XDR TB will become more common in India, Russia, South Africa and Philippines, given the current treatment regimens and control methods. As such, such models are helpful in raising alarm about the TB situation in general, and the need for greater investments to control TB in these countries.
For India, I found the model to be simplistic because it ignores the huge proportion of TB (well over 50%) that is managed in the private sector with suboptimal diagnostics, widespread empirical antibiotic abuse, and limited capacity to ensure adherence among TB patients. So, unless something is done about improving quality of TB care in the private sector, the situation for India might be worse than what is predicted by this modelling study. Also, the modelers did not have access to the results of the Indian national drug-resistance survey that has been completed, but results not publicly available.
But I do agree with the conclusions that existing drug regimens and tools are inadequate for dealing with the MDR/XDR epidemic, and much more needs to be done to support R&D.”
Health Issues India interviewed Prof. Pai earlier this year on World TB Day. Here, he said “drug-resistance is a sign that quality of TB care is suboptimal.”
“poor quality of care, in both public and private sectors, increases the risk of drug-resistance and mortality. Persons with TB must take medications without stopping. Otherwise, TB bacteria can become resistant to the common, first-line drugs that are used. This usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs. Drug-resistance can also emerge when the supply of drugs is not continuous; or when poor quality drugs are used.”
India is adopting the role of a global hotspot of TB, and MDR-TB in particular. This lends a grim truth to Dr. Pai’s comments. It shows India needs to prioritise its treatment of the disease in order to adhere to both government and WHO targets of elimination. In order to accomplish this, healthcare spending will need to be markedly raised.
As Prof. Pai mentioned, research and development will be essential to continuing the struggle against TB. Funding must be allocated to deal with current cases, but research must also be prioritised to deal with the increasing threat of MDR-TB. In India, collaboration in data management between private and government hospitals will also be a fundamental requirement to manage outbreaks, as inconsistencies between the two could lead to patients slipping through the net, causing future infections.