First cases of totally drug resistant TB in India, one dead

This is as scary as it can get. The PD Hinduja hospital detected four people with total drug resistant (TDR) tuberculosis (TB), the first such cases in the country till November last year. In the last two months, eight others have been detected with TDR-TB.

Of the 12 patients, a 31-year-old woman from Dharavi died in November 2011. She underwent a surgery to remove one of the infected lungs before she passed away. Doctors say the condition is a result of inappropriate treatment of TB patients in private clinics. A person with TB can infect 15 people a year and cause an epidemic, according to doctors.

“Our last study on prescribing practices of private practitioners in the treatment of TB patients showed that only five of 106 private practitioners wrote the correct prescription for treating TB,” said Dr Zarir F Udwadia, chest physician at PD Hinduja Hospital who led the study. The hospital detected extreme drug resistant (XDR) TB cases five years ago.

Till November 2011, the hospital got four TB patients resistant to all first-line (Isoniazid, Rifampicin, Ethambutol, Pyrazinamide and Streptomycin) and second-line (Ofloxacin, Moxifloxacin, Kanamycin, Amikacin, Capreomycin, Para-aminosalicylic acid and Ethionamide) drugs.
 
“After thoroughly checking their prescriptions, we found that three of them had received erratic and unsupervised second-line drugs. They were often given in incorrect doses by multiple private practitioners to cure their multi-drug resistant (MDR) TB,” Dr Udwadia said. “The mortality rate of MDR, XDR and TDR-TB is 30%, 60% and 100% respectively.”

Patients with TDR-TB are put on a salvage regime - they are either asked to undergo surgeries or put on experimental drugs and antibiotics such as Linezolid. The antibiotics can have dreadful side effects like neuropathy which damages a single nerve or nerve group that can lead to a loss of sensation of that nerve. 

Dr Udwadia said India has only 27 laboratories to test drug sensitivity. He said the government needs to address the issue immediately and increase such laboratories. “The doctors must also respond to cases quickly. If a TB patient does not react to direct observed treatment short course in 3-4 months, he should be sent for a sputum culture test. The treatment for an MDR-TB patient should begin accordingly,” he said.

“TB which could be treated earlier became mutated because of mismanagement in the treatment and resulted in MDR-TB in 1992. It further got mutated to XDR-TB in 2006 and in 2011, it became TDR-TB for the same reason,” said Dr Udwadia.

“TB is no longer a poor man’s disease. I am seeing more and more people from all sections of society suffering from TB. The manifestation of the disease has changed and it is no longer restricted to the chest. We are seeing TB infection in scalp, skin and even nails. It is the more aggressive form of TB,” said Dr Om Shrivastav, consultant for infectious diseases at Jaslok hospital.

The prevalence of MDR-TB has grown significantly in India over the last two decades. India accounted for 20% of the global MDR-TB cases in 2006. The figure could be higher as such cases diagnosed in the private sector are not reported. A recent study in Mumbai found 24% newly diagnosed patients with MDR-TB and 41% cases of first-line drugs failure.

Dr Udwadia co-wrote a paper on TB along with Dr Camilla Rodrigues, head of microbiology department at Hinduja, and their students, Dr Rohit Amale and Kanchan Ajbani. It was published in the science publication Clinical Infectious Diseases Advance Access on December 21, 2011.