TB News from India: July-August 2007

Health and Development Initiative-India, (www.healthinitiative.org), publishes 'TB News from India' once every two months. The objective of newsletter is to highlight issues related to Tuberculosis and HIV/AIDS control in India and enlist political, public, professional and administrative support for its cause. Health and Development Initiative-India is a not-for-profit organization and the news items have been quoted from various sources for fair use and in public interest. Reproduction of the material published is welcome provided a reference is made to the original source of the news item and `TB News from India'.

Editorial Note: DOTS or more

Questions are already being raised regarding efficacy of Directly Observed Treatment Shortcourse (DOTS) programme to control of tuberculosis in India. DOTS reached all districts of country under the aegis of Revised National Tuberculosis Control Programme (RNTCP). However emergence of Multi Drug Resistant TB (MDR-TB) and reports about presence of XDR-TB along with continuing high mortality due to tuberculosis has set the alarm bells ringing in the minds of health experts in country.

The premier Indian Medical Association (IMA) a partner of RNTCP has expressed concerns over the methodology adopted for implementation of DOTS in the country. Although DOTS has established its presence up to community health centre level, it still has to make deeper inroads. According to Dr. L S Chauhan Chief of RNTCP in India, in addition to government facilities 12 000 private practitioners, over 2000 NGOs, over 230 medical colleges and 110 corporate sector health facilities are involved in programme activities. These figures may appear impressive but in a country as vast as India the inadequacy of present expanse of programme is readily visible.

However the concerns expressed by IMA or other experts can not be wished away, they may be seen as premature. The RNTCP is still in an incipient stage in the country and needs to be given time to establish its roots. While keeping door open for improvisation and local amendments to this trusted and tried public health strategy, there is a need to consolidate the current achievements of the DOTS programme. For the time being DOTS is the right recipe for tuberculosis control in India.

Health Experts Discuss Effect of DOTS on TB Control in India

Some health experts in India are questioning the efficacy of the DOTS program to control the spread of tuberculosis in the country, the trade publication PharmaBiz.com reports. The increasing number of TB cases recorded throughout the country indicates that there are problems with how the DOTS strategy has been implemented, according to IMA.

India routinely has implemented various TB control programs that are used for a few years before being replaced, according to Hisamuddin Papa, a pulmonologist who founded the HUMA Specialists Hospital and Research Centre. Papa said that TB diagnosis using sputum microscopy, which was developed more than 100 years ago, also presents a challenge to TB control because it is the primary method used to diagnose the disease. Sputum microscopy also cannot detect if a person has a drug-resistant TB strain, he said, adding that in many areas, a lack of commitment and resources has resulted in inadequate TB diagnostic and laboratory services. According to Papa, although India's TB drug delivery systems have improved, the country's National Sample Survey has not been used to examine India's current TB situation.

IMA President Anil Pachnekar said that although DOTS is supposed to curb the spread of drug-resistant TB, insufficient implementation of the program has hindered such efforts. Pachnekar also said that many doctors in the country use trial-and-error methods to treat drug-resistant TB, turning to second-line treatments after first-line drugs fail and the bacteria has had more time to develop resistance.

IMA Secretary Ramesh Shah said that the incorrect use of antibiotics, interruptions in treatment regimens and inadequate DOTS monitoring are responsible for the spread of drug-resistant TB. "The recipe for spreading the disease is the same throughout the world," he said, adding that the increasing numbers of drug-resistant TB cases has hindered the efficacy of the DOTS strategy

Source: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=44940

 Deadly TB-HIV combo haunts tribal Chhattisgarh

Tribal dominated Central Indian state of Chhattisgarh may emerge as a high risk AIDS prevalence state due to its geographical location, poor awareness and backwardness according to health experts, reports Hindustan Times. The experts fear that it may further snowball into tuberculosis/HIV co-infection as tuberculosis is cause of most deaths in the state.

Chhattisgarh shares its geographical borders with states like Maharashtra, Andhra Pradesh,West Bengal and Orrisa, which are high AIDS prevalence states. Only six districts of the state have been rated as educated about AIDS awareness. The persistent migration into the state creates a fertile ground for HIV infection.

Officially, Chhattisgarh now has over 2000 cases of recorded HIV positive with around 383 confirmed AIDS patients. "The statistics on HIV/AIDS and deaths owing to it is just the tip of an iceberg", admits State AIDS Control Programme Project Director, Dr RK Rajmani.

Now with TB becoming a leading cause of illness and death among people living with HIV/AIDS, the state has begun linkage between TB and HIV/AIDS this year. But it is yet to be strengthened as official data and preliminary surveys are missing.

Dr SK Anum, Secretary, Chhattisgarh Fellowship of College of General Practitioners (CGFCGP) believes that information on AIDS and TB is highly under-reported and the ground reality could be mind- boggling.

Dr Anurag Bhargava, a well known health expert of the state says that there is little coordination between TB and HIV control cells of the health department.

According to health officials the state health department is to enter into understanding with the National AIDS Control Organization for the third phase of implementation of AIDS control later this year that will take care of linkage in a better way.

