“It is still possible for public health
systems to take a pro-active step, as the Mumbai officials are now doing to
stem the problem,” Dr Dewan told India Together. “TB Control in Mumbai can be
transformed. The challenge is to ensure that all TB patients get the support
they need and that would prevent the emergence of drug resistance
Indeed, while health officials may want
to downplay the notion that the TB cases Udwadia et al were totally drug
resistant, they do at least appear to be taking the ‘threat’ of TDR-TB more
What is being done about
the ‘TDR-TB cases identified in these reports?
the cases identified by Udwadia et al: the Central Team announced that the Revised
National Tuberculosis Control Programme (RNTCP) Maharashtra
would be adopting all these cases and offering them their entire course of
treatment free of charge. [It is
hoped that this treatment will at least include the medications devised by
Udwadia et al, if the patients are indeed responding to treatment, but we have
been un able to confirm this as of yet. Treatment for drug resistant TB in India
is generally standardised, as access to second-line DST has been too limited to
allow for individualised regimens).
to isolate the ‘TDR-TB’ patients in a remote facility appear to have been put
on hold for now. Shortly before the Central Team visit, an emergency plan had
been approved to send the cases identified thus far to a 30 bed sanatorium facility
in Jaysingpur, 400 kilometers (250 miles) south of Mumbai.
number of experts and activists criticised isolation in a remote location as
unnecessary and a kneejerk reaction — and
potentially a violation of the patient’s human rights. Rather it was suggested
that they would be better managed in the TB wards of their local hospital.
such as Nerges Mistry, the director of the Foundation for Medical Research in
Mumbai, voiced concerns in the Lancet about the lack
of good infection control to prevent the spread of highly drug-resistant TB to
staff and other patients.
a more patient- and staff-centred
approach would be to introduce good infection control in these facilities,
given the fact that these cases probably represent the tip of the iceberg, in
order to prevent the spread of difficult-to-treat TB strains that are probably
already present but not yet detected in the facility — or deliver home-based
care provided that infection control in the home can be established (and if not
in the home, at least near to it).
researchers believe that there are some circumstances where isolation in
sanatoria might indeed be the best and most compassionate options for some
patients, as long as certain criteria are in place, such as easy access for
friends and family. This will be discussed in a future entry in the HATIP
the Central Team advocated against isolation of these ‘TDR-TB’ cases,
suggesting that treatment was greatly reducing their infectiousness — even
though only some of the patients were smear-negative at the time of its visit.
Of course, all of the cases probably spent at least some time infectious, so contact
tracing for each of these patients and their families is underway.
is being done to fight and prevent drug resistant TB in Mumbai?
After input from the Central Team, the Maharashtra state government, Brihanmumbai Municipal
Corporation (BMC) and private hospitals came up with a plan to deal much more
aggressively with drug-resistant TB in Mumbai. Several of these steps are
described in a press release, though reports
in the Times of India on 19 January and 20 January, and elsewhere in
the Indian media have clarified a number of key points.[i]
Immediately and dramatically strengthening the TB control staff in Mumbai.
of Mumbai’s 24 wards are now designated as 24 RNTCP districts, each hiring its
own district TB officer, coordinated by one senior TB officer for all of
Mumbai. All 25 doctors hired as TB officers will be sent
for training at Bengaluru's National TB Institute. They will be responsible for
administration, and also follow up and monitoring of patients to ensure they do
not drop out of treatment.
Dramatically strengthening the infrastructure to support the TB programme.
Each TB district will be supported with infrastructure including
24 district TB drug stores and one additional state level TB pharmacy. The TB
programme will decentralise further so that that there will be a basis TB unit
for every 200,000 people (rather than for every 500,000 people). Overall this
will add 35 additional TB units, overseen by TB control officers, supported by
20 additional microscopy centres (and lab technicians to be hired immediately).
number of TB beds at GTB hospital in Sewri will be increased from 45 to 90.
additional DOTS-Plus sites (for drug-resistant TB) will be established.
Crucially, Mumbai’s public sector has lacked the laboratory infrastructure to
identify and confirm the diagnosis of drug-resistant TB, so additional culture and
second-line DST laboratories are to be established and accredited at GTB Hospital
in Mumbai in the next five to six months, and at two private laboratories as
soon as possible.
3) The programme will try
to ensure case notification by implementing the notification system under the BMC Public
Health Act for TB, which establishes with punitive measures for whenever
healthcare providers fail to report TB cases (this should assist TB district
officers keep track of patients going onto treatment.
laboratory notification will be introduced for M/XDR TB from all public and
private sector laboratories of Mumbai, with retesting and confirmation under
4) Contract tracing will
be performed for all patients diagnosed in Mumbai with M/XDR TB, and TB
screening performed on all of their close contacts. A similar exercise will
also be undertaken in other districts and municipal corporation areas in the
5) There will be universal
access to MDR TB screening in Mumbai including those treated by the private sector (they no
longer have to repeat a failed course of treatment in the public sector in
order to qualify for DST).
And, last but not least, there will be universal access to treatment for
patients diagnosed with drug-resistant TB in Mumbai, who will be treated free,
with treatment support whether they have enrolled with RNTCP or not.
high expense of second-line medication is one of the reasons why patients stop
taking treatment and become even more resistant. While first-line treatment
costs around US $45, treatment for drug resistant TB costs around $4000, while
treatment for XDR-TB can cost at least 2 and a half times as much. Few Indians
can afford appropriate M or XDR-TB treatment, but it has been decided, in
Mumbai at least, that it would be more expensive not to treat it.
