Nudge to tweak TB treatment rules -GS Mudur

-The Telegraph

New Delhi: India could prevent on average 18,000 people from developing multi-drug-resistant tuberculosis every year over the next decade if the health ministry accelerates proposed changes in TB diagnosis and treatment policies, public health experts have said.

A study by the health ministry's TB division has estimated that India could avert 180,000 cases of MDR-TB between 2015 and 2025 if most patients who seek government treatment are tested for MDR-TB at the time of diagnosis and provided appropriate drugs.

Under standard treatment protocols, patients with TB receive four different drugs for two months and two drugs for four additional months, while patients with MDR-TB need to be given some medicines outside this quartet of drugs for 18 months or longer.

The health ministry's TB control programme treats about 1.2 million people annually, but only about 250,000 patients were tested for MDR-TB. Health officials say MDR-TB testing at the outset of diagnosis is currently provided only to children with TB, HIV-positive persons and patients who do not respond to standard treatment protocol after two months of treatment.

"We're gradually expanding upfront MDR-TB testing to more patients and hope to provide it to all patients with TB by 2019," Kuldeep Singh Sachdeva, a senior official in the central TB division who led the study, told The Telegraph.

In the study, Sachdeva and his collaborators from other institutions used a TB transmission model to calculate how rapid expansion of a diagnostic tool for MDR-TB would impact the numbers of patients who develop MDR-TB in India.

Their modelling exercise has estimated that providing 75 per cent of all patients diagnosed with TB in the government programme MDR-TB tests at the time of diagnosis would help avert 180,000 cases of MDR-TB over the next decade.

Their results, just published in the journal PLOS ONE, suggest that widespread deployment of a rapid MDR-TB diagnostic tool could "turn an increasing MDR epidemic into a diminishing one."

"The academic community has long argued for the introduction of MDR-TB tests to all patients," said Sarman Singh, professor of laboratory medicine at the All India Institute of Medical Sciences, New Delhi, who was not involved in the study. "The issue has always been whether there are sufficient financial and human resources for this," Singh told this newspaper.

The current incremental cost of the test for MDR-TB is about $12 (Rs 760) per test, Sachdeva said, not counting the charges for personnel and laboratory facilities.

India has the world's highest burden of MDR-TB with an estimate of over 61,000 patients during 2014, followed by China's 55,000 and Russia's 41,000.

Health experts are particularly worried about patients not recognised as having MDR-TB because they may receive inappropriate treatment and continue to spread the TB bacilli which can serve as sources of infection to others.

Medical studies suggest that a patient with MDR-TB can potentially infect five patients over a year.

"It is important to quickly expand MDR-TB testing at least in hotspots of MDR such as Mumbai," said Narges Mistry, director of The Foundation for Medical Research, a non-government organisation that has been tracking the TB epidemic in Mumbai. "We need to close the two-month gap," she said, referring to the two months during which some patients not diagnosed as having MDR-TB may receive standard four-drug treatment even though they should be receiving other anti-TB drugs.

Public health experts from the World Health Organisation, the Bill and Melinda Gates Foundation and Imperial College, London, collaborated in the study that focused on a diagnostic tool called Xpert which can determine whether a patient's TB bacilli are resistance to a key anti-TB drug called rifampicin within two hours.

But the experts say their results could also be valid with other similar diagnostic tools that test for MDR-TB. "We ideally need a test that detects resistance for both rifampicin and isoniazid (another anti-TB drug)," said Singh.