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Management and control of multidrug-resistant tuberculosis (MDR-TB): Addressing policy needs for India

Journal of Public Health Policy volume 37, pages 277–299 (2016)Cite this article

Abstract

Multidrug-resistant tuberculosis (MDR-TB) challenges TB control efforts because of delays in diagnosis plus its long-term treatment which has toxic effects. Of TB high-incidence countries, India carries the highest burden of MDR-TB cases. We describe policy issues in India concerning MDR-TB diagnosis and management in a careful review of the literature including a systematic review of studies on the prevalence of MDR-TB. Of 995 articles published during 2001–2016 and retrieved from the PubMed, only 20 provided data on the population prevalence of MDR-TB. We further reviewed and describe diagnostic criteria and treatment algorithms in use and endorsed by the Revised National TB Control Program of India. We discuss problems encountered in treating MDR-TB patients with standardized regimens. Finally, we provide realistic suggestions for policymakers and program planners to improve the management and control of MDR-TB in India.

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Notes and References

  • Mitnick, C.D. et al (2013) Aggressive regimens for multidrug-resistant tuberculosis decrease all-cause mortality. PLoS ONE 8(3): e58664.

    Article  Google Scholar 

  • World Health Organization. (2015) Global Tuberculosis Control Report, (WHO/HTM/TB/2015.22) Geneva, Switzerland: World Health Organization.

  • Udwadia, Z.F., Pinto, L.M. and Uplekar, M.W. (2010) Tuberculosis management by private practitioners in Mumbai, India: Has anything changed in two decades? PLoS ONE 5(8): e12023.

    Article  Google Scholar 

  • Uplekar, M., Pathania, V. and Raviglione, M. (2001) Private practitioners and public health: Weak links in tuberculosis control. The Lancet 358(9285): 912–916.

    Article  Google Scholar 

  • Yadav, A. et al (2012) Treatment practices in pulmonary tuberculosis by private sector physicians of Meerut, Uttar Pradesh. Indian Journal of Chest Diseases and Allied Sciences 54(3): 161–163.

    Google Scholar 

  • Dye, C. et al (2008) Measuring tuberculosis burden, trends and the impact of control programs. The Lancet Infectious Diseases 8(4): 233–243.

    Article  Google Scholar 

  • Kapoor, S.K., Venkat Raman, A., Sachdeva, K.S. and Satyanarayana, S. (2012) How did the TB patients reach DOTS services in Delhi? A study of patient treatment seeking behavior. PLoS ONE 7(8): e42458.

    Article  Google Scholar 

  • Satyanarayana, S. et al (2011) From where are tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts. PLoS ONE 6(9): e24160.

    Article  Google Scholar 

  • Indian Council of Medical Research. (1959) Tuberculosis in India-A National Sample Survey: 1955–58 ICMR Special Report Series, New Delhi, No. 34.

  • International Institute for Population Sciences (IIPS) and Macro International. (2007) National family health survey (NFHS-3), 2005–06, Vol I. Mumbai, India: IIPS; pp. 411-418, http://www.rchiips.org/NFHS/NFHS-3%20Data/VOL-1/India_volume_I_corrected_17oct08.pdf, accessed 14 November 2014.

  • WHO Report. (2007) Global Tuberculosis Control. Surveillance, Planning and Financing. Geneva, Switzerland, World Health Organization WHO/HTM/TB/2007.376.

  • Chadha, V.K. et al (2012) Prevalence of Pulmonary Tuberculosis among Adults in a Rural Sub-District of South India. PLoS ONE 7(8): e42625.

    Article  Google Scholar 

  • Rao, V.G. et al (2012) Prevalence of pulmonary tuberculosis – A baseline survey in central India. PLoS ONE 7(8): e43225.

    Article  Google Scholar 

  • World Health Organization. (2013) Global Tuberculosis Control Report. Geneva, Switzerland: World Health Organization.(WHO/HTM/TB/2013.13).

  • Institute of Medicine (USA). (2012) Facing the reality of drug-resistant tuberculosis in India: Challenges and potential solutions: Summary of a joint workshop by the institute of medicine, the Indian national science academy, and the Indian council of medical research. Washington DC: National Academies Press, http://www.ncbi.nlm.nih.gov/books/NBK92617/pdf/TOC.pdf, accessed 14 November 2014.

  • Bhat, J. et al (2015) Situation of drug resistant tuberculosis in Saharia tribe of central India. Indian Journal of Medical Research 141(5): 636–639.

