Indian health ministry challenges report of totally drug resistant tuberculosisBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e702 (Published 27 January 2012) Cite this as: BMJ 2012;344:e702
Sections of India’s medical community have decried what they see as an attempt by the Indian health ministry to underplay the country’s first report of totally drug resistant tuberculosis and to censure the hospital that reported the infection last month.
A team of doctors at the Hinduja Hospital in Mumbai described four patients infected with tuberculosis bacilli resistant to all first line and second line drugs conventionally used to treat tuberculosis in the Journal of Clinical Infectious Diseases last December (doi:10.1093/cid/cir889).
The health ministry, which independently examined the patients’ records, has said that the term “totally drug resistant” tuberculosis is “misleading” and has not been endorsed by the World Health Organization. It has classified the cases as extensively drug resistant tuberculosis.
In a statement, the ministry also said that the Hinduja Hospital had not received accreditation from the government to conduct drug sensitivity tests for second line drugs. It added that a “poor clinical response to treatment has not yet been correlated with diagnosis of drug resistant tuberculosis,” without tests in accredited laboratories.
But pulmonary and public health specialists believe the government’s response, particularly its focus on the terminology of resistance, seems intended to turn the spotlight away from India’s growing problem of drug resistant tuberculosis.
“This seems like an attempt to question the messenger,” said Bobby John, a doctor and president of Global Health Advocates, a non-government public health organisation that has been tracking India’s national tuberculosis control programme. “The Hinduja Hospital laboratory has certification from the College of American Pathologists. Is it fair to pick on accreditation when something unpalatable is reported?” Dr John said.
India has the world’s highest burden of tuberculosis with an estimated annual incidence of two million patients. Health officials say that the government programme treats more than 70% of these cases and achieves a cure rate of 87%.
Public health experts have in the past expressed concerns about poor laboratory capacity for drug sensitivity testing and the use of inappropriate treatment for patients who fail first line drugs. For example, doctors point out that many patients not cured after initial treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol receive a regimen that adds a single drug, streptomycin, to the original four, breaching standard treatment rules to test for drug sensitivity (BMJ 2009; 338:b8, doi:10.1136/bmj.b8).
Nerges Mistry, an immunologist and director of the Foundation for Research in Community Health in Mumbai, said, “It is unfortunate that the treatment being offered to many patients may contribute to extensive drug resistant tuberculosis.”
The health ministry estimates that about 50 000 cases of multidrug resistant tuberculosis emerge in the country each year. But until July 2011, fewer than 6000 patients with multidrug resistant tuberculosis had drug sensitivity tests and second line drugs under the government programme.
Doctors say that even patients who have been screened through drug sensitivity tests do not always receive appropriate drugs.
Yatin Dholakia, a chest physician and technical adviser to the Maharashtra State Anti Tuberculosis Association, said, “The government programme offers a standard treatment regimen of six second line drugs instead of offering an individualised treatment regimen to each patient with drug resistant tuberculosis.”
Writing in an Indian journal this month he said the situation “raises issues of ethics and human rights” (Lung India 2012;29:95).
But a tuberculosis programme official said that a public health programme “cannot be expected to offer individualised treatment to each patient.”
Community medicine specialists also say the health ministry has failed to adequately address poor treatment practices in the private sector which remains one of the biggest drivers of drug resistant tuberculosis in the country. Some estimate that nearly half of tuberculosis patients seek private care.
Madhukar Pai, an epidemiologist at McGill University in Canada who has been studying the Indian tuberculosis control programme, said, “Patients in India are trapped between an unregulated private sector and a government sector with limited capacity for drug sensitivity testing and treatment.”
A study by doctors from the Hinduja Hospital two years ago found that only five out of 106 private practitioners in Mumbai asked to write prescriptions for multidrug resistant tuberculosis were able to write a correct prescription (PLoS One 2010;5:e1203).
The health ministry said that three of the four patients with extensively drug resistant tuberculosis reported by the Hinduja doctors last month had also received erratic, unsupervised, second line drugs added individually and often in incorrect doses by private practitioners.
Cite this as: BMJ 2012;344:e702