Full story at: http://www.hindustantimes.com/StoryPage/StoryPage.aspx?id=7da448a0-100a-443a-8b24-9e600b6fb6db

 Drug-resistant TB rampant in India

The world's most untreatable form of tuberculosis, extreme drug-resistant TB, has been detected in India and could account for 8% of those who suffer from the strain of the disease which develops resistance to multiple drugs, reports Times of India.

In a study to look at prevalence of XDR-TB in the country, researchers from Hinduja National Hospital in Mumbai found that the type has struck root in India. The team, led by Dr Sushil Jain, examined 3,904 lab samples and found 1,274 were positive for TB. Of these, 32% were multiple drug resistance (MDR-TB), of which 8% were XDR-TB cases. Mortality rate of XDR-TB patients in the study was as high as 42%. What's worse, majority of patients in the study with XDR-TB were from a younger age group, their average age being 30 years. All XDR-TB cases were in-patients with pulmonary tuberculosis which can be spread by coughing, sneezing, laughing or even singing.

Even now, India's Revised National Tuberculosis Control Programme has no official data on the prevalence of XDR-TB in India. The Union health ministry fears that detection of strain was a matter of time. What's worse, it is nearly impossible to determine prevalence of XDR-TB in India. 

Source: http://timesofindia.indiatimes.com/articleshow/2067931.cms

Tab on TB

There's a dire need for renewed commitment to DOTS and prevent multi-drug resistance to anti-TB drugs says Indian Express.

According to the Government of India's Central Tuberculosis Division a total of 6.8 million TB patients have been treated under the Directly Observed Treatment Short Course (DOTS) programme since its inception in 1993. The entire country was brought under the DOTS programme last year and India has also achieved the global target of detection of 70 per cent new cases. In 2006 itself a total of 1.4 million cases were brought under DOTS. With a successful revised national strategy in place and the fact that TB is cent per cent curable, why are 400,000 people still dying of TB every year wonders Anuradha Mascarenhas. 

There are reports that in year 2004 more than 400,000 persons were found to have developed multi-drug resistant (MDR) strains that could not be treated with at least two key first line TB drugs—most cases were in China, India and Russia. And now a new super bug that resists three or more classes of second line tuberculosis drugs—known as XDR-TB (Extremely Drug Resistant -TB) has been identified in 28 countries worldwide.

Dr L S Chauhan, deputy director general (Tuberculosis) and programme manager of the Revised National Tuberculosis Control Programme (RNTCP) in India, does not really set aside these worries. "According to our latest survey, there are less than three per cent of MDR-TB patients among new cases. So far XDR-TB cases are not reported. But yes, second line drugs are being used for treatment," says Chauhan.

Even if two per cent of new patients in India have MDR-TB, this represents some 20,000 new infectious cases every year. The financial and human resources to treat one patient with MDR-TB are greater than those required to treat 100 other patients, says Dr. Rajendra Prasad, head of department of pulmonary medicine at K G Medical University, Lucknow and one of the technical experts for framing the country's expanded programme DOTS-PLUS for MDR-TB patients.

Chauhan emphasizes the need to consolidate the achievements of the DOTS programme to improving the quality of diagnosis and decentralizing it to the village level. So, despite efforts now stepped up to introduce DOTS-PLUS for treating MDR-TB patients, he appeals for a renewed commitment to DOTS to prevent multi-drug resistance to anti-TB drugs.

Source: http://cities.expressindia.com/fullstory.php?newsid=245267

Haryana gets compliments for implementing TB control programme     

The Second National TB Control Implementation Support Mission has complimented the North Indian state of Haryana for its successful implementation of the TB Cure Programme in the State saying that the Programme is going in the right direction, reports Punjab Newsline Network.

A spokesman of the Haryana Health Department said that a team of the Mission had visited Haryana from May 31 to June 1 2007, with the purpose to review the implementation of the RNTCP in the state. The team also lauded the efforts of the State Government in involving the participation of community DOT Providers and Private sector in the programme.

The also team visited a house wife and a community DOTS Provider in Karnal who has helped cure about 318 TB patient.

Full story at: http://www.punjabnewsline.com/content/view/4359/57/ 

UK want Indians screened for TB

Amidst rising incidence of tuberculosis in Britain, senior doctors here want all immigrants from the Indian subcontinent to be screened for the disease. The doctors want the screening to also include immigrants from Africa reports Times of India.

The Observer reported that two new outbreaks, in Luton and Cardiff, had prompted concern that public health officials were failing to come to grips with the disease. Vivienne Nathanson, the British Medical Association's head of science and ethics, said the re-emergence of TB was so serious that ministers should consider the mandatory immunisation of all school children. He added that general practitioners should offer screening to new patients who come from parts of the world where the disease is common, including Eastern Europe

Mayur Lakhani, chairman of the Royal College of General Practitioners, said: "My sense is that the health community has taken its eye off the ball a bit in relation to TB. We shouldn't think that this is a disease of the past." Lakhani said primary care trusts, which deliver healthcare in local areas, must do more to ensure that people coming to live in Britain from high-risk countries were screened when they arrived at an airport or port or when they registered with a general practitioner. Students coming to Britain should also be tested.