    Google Scholar 

  • Myneedu, V. et al (2015) First and second line drug resistance among treatment naïve pulmonary tuberculosis patients in a district under Revised National Tuberculosis Control Programme (RNTCP) in New Delhi. Journal of Epidemiology & Global Health 5: 365–373.

  • Selvakumar, N. et al (2015) High rates of ofloxacin resistance in Mycobacterium tuberculosis among both new and previously treated patients in Tamil Nadu, South India. PLoS ONE 10(3): e0117421.

    Article  Google Scholar 

  • Salvo, F. et al (2014) Survey of tuberculosis drug resistance among Tibetan refugees in India. International Journal of Tuberculosis and Lung Disease 18(6): 655–662.

    Article  Google Scholar 

  • Das, D., Dwibedi, B. and Kar, S.K. (2014) Low levels of anti TB drug resistance in Rayagada district of Odisha, India. International Journal of Mycobacteriology 3(1): 76–78.

    Article  Google Scholar 

  • Gupta, H., Kant, S., Jain, A., Natu, S.M. and Ahluwalia, S. (2013) Initial drug resistance pattern among pulmonary tuberculosis patients. Indian Journal of Tuberculosis 60(3): 154–161.

    Google Scholar 

  • Yadav, R., Sethi, S., Dhatwalia, S., Gupta, D., Mewara, A. and Sharma, M. (2013) Molecular characterization of drug resistance in Mycobacterium tuberculosis isolates from North India. International Journal of Tuberculosis and Lung Disease 17(2): 251–257.

    Article  Google Scholar 

  • Sharma, S.K. et al (2011) Prevalence of multidrug-resistant tuberculosis among category II pulmonary tuberculosis patients. Indian Journal of Medical Research 133(3): 312–315.

    Google Scholar 

  • Sharma, S.K. et al (2011) Prevalence of multidrug-resistant tuberculosis among newly diagnosed cases of sputum-positive pulmonary tuberculosis. Indian Journal of Medical Research 133(3): 308–311.

    Google Scholar 

  • Ramachandran, R. et al (2009) Surveillance of drug-resistant tuberculosis in the state of Gujarat. India International Journal of Tuberculosis and Lung Disease 13(9): 1154–1160.

    Google Scholar 

  • D’Souza, D.T. et al (2009) High levels of multidrug resistant tuberculosis in new and treatment-failure patients from the Revised National Tuberculosis Control Program in an urban metropolis (Mumbai) in Western India. BMC Public Health 9: 211.

    Article  Google Scholar 

  • Joseph, B.V. et al (2009) Drug resistance in Mycobacterium tuberculosis isolates from tuberculosis patients in Kerala, India. International Journal of Tuberculosis and Lung Disease 13(4): 494–499.

    Google Scholar 

  • Jain, A., Mondal, R., Prasad, R., Singh, K. and Ahuja, R.C. (2008) Prevalence of multidrug resistant Mycobacterium tuberculosis in Lucknow, Uttar Pradesh. Indian Journal of Medical Research 128(3): 300–306.

    Google Scholar 

  • Joseph, M.R., Shoby, C.T., Amma, G.R., Chauhan, L.S. and Paramasivan, C.N. (2007) Surveillance of anti-tuberculosis drug resistance in Ernakulam District, Kerala State, South India. International Journal of Tuberculosis and Lung Disease 11(4): 443–449.

    Google Scholar 

  • Anuradha, B. et al (2006) Prevalence of drug resistance under the DOTS strategy in Hyderabad, South India, 2001–2003. International Journal of Tuberculosis and Lung Disease 10(1): 58–62.

    Google Scholar 

  • Dhingra, V.K., Rajpal, S., Bhalla, P., Yadav, A., Jain, S.K. and Hanif, M. (2003) Prevalence of initial drug resistance to M. tuberculosis in new sputum positive RNTCP patients. Journal of Communicable Diseases 35(2): 82–89.

    Google Scholar 

  • Negi, S.S., Gupta, S. and Lal, S. (2003) Drug resistance in tuberculosis in Delhi: A 2 year profile (2001–2002). Journal of Communicable Diseases 35(2): 74–81.

    Google Scholar 

  • Shah, A.R., Agarwal, S.K. and Shah, K.V. (2002) Study of drug resistance in previously treated tuberculosis patients in Gujarat, India. International Journal of Tuberculosis and Lung Disease 6(12): 1098–1101.

