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No time to lose

If globally containing tuberculosis, the incidence of which is estimated to be growing at one per cent a year, is proving to be a big challenge, the spread of multi-drug resistant tuberculosis (MDR-TB) — caused by a bacterial strain that is resistant to at least two of the best first-line drugs — is not making things any easier. According to the latest report of the World Health Organisation on anti-tuberculosis drug resistance surveillance, the fourth by the world body, an estimated 4.9 lakh new drug resistant cases emerged in 2006. India and China alone account for 50 per cent of the global burden. The percentage of people affected by MDR-TB is likely to increase in India as the DOTS Plus programme to diagnose and treat such cases was started only in August last year. MDR-TB, unlike TB, requires specialised laboratories for diagnosis; it cannot be detected clinically. At present, there are only five laboratories equipped to undertake the tests and three more are expected to be in place by the end of this year. It is planned to have 24 regional laboratories capable of identifying such cases and managing 5,000 cases annually by 2010. While pinpointing “insufficient laboratory capacity” as the “primary limitation” in addressing the problem, the WHO report warns that any slackness on government’s part in creating the facility will result in the “unregulated private sector” entering the arena in a big way.

Though tuberculosis is endemic in India, which is one of the high TB burden countries in the world, it was only two years ago that the Revised National TB Control Programme could achieve population coverage of directly observed treatment, short-course (DOTS) in all districts. Despite a detection rate of 61 per cent and treatment success rate of 86 per cent, the prevalence of drug resistance in new cases is about 3 per cent and over 17 per cent in the previously treated cases. Apart from the well-known tendency of patients not to complete the full course of treatment, the indiscriminate use of second-line drugs by private practitioners is a major factor that pushed up the number of drug resistant patients. More efforts have to be directed at educating healthcare providers on correct prescribing methods, as some of the MDR-TB cases would eventually become resistant to three or more of the six classes of second-line drugs leading to extremely drug resistant TB (XDR-TB). XDR-TB cases have already been reported in the country. A multi-pronged strategy is imperative to tackle MDR if the extremely drug resistant cases, for which there is no treatment at present, are not to multiply.

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