Status of Drug Resistant Tuberculosis Mumbai Cases

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 New Delhi (ABC Live) The Central Team that visited Mumbai to examine the reported Drug resistant cases has submitted its report to the Union Minister of Health and Family Welfare Mr. Ghulam Nabi Azad. The following points emerged unanimously from the consultations held at Mumbai:

–     The reported cases by Hinduja hospital fall only within the category of Extensively Drug Resistant TB (XDR TB) based on standard WHO definitions and not at all as “Totally Drug Resistant” TB (TDR TB).

–     TDR TB is a non standard term, not endorsed by WHO

–     RNTCP Guidelines for quality diagnosis and management of XDR TB are to be applied in all such cases

–     Diagnosis of XDR TB must be based on microbiological confirmation from the accredited national reference laboratories namely National Institute of Research in TB - Chennai, National TB Institute -   Bangalore and LRS Institute of TB and Respiratory Diseases- New Delhi.

–     Revised National Tuberculosis Control Programme (RNTCP) Maharashtra will adopt all these cases and offer them the entire treatment free of cost.

–     Isolation of these cases is not advocated as this is a chronic disease and the transmissibility is reduced drastically by treatment.

Out of the reported 12 patients, 9 patients were traced and found to be stable on the current treatment while 3 have since died. Seven of these 9 patients are residents of Mumbai and one each from Meera-Bhayandar Municipal Corporation and Ratnagiri district of Maharashtra.

Municipal Corporation of Greater Mumbai (MCGM) and Government of Maharashtra have taken the following decisions for immediate implementation:

•      Strengthen the TB service delivery systems in Mumbai by immediately converting all the 24 wards of MCGM to 24 RNTCP districts, with placement of 24 ------- DTOs under one Sr. Mumbai TB Officer with infrastructure for 24 district TB drug stores and one additional State level TB Drug store at Mumbai.

•      MCGM to decentralize basic Tuberculosis Unit (TU) from the current population level of 1 TU per 5 lakhs to one TU per 2 lakhs population for enhanced outreach and services delivery. Additional 35 TUs with Medical Officer TB Control and 20 Microscopic centers with Lab technicians will be immediately created.

•      Three additional DOTS-Plus site along with additional culture & Drug Susceptibility Testing (DST) laboratories will be established at GTB Hospital under MCGM at Mumbai.

•      Immediate up-scaling of Drug Resistant TB services to universal access criteria to test patients for MDR TB in Mumbai including those from the private sector.

•      Widely publicize availability of free diagnostic and treatment services for all types of TB, through regular and repeated advertisements and publicity measures.

•      Ensure the implementation of the notification system under the BMC Public Health Act for TB with punitive measures for non compliance.

•      Introduce mandatory laboratory notification for M/XDR TB from all public and private sector laboratories of Mumbai, trace such diagnosed drug resistant TB patients, re-test them from an RNTCP accredited laboratory and treat all such confirmed drug resistant TB cases under RNTCP.

•      Centre assured full supply of DR-TB Drugs to all such patients along-with requisite technical assistance on regular basis.

It may be recalled that recently, a letter to Clinical Infectious Disease Journal in December 2011 described four patients from Mumbai, with extensively drug resistant tuberculosis (XDR TB), erroneously labeled as “TDR-TB” by the authors. 

A careful audit of their prescriptions revealed that these three patients had received erratic, unsupervised second-line drugs, added individually and often in incorrect doses, from multiple private practitioners (on average from four physicians during a 18-month period) in an attempt to cure their multi-drug resistant (MDR) tuberculosis.

The author also urged that patients with MDR tuberculosis only be treated within the confines of government sanctioned MDR TB treatment programs to prevent the emergence and spread of further drug resistance. Subsequently, eight more cases have been reported by Hinduja Hospital, subsequent to the publication in the journal.

The Central team steered a scientific discussion at the KEM Hospital, Mumbai with eminent experts on the subject from medical colleges in Mumbai, some premium private hospitals, civil society representatives, professional associations, chemist/pharmacist association to discuss the present situation, the magnitude of the problem of drug resistance and the way forward.

The central team also met the higher authorities of Municipal Corporation of Greater Mumbai (MCGM) and Maharashtra state government.