    Google Scholar 

  • Paramasivan, C.N., Venkataraman, P., Chandrasekaran, V., Bhat, S. and Narayanan, P.R. (2002) Surveillance of drug resistance in tuberculosis in two districts of South India. International Journal of Tuberculosis and Lung Disease 6(6): 479–484.

    Google Scholar 

  • Although India has 29 States and 7 Union territories as of 2014. at the time of analysis data was only available for 28 States.

  • Government of India Planning Commission data book. (2014) http://planningcommission.nic.in/data/datatable/0814/comp_databook.pdf, accessed 9 November 2014.

  • Government of India – TB India. (2014) Revised National TB Control Program Annual Status Report, New Delhi, http://www.tbcindia.nic.in/pdfs/TB%20INDIA%202014.pdf, accessed 15 April 2014.

  • Warner, D.F. and Mizrahi, V. (2006) Tuberculosis chemotherapy: The influence of bacillary stress and damage response pathways on drug efficacy. Clinical Microbiology Review 19(3): 558–570.

    Article  Google Scholar 

  • WHO/IUATLD. (2004) Global Project on Anti-Tuberculosis Drug Resistance Surveillance. Anti-Tuberculosis Drug Resistance in the World. Geneva, Switzerland: World Health Organization. Report No.3.

  • Dye, C. et al (2002) Erasing the world’s slow stain: Strategies to beat multi drug-resistant tuberculosis. Science 295(5562): 2042–2046.

    Article  Google Scholar 

  • Billington, O.J., McHugh, T.D. and Gillespie, S.H. (1999) Physiological cost of rifampicin resistance induced in vitro in Mycobacterium tuberculosis. Antimicrobial Agents and Chemotherapy 43(8): 1866–1869.

    Google Scholar 

  • Nardell, E. and Dharmadhikari, A. (2010) Turning off the spigot: Reducing drug-resistant tuberculosis transmission in resource-limited settings. International Journal of Tuberculosis and Lung Disease 14(10): 1233–1243.

    Google Scholar 

  • Zhao, M. et al (2009) Transmission of MDR and XDR tuberculosis in Shanghai, China. PLoS ONE 4(2): e4370.

    Article  Google Scholar 

  • Grandjean, L. et al (2015) Transmission of multidrug-resistant and drug-susceptible tuberculosis within households: A prospective cohort study. PLoS Medicine 12(6): e1001843.

    Article  Google Scholar 

  • Cohen, T. and Murray, M. (2004) Modeling epidemics of multidrug-resistant M. tuberculosis of heterogeneous fitness. Nature Medicine 10(10): 1117–1121.

    Article  Google Scholar 

  • Cohen, T., Sommers, B. and Murray, M. (2003) The effect of drug resistance on the fitness of Mycobacterium tuberculosis. The Lancet Infectious Diseases 31: 13–21.

    Article  Google Scholar 

  • Waisbord, S. and Zimicki, S. http://www.popline.org/node/264997, accessed 9 November 2014.

  • Weiss, M., Auer, C., Somma, D. and Abouihia, A (2006) Gender and tuberculosis: Cross-site analysis and implications of a multi-country study in Bangladesh, India, Malawi and Colombia. Special Programme for Research and Training in Tropical Diseases (UNICEF/UNDP/World Bank/WHO), TDR/SDR/SEB/RP/06.1. Geneva, Switzerland: WHO. Report Series No. 3, http://www.who.int/tdr/publications/documents/sebrep3.pdf, accessed 5 May 2014.

  • Atre, S. et al (2011) Gender and community views of stigma and tuberculosis in rural Maharashtra, India. Global Public Health 6(1): 56–71.

    Article  Google Scholar 

  • Somma, D. et al (2008) Gender and socio-cultural determinants of TB-related stigma in Bangladesh, India, Malawi and Colombia. International Journal of Tuberculosis and Lung Disease 12(7): 856–866.

    Google Scholar 

  • Jaramillo, E. (1998) Pulmonary tuberculosis and health-seeking behaviour: how to get a delayed diagnosis in Cali, Colombia. Tropical Medicine & International Health 3(2): 138–144.

    Article  Google Scholar 

  • Liefooghe, R. et al (1997) From their own perspectiveA Kenyan Community’s Perception of Tuberculosis. Tropical Medicine & International Health 2(8): 809–821.

