Published Date: 2012-04-26 14:15:05
Subject: PRO/EDR> Tuberculosis, MDR - India: (MH)
Archive Number: 20120426.1114435
TUBERCULOSIS, MDR – (INDIA): (MAHARASHTRA)
A ProMED-mail post
ProMED-mail is a program of the
International Society for Infectious Diseases
Date: Tue 24 Apr 2012
Source: health.india.com, IANS (Indo Asian News Service) report [edited]
As many as 63 new MDR-TB [multidrug resistant tuberculosis] cases have been reported in [Pune] district over the last 2 months. 26 of them are from Pimpri-Chinchwad and 23 from Pune. The districts rural interiors have reported 14 new MDR-TB patients as well. Since the State TB Training and Demonstration Centre (STDC) became functional, experts have been separating MDR cases from TB cases.
Tuberculosis can become resistant if any of the following occurs: patient is not treated well enough; patient is not treated long enough; patient doesn't take the prescribed medication properly; or, patient is prescribed the wrong drugs.
Of the 1.2 million "new" TB cases notified in 2009 in India, as many as 14 991 (1.3 per cent) were reported to have failed the regular anti-TB drug regimen. Similarly, of the [289 756] re-treatment TB cases, 11 265 (4 per cent) failed the 1st line re-treatment regimen.
MDR-TB (resistance to [at least] 2 of the potent 1st line anti-TB drugs, isoniazid and rifampicin) is one of the important causes for the failure of TB treatment. As per the guidelines of the Revised National Tuberculosis Control Programme (RNTCP), patients with drug susceptibility test (DST) results showing resistance to rifampicin are considered eligible for MDR-TB treatment, irrespective of resistance to isoniazid, streptomycin, or ethambutol.
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[According to the World Health Organization (WHO), the proportion of new TB cases reported from 80 countries and 8 territories as showing resistance to rifampin and isoniazid (that is, MDR-TB) ranged from 0 per cent to 28.9 per cent and in previously treated cases, 0-65 per cent in the years 2007 to 2010 (table 1, http://www.who.int/bulletin/volumes/90/2/BLT-11-092585-table-T1.html). Data on XDR (extensively drug resistant)-TB (that is, resistance to any fluoroquinolone and 2nd line injectable agent, in addition to resistance to rifampin and isoniazid) were reported to WHO from 38 countries and 3 territories, 34 of which routinely test all patients with MDR-TB for 2nd line anti-TB drug resistance. Only 6 out of 41 (15 per cent) countries and territories reported more than 10 cases of XDR-TB; the proportion of MDR-TB cases that were extensively drug resistant exceeded 10 per cent in Estonia (19.7 per cent), Latvia (15.1 per cent), South Africa (10.5 per cent), and Tajikistan (Dushanbe city and Rudaki district, 21.0 per cent) (table 2, http://www.who.int/bulletin/volumes/90/2/BLT-11-092585-table-T2.html).
However, WHO reported that national data are lacking on the frequency of MDR-TB among new or previously treated patents and the frequency of XDR-TB among MDR-TB cases in many large countries, including India (figure 1, http://www.who.int/bulletin/volumes/90/2/11-092585.pdf). India and the Russian Federation -- the other 2 large countries that, with China, contribute to more than 50 per cent of the estimated global burden of MDR-TB -- have only produced reliable subnational level data to date. A survey in 2006 in the Indian state of Gujarat found that 3.2 per cent of 216 MDR isolates tested were XDR (table 2, http://www.who.int/bulletin/volumes/90/2/BLT-11-092585-table-T2.html).
Conventional diagnosis of drug resistant TB relies on mycobacterial culture and drug susceptibility testing, a slow and cumbersome process. During the prolonged time required for testing, patients may be inappropriately treated and drug resistant strains may continue to spread in the community. In addition, although routine drug susceptibility testing of all confirmed TB cases should be the goal, there are very few laboratories that can diagnose MDR-TB in developing countries, and only 34 countries and settings have a system in place to routinely test all patients with MDR-TB for 2nd line anti-TB drug resistance.
The availability of a new molecular technology -- that is, Xpert MTB/RIF -- allows in less than 2 hours the detection of _Mycobacterium tuberculosis_, as well as detection of rifampin resistance, by amplifying DNA present in unprocessed sputum samples with minimal hands-on technical time, even in countries with severely limited laboratory infrastructure (Boehme CC, Neeta P, Hillman D, et al. Rapid molecular detection of tuberculosis and rifampin resistance. N Engl J Med. 2010; 363(11): 1005-15; available at http://www.nejm.org/doi/full/10.1056/NEJMoa0907847). Rifampin resistance often indicates MDR-TB. Molecular technologies are expected to contribute substantially to surveillance of drug resistant TB in low-resource settings in the future (Small PM, Pay M. Tuberculosis diagnosis -- time for a game change. N Engl J Med. 2010; 363(11): 1070-1; available at http://www.nejm.org/doi/full/10.1056/NEJMe1008496).
Pune is the 8th largest metropolis in India and the 2nd largest in the state of Maharashtra after Mumbai, the capital of Maharashtra (http://en.wikipedia.org/wiki/Pune). Pimpri-Chinchwad is a city in the Pune district (http://en.wikipedia.org/wiki/Pimpri-Chinchwad).
A map of the states of India can be accessed at http://www.globalsecurity.org/military/world/india/images/IndiaMap_tourism.gif. The HealthMap/ProMED-mail interactive map of India can be accessed at http://healthmap.org/r/2gZV. - Mod.ML]