Full story at: http://timesofindia.indiatimes.com/articleshow/2077533.cms 

Extension of RNTCP in Chhattisgarh, Jharkhand and Uttranchal gets Central Government Approval

India's Cabinet Committee on Economic Affairs (CCEA) on Thursday approved the extension of the Revised National Tuberculosis Control Programme for five years in the states of Chhattisgarh, Jharkhand and Uttranchal, ANI/DailyIndia.com reports. Under the approval, RNTCP will run through March 2012 in those states. CCEA also approved the implementation of a public-private partnership project involving the Indian Medical Association with assistance from the Global Fund To Fight AIDS, Tuberculosis and Malaria. The project will take place in Andhra Pradesh, Chandigarh, Haryana, Maharashtra, Punjab and Uttar Pradesh, according to ANI/DailyIndia.com.

On a national level, the project will be implemented by the Central TB Division of the Directorate General of Health Services under the Ministry of Health and Family Welfare. On the local level, the program will be implemented through the state or district's primary health care infrastructure. The goal of the project is to decrease TB cases and deaths and expand the reach of RNTCP through enhanced coordination with private health providers, ANI/DailyIndia.com reports. The project is expected to cost 917,900,000 rupees, or about $22.7 million, for RNTCP implementation and 174,400,000 rupees, or about $4.3 million, for the public-private partnership. According to ANI/DailyIndia.com, the total cost of the project is expected to be 1,092,220,000 rupees, or about $27 million. It is estimated that 440,000 people with TB will receive treatment access through the project and that 374,000 will complete treatment successfully. This could avoid a total of 80,000 deaths, almost half of which would occur among adults, according to ANI/DailyIndia.com

Source: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=46045

Drug-resistant TB: Smuggled medicines from India raise cost of treatment in Pakistan

Medication for Multi-Drug Resistant Tuberculosis (MDR-TB) is generally smuggled into Pakistan from parts of India, sources in the federal health department and medicine-vendors in Karachi told Daily Times reports Urooj Zia. Four major drugs are used to combat MDR-TB – Cycloserene, Oflobid (a wide-spectrum antibacterial), PAS, and Ethomid. Each of these medicines costs less than Rs 10 in India. After being smuggled into Pakistan, however, the cost increases to between Rs 50 and Rs 75 per capsule. An MDR-TB patient is expected to take at least two of each daily for the duration of the treatment. The total cost of treatment depends on the combination of drugs being used – all four medicines are not used at the same time.

Interestingly three of the four medicines are also produced locally in Pakistan, "but they are produced by multi-national companies (MNCs), so the difference in cost isn't much," a shopkeeper at the Medicine Market in Katchhi Gali # 2 (behind M.A. Jinnah Road) told Daily Times. "MNCs have their own costs of production to look at too." "Locally-produced" versions of PAS, however, cost Rs 375 for a box of 50 tablets (Rs 7 per tablet). Ethomid costs Rs 476.85 for a pack of 30 tablets (Rs 16 per tablet), and Oflobid costs Rs 115 for a pack of 10 tablets (Rs 11.5 per tablet).

A cheaper variant of Ethomid is sold under the trade name "Marbital." These are available at Rs 175 for 100 tablets (Rs 1.75 per tablet). Both versions are "legal" – the more expensive Ethomid is produced in Lahore, while the cheaper Marbital is produced in Karachi. Cycloserine is produced in Seoul, Korea, and is marketed by a firm in Karachi. It is available at Rs 59 for a pack of 30 tablets (Rs 2 per tablet).

These are the prices that are generally applicable. "Most of the time, the supply of the locally-produced medicines falls short in the market, and drugs smuggled in from India have to be used," medicine-vendors said. "That is when prices shoot up. If a patient has to take these medicines for two years, he or she will find the cheaper versions readily available for merely three to four months out of a total of 24. The rest of the time, the patient's family will have to search hard and long for even the Indian versions of the medicines. This is how the treatment costs for MDR-TB shoot up.

The WHO programme for treating MDR-TB, DOTS Plus is yet to be implemented in Pakistan. "Right now, we are concentrating on implementing the DOTS programme completely. We have been advised by the WHO to not touch MDR-TB as a programme yet," Sindh TB Control Programme director, Prof. Iqtedar Ahmed, told Daily Times. "Keeping our human resources, financial resources, and technical resources in mind, our first priority is the first line of treatment for TB (under the DOTS programme). Our next target is paediatrics (incidence of TB in children under the age of 12)."

The National TB Control Programme has started to work on a protocol for implementing a programme for MDR-TB too, Prof. Ahmed said, adding however, that implementation will take time. "It could take anywhere from two to six months, I can't be sure at this time," he said.

Full story at: http://www.dailytimes.com.pk/default.asp?page=2007%5C07%5C12%5Cstory_12-7-2007_pg12_8

Editorial Team:

Dr.Dinesh Kumar Sharma; dineshkumrsharma@gmail.com

Dr. Jatinder Singh; jatindersingh@vsnl.com