    Article  Google Scholar 

  • Portero, L.J. and Rubio, M. (2003) Private practitioners and tuberculosis control in the Philippines: Strangers when they meet? Tropical Medicine & International Health 8(4): 329–335.

    Article  Google Scholar 

  • Pinto, L.M. and Udwadia, Z.F. (2010) Private patient perceptions about a public programme; what do private Indian tuberculosis patients really feel about directly observed treatment? BMC Public Health 10: 357.

    Article  Google Scholar 

  • Jaggarajamma, K., Balambal, R. and Muniyandi, M. (2009) Perceptions of tuberculosis patients about private providers before and after implementation of Revised National Tuberculosis Control Program. Indian Journal of Tuberculosis 56(4): 185–190.

    Google Scholar 

  • Uplekar, M. et al (1998) Tuberculosis patients and practitioners in private clinics in India. International Journal of Tuberculosis and Lung Disease 2(4): 324–329.

    Google Scholar 

  • Pathania, V., Almeida, J. and Kochi, A. (1997) TB Patients and Private for Profit Health Care Providers in India. Geneva, Switzerland: World Health Organization, WHO/TB/97.223.1997.

    Google Scholar 

  • Srivastava, D.K. et al (2011) An assessment of knowledge and practices regarding tuberculosis in the Context of RNTCP among non-allopathic practitioners in Gwalior District. Online Journal of Health and Allied Sciences 10(2): 5.

    Google Scholar 

  • Bhargava, A., Pinto, L. and Pai, M. (2011) Mismanagement of tuberculosis in India: Causes, consequences, and the way forward. Hypothesis 9(1): e7.

    Article  Google Scholar 

  • Datta, K., Bhatnagar, T. and Murhekar, M. (2010) Private practitioners’ knowledge, attitude and practices about tuberculosis, Hooghly district India. Indian Journal of Tuberculosis 57(4): 199–206.

    Google Scholar 

  • Uplekar, M., Juvekar, S. and Morankar, S. (1996) Tuberculosis patients and practitioners in private clinics, Bombay [Research Newsletter]. Foundation for Research in Community Health.

  • Jagota, P. (1998) Case finding policy for national tuberculosis program. Indian Journal of Tuberculosis 45(1): 3–7.

    Google Scholar 

  • Central TB Division (CTD). (2012) Guidelines on programmatic management of drug resistant TB (PMDT) in India. Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi, http://tbcindia.gov.in/WriteReadData/l892s/8320929355Guidelines%20for%20PMDT%20in%20India%20-%20May%202012.pdf, accessed 21 February 2016.

  • Government of India – TB India. (2015) Revised National TB Control Program Annual Status Report, New Delhi, http://tbcindia.gov.in/showfile.php?lid=3166, accessed 25 November 2015.

  • Sachdeva, K. (2013) Management of tuberculosis: Indian Guidelines 2013, http://www.apiindia.org/medicine_update_2013/chap105.pdf, accessed 25 November 2015.

  • Census of India (State Census). (2011) http://www.census2011.co.in/states.php, accessed on 25 November 2015.

  • Chadha, S. et al (2011) Operational challenges in diagnosing multi-drug resistant TB and initiating treatment in Andhra Pradesh, India. PLoS ONE 6(11): e26659.

    Article  Google Scholar 

  • Global Alliance for TB drug development. (2007) Pathway to Patients: Charting the Dynamics of the Global TB Drug Market. New York: TB Alliance.

  • Greaves, F., Ouyang, H., Pefole, M, MacCarthy, S. and Cash, R.A. (2007) Compliance with DOTS diagnosis and treatment recommendations by private practitioners in Kerala, India. International Journal of Tuberculosis and Lung Disease 11(1): 110–112.

    Google Scholar 

  • Pathania, V.S. (2001) Why the Indian TB control program must stop ignoring private practitioners. International Journal of Tuberculosis and Lung Disease 5(2): 201–203.

    Google Scholar 

  • Uplekar, M.W. and Shepard, D.S. (1991) Treatment of tuberculosis by private general practitioners in India. Tubercle 72(4): 284–290.

    Article  Google Scholar 

  • Gupta, S., Gupta, S. and Behera, D. (2011) Reasons for interruption of anti-tubercular treatment as reported by patients with tuberculosis admitted in a tertiary care institute. Indian Journal of Tuberculosis 58(1): 11–17.

