Global TB Fight Hits a Wall

Geeta Anand, Wall Street Journal, February 15, 2013

Here on center stage in the global crisis of drug-resistant tuberculosis, top doctors are sounding a new alarm: India’s emergency strategy to defeat the disease may be having the opposite effect—encouraging TB instead to mutate into more deadly and unstoppable strains.

In its new strategy, India is treating some, and perhaps many, drug-resistant TB patients with drugs that they are already resistant to. That can allow the bacteria to build resistance to new drugs as well.

On Friday, a prominent specialist described research to The Wall Street Journal showing that the government’s treatment plan wouldn’t work on fully two-thirds of the 300 patients analyzed at one major Mumbai hospital. The results suggest India’s plan is “a futile exercise” that will “serve to amplify resistance,” said the researcher, Dr. Zarir Udwadia. “It is morally and medically disastrous.”

Shown the findings, Mario Raviglione, director of the World Health Organization’s Stop TB Department, called India’s approach to treating drug-resistant TB “complete nonsense.”

Ashok Kumar, head of the Central TB Division of India’s health ministry, declined several requests for comment.

India estimates it is home to 100,000 patients with drug-resistant TB—the most in the world—but for years it officially ignored them in favor of treating traditional TB, which is more common and curable. That policy left drug-resistant strains to spread and worsen. For countless thousands of people, it amounted to a death sentence.

Last year New Delhi made a historic policy reversal, scaling up a new strategy for treating drug-resistant patients. The change followed a Journal investigation in 2012 revealing that India, for years, had ignored evidence of increasing drug resistance and today likely has far higher rates of resistant TB than officially reported. The Journal also showed that the WHO’s own policies inadvertently helped drug-resistant TB to flourish.

Drug-resistant strains are edging up in the U.S. and increasing in parts of Europe, though most cases are in India, China and Russia, the WHO says. In some Indian patients, TB is now all but incurable.

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The issue with India’s new program, doctors say, is that tries to be one-size-fits-all: The same six-drug cocktail is given to every drug-resistant patient, without thorough testing to see which they are resistant to.

Experts say at least four of the six drugs must work for most patients to be cured.

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The WHO’s Dr. Raviglione said, “It is silly to use drugs that there is proven high resistance to, thinking they will work.” The WHO recommends testing patients for drug resistance. If there aren’t enough labs to do that, he said, Mumbai should conduct surveys to see which drugs its patients are most resistant to, then replace those drugs in the standard cocktail.

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The world is battling an epidemic of drug-resistant TB. India has about 2.2 million of the estimated 8.7 million total TB patients world-wide, the most of any country. Last year it said it would scale up its treatment of drug-resistant TB and eventually test all TB patients for resistance at their initial diagnosis.

Several studies suggest substantial resistance here in Mumbai to many drugs in the government’s treatment regimen. A preliminary analysis of one study under way showed that 28% of all TB patients tested in Mumbai were drug-resistant.

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One basic problem: India doesn’t have enough labs to test every patient for resistance, and likely won’t for years. {snip}

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