Beyond the numbers: India's first anti-TB drug resistance survey reveals the shortcomings of the tuberculosis-control programme

17 May 2018
The failure to test for resistance to multiple drugs very often drives patients with drug-resistant tuberculosis from doctor to doctor—both public and private—in search of the right diagnosis, which, in turn, may likely lead to further drug resistance.
Rafiq Maqbool/AP Photo

The results of the first anti-tuberculosis drug resistance survey in India indicate that the country’s national tuberculosis-control programme is ill-equipped to detect the drug-resistant strains prevalent in India. The report, which was released in March this year, reveals that nearly a quarter of India’s new tuberculosis patients are resistant to at least one of 13 drugs used for its treatment, whereas the control programme only accounts for resistance to one particular drug. “Resistance to certain drugs such as isoniazid are ignored by the system,” Dr Yogesh Jain, one of the founder members of Jan Swasthya Sahyog, a community health organisation in Bilaspur, in Chhattisgarh, said. “If the objective is to diagnose drug-resistant tuberculosis, then the algorithm used by the programme is inappropriate.”

The health ministry enrolled a total of 5,280 tuberculosis patients—3,240 new patients and 2,040 who were previously treated—for the drug-resistance survey, which was conducted from July 2014 till May 2016. The survey sought to study the proportion of patients suffering from multi-drug resistant tuberculosis, or MDR-TB, among the patients treated under the Revised National Tuberculosis Control Programme—a central-government initiative to arrest the spread of the disease. MDR-TB refers to tuberculosis that does not respond to the two powerful first-line drugs—rifampicin and isoniazid—and a person afflicted with it requires second-line treatment, which comprises drugs that are more aggressive and require a longer regimen.

On 24 March this year, four years after initiating the survey and 11 days after Prime Minister Narendra Modi inaugurated the Delhi END TB Summit, the union health ministry released the report. Several international dignitaries, including the health ministers of over 20 countries, and the WHO director-general, Dr Tedros Adhanom, were in attendance at the summit, where Modi declared, “I am confident that India can be free of TB by 2025.”

The health ministry’s report notes that although the proportion of MDR-TB cases within India’s total cases of tuberculosis is lower than the official global estimates, the absolute number of drug-resistant tuberculosis patients in India is the highest in the world. Of the 27 lakh tuberculosis patients in the country, a 2017 report by the World Health Organisation notes, approximately 1.47 lakh, or 5.44 percent, are cases of MDR-TB. Among those enrolled for the survey, the report noted that 6.19 percent suffered from MDR-TB—including an affliction among 2.84 percent of the new tuberculosis patients, and among 11.60 percent of the previously treated patients. The worldwide estimates, as stated in the survey report, show an affliction of MDR-TB among 4.1 percent of new patients and 19 percent of previously treated patients. But the figures for India arising from the survey are particularly grave given the report’s finding that Indian tuberculosis patients showed a resistance to a wide range of drugs, which the country’s tuberculosis-control programme fails to address.

Drug-resistant tuberculosis can be a result of an infection of drug-resistant bacteria, an incomplete prior treatment, or an irrational use of tuberculosis antibiotics. Its prevalence among new patients, which is termed primary infection, means that they contract the drug-resistant strain directly, without ever being treated for it earlier. This could occur in crowded cities such as Mumbai and Delhi, where drug-resistant tuberculosis cases are high, or through close contact with any patient previously suffering from it.

Menaka Rao is a freelance journalist from Mumbai. She writes on law and health.

Keywords: Tuberculosis Health World Health Organisation health policy drug resistance