‘’It only takes 2.1 treatment errors to convert a TB patient into an MDR patient’’

Dr Zarir F Udwadia

Multi drug resistant TB (MDR TB) is a result of the way we treat TB. For instance, in public hospitals, Category II cases (consisting of retreatment cases including patients with relapse, failure and those who return after default. Such patients are generally sputum positive and have longest duration of treatment) treatment is given in two phases. The intensive phase consist of two months (24 doses)of isoniazid, rifampicin, pyrazinamide, ethambutol and injection streptomycin followed by one month (12 doses) of isoniazid, rifampicin, pyrazinamide and ethambutol all given under direct observation thrice weekly on alternate days. In total the intensive phase in category II is three months. This is immediately followed by continuation phase, which consists of five months (22 weeks, 66 doses) of isoniazid, rifampicin and ethambutol given thrice daily on alternate days, the first dose each week directly observed.

If the sputum smear is positive after three months of treatment, the four oral intensive phase drugs are continued for another one month (12 doses) before starting five months of continuation phase. In normal circumstances, the total duration of treatment is of eight months.

Instead of using sputum smears, we should in fact be using the latest testing technologies, i.e. the Gene Xpert test kit, first along with sputum smear testing at more frequent intervals to detect TB.

In the private sector, bad/ irresponsible prescription patterns are fuelling the MDR TB epidemic and it only takes 2.1 treatment errors to convert a TB patient into an MDR patient.

Patients/ lay public are also to at fault. Today anyone in India can walk into a chemist and buy a week’s supply of TB drugs, not realising that they have taken the first step towards developing MDR TB. Such self medication is harmful because if such a person does contract TB later, the infection will be already resistant to the first lot of drugs he has consumed unsupervised.

Why can’t the Drug Controller (India) pass an order banning the prescription of TB drugs by all except a few approved doctors? This has been done in Brazil with very good impact. Such a ban will cut short the drain of precious medicine resources as well as curb the spread of MDR TB.

I expect this is not being done thanks to opposition from vested interests like the pharmaceutical companies as well as the doctor community, especially private practitioners, who would see it as a loss of business. But such a ban is really the need of the hour. Better access, more affordability are of course required but more judicious use of the resources that we already have currently will also have a major impact.

(Dr Zarir F Udwadia is a consultant chest physician at the Hinduja Hospital, Breach Candy Hospital and Parsee General Hospitals, Mumbai. Dr Udwadia and team were the first to describe Totally Drug Resistant TB (TDR-TB) from India, in October 2011, and published a report on these cases and their treatment in January 2012. In February this year, the PD Hinduja National Hospital and Medical Research Centre received the first TB Champion Award from Global Health Strategies (GHS), an international consulting company, in recognition of the importance the organisation has given to accurate diagnosis and treatment and to optimally manage TB patients, provide reliable diagnostics and develop techniques for rapid diagnosis of TB and drug susceptibility testing.)