A publicity campaign will be launched widely in order to spread awareness of
the availability of free diagnostic and treatment services for all types of TB.
according to a report in the Gulf News, a
research project on the prevalence of TB in the congested slums of Dharavi will
also be undertaken with technical assistance from the World Health
Are these measures enough?
these measures are enough will of course depend upon how well they are
implemented — as well as whether estimates are accurate about how much
drug-resistant TB there is in Mumbai.
are some risks with implementation. Where and how people with drug-resistant TB
are treated is an issue. Without addressing factors such as poor infection
control, it is possible that bringing more people with drug-resistant TB into
facilities could lead to its spread to other patients, and staff. This is less
likely if treatment for drug resistant TB is ambulatory. Spreading drug
resistance within a health facility has been the cause of other drug-resistant
TB outbreaks (such as the initial XDR-TB outbreak in Tugela Ferry (Church of
Scotland Hospital), KwaZulu-Natal, South Africa in 2005), and without good
infection control, serious illness and potential deaths among healthcare providers - not to mention poor morale and staff retention
- could undermine TB control efforts.
issue HATIP is currently uncertain about is whether second-line TB treatment
will be an empiric standardised regimen in Mumbai (second line is often
standardised when there is inadequate access to second-line DST for
individualised or optimised treatment) and if so, how well is it tailored to
the local resistance patterns.
a standardised second line regimen that is effective in most of the TB cases in
a population, can be difficult when people have very different treatment
histories. According to the report in PLos Med, the poorly trained private
practitioners in Mumbai prescribed a wide range of treatment regimens, and
theirpatients, could have developed very different resistance profiles.
that is the case, a standardised drug-resistant TB regimen may fail to
adequately control the infections in many of the M/XDR-TB patients in Mumbai —
and suboptimal treatment could thus lead to increased resistance.
the other hand, when the resistance profiles in a population are relatively
homogenous, a standardised empiric regimen that suits the population would be simpler and more cost-effective than
performing all that DST testing, and procuring a wider array of anti-TB
treatment medications. WHO recommends ongoing continuous resistance
surveillance to inform these decisions.[ii]
CID, Udwadia et al recommended that the public sector take over all treatment of drug-resistant TB.
While the Global Plan to Stop TB recommends engaging all health care providers,
is it wise to empower private practitioners to continue treating drug-resistant
TB patients without first providing further training to make sure that
treatment, care and support conforms to international standards? Or will
enforcing the case notification system work well enough that district TB
officers will be able to keep a close eye on all the people with M/XDR-TB
treatment in their district?
et al also suggested, as have others, that India needs to more tightly
regulate access to TB medications. It is important to note that some TB drug
resistance could be the result of inadvertent exposure to TB medications. Some
second and third-line anti-TB drugs are also commonly used to treat other
conditions. If a healthcare provider or pharmacist provides one of these
medications, such as a fluoroquinolone without first screening the patient for
TB or checking to see whether they are on TB treatment, it could foster drug
resistance. WHO urges strict enforcement of regulations for the quality and
dispensing of anti-TB drugs, particularly of the second-line drugs. Other
steps, such as guidance to pharmacists and non-TB specialists might also help
avoid such mishaps.
initial steps being taken in Mumbai are primarily focused on traditional TB
control programme elements but we have yet to see any mention of marginalised
populations who tend to have a greater risk of drug-resistant TB and who can be
difficult for the formal health sector to reach. Is the need to consider, reach
out to, engage and address the needs of poor and vulnerable populations such as
people living with HIV, the poor, low caste, migrants, and people who use drugs
adequately addressed by the TB programme in Mumbai? Will universal access to
M/XDR-TB diagnosis and treatment going to be extended to the prisons of Mumbai
or will it be a blind spot - as in so many other settings?
of the pillars of the Global Plan to Stop TB is that community engagement in
the TB response is critical. For instance, could accessing DR-TB treatment, even if free,
jeopardise relationships, employment or housing because of TB-stigma; does it
interfere with mobility or work? do people have to trade putting food on the
table, for treatment?
with the various communities at risk can help identify these issues, lead to
more effective outreach, support services, follow-up, contact tracing and so
on. Empowered and informed patients and communities may also be able to
influence national policy and help leverage more support for health systems and
TB services. Service integration or collaboration with other health sectors is
needed in order to guarantee that other essential care in these populations — such
as HIV prevention, testing, treatment (especially early ART) and care, or
substitution maintenance therapy for people who use drugs — is integrated at or
effectively linked with TB service delivery points and vice versa.
and most glaringly, the reports describe these efforts as being Mumbai-specific.
What about the rest of India?
Dr Paul Nunn from WHO's Stop TB Department told The Lancet: “Until recently,
care for MDR-TB was not available in the public sector in India. Thus those with MDR-TB were
forced in to the private sector where availability of anti-TB drugs is
effectively unregulated and care is uncoordinated and unsupervised…This problem
was predictable, and indeed was predicted.”
would be a fallacy to assume that serious TB drug resistance will only be
limited to Mumbai and its slums when the conditions that lead to virtually
untreatable TB exist in many other areas in India.
 Ministry of Health and Family
Welfare. Central Team Submits Report on Drug Resistant Tuberculosis Mumbai
Cases. Centre Assures full Supply of DR-TB Drugs and Technical help.
RNTCP Maharashtra to Adopt Identified Cases and Offer free Treatment. January
 WHO. Guidelines for the programmatic management of drug resistant
Tuberculosis. 2011 Update. Geneva, 2011.