    Google Scholar 

  • Atre, S. (2015) Notification of multidrug-resistant tuberculosis cases and their treatment outcomes from the private sector. International Journal of Tuberculosis and Lung Disease 19(9): 1126.

    Article  Google Scholar 

  • Sharma, S. and Mohan, A. (2006) Multidrug-resistant tuberculosis: A menace that threatens to destabilize tuberculosis control. Chest 130(1): 261–272.

    Article  Google Scholar 

  • Farmer, P. and Kim, J.Y. (1998) Community based approaches to the control of multidrug-resistant tuberculosis: Introducing ‘DOTS-plus’. BMJ 317(7159): 671–674.

    Article  Google Scholar 

  • Atre, S., D’Souza, D.T.B., Dholakia, Y.N. and Mistry, N.F. (2007) Observations on categorization of new TB cases: Implications for controlling drug resistance. International Journal of Tuberculosis and Lung Disease 11(10): 1152–1153.

    Google Scholar 

  • Mphahlele, M. et al (2008) Pyrazinamide resistance among South African multidrug-resistant Mycobacterium tuberculosis isolates. Journal of Clinical Microbiology 46(10): 3459–3464.

    Article  Google Scholar 

  • Khurram, M., Khaar, H.T. and Fahim, M. (2012) Multidrug-resistant tuberculosis in Rawalpindi, Pakistan. The Journal of Infection in Developing Countries 6(1): 29–32.

    Article  Google Scholar 

  • Whitfield, M.G. et al (2015) A global perspective on pyrazinamide resistance: Systematic review and meta-analysis. PLoS ONE 10(7): e0133869.

    Article  Google Scholar 

  • Otu, A., Umoh, V., Habib, A., Ameh, S., Lawson, L. and Ansa, V. (2013) Drug Resistance among Pulmonary Tuberculosis Patients in Calabar. Pulmonary Medicine doi: 10.1155/2013/235190.

  • Franke, M. et al (2015) Counting pyrazinamide in regimens for multidrug – Resistant tuberculosis. Annals of American Thoracic Society 12(5): 674–679.

    Article  Google Scholar 

  • Laniado-Laborin, R. (2010) Multidrug-resistant tuberculosis: standardized or individualized treatment? The question has already been answered. Expert Review of Respiratory Medicine 4(2): 143–146.

    Article  Google Scholar 

  • Suárez, P. et al (2002) Feasibility and cost – effectiveness of standardized second-line drug treatment for chronic tuberculosis patients: A national cohort study in Peru. The Lancet 359(9322): 1980–1989.

    Article  Google Scholar 

  • Park, S., Lee, W.C., Lee, D.H., Mitnick, C.D., Han, L. and Seung, K.J. (2004) Self-administered, standardized regimens for multidrug-resistant tuberculosis in South Korea. International Journal of Tuberculosis and Lung Disease 8(3): 361–368.

    Google Scholar 

  • Mitnick, C. et al (2003) Community-based therapy for multidrug-resistant tuberculosis in Lima, Peru. The New England Journal of Medicine 348: 119–128.

    Article  Google Scholar 

  • Leimane, V. et al (2005) Clinical outcome of individualized treatment of multidrug-resistant tuberculosis in Latvia: A retrospective cohort study. The Lancet 365(9456): 318–326.

    Article  Google Scholar 

  • Government of India. TB India. (2013) Revised national TB control program annual status report, New Delhi, http://www.tbcindia.nic.in/pdfs/TB%20India%202013.pdf, accessed 15 April 2014.

  • World Bank. (2013) Public health expenditure data, http://data.worldbank.org/indicator/SH.XPD.PUBL.ZS, accessed 5 March 2014.

  • Escombe, A.R. et al (2013) Upper-room ultraviolet light and negative air ionization to prevent tuberculosis transmission. PLoS Med 6(3): e1000043.

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Acknowledgements

Sachin Atre gratefully acknowledges funding support from US Department of State through the United States India Educational Foundation (USIEF) toward his one-year Fulbright-Nehru Postdoctoral fellowship at Harvard Medical School from September 2013. The authors thank Ms. Caroline McCallum for her editorial assistance.

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Authors and Affiliations

  1. Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA 02115, USA

    Sachin R Atre & Megan B Murray

  2. Maharashtra Association of Anthropological Sciences, Centre for Health Research and Development (MAAS-CHRD), Pune, and Savitribai Phule Pune University, Pune, 411007, India

    Sachin R Atre

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Atre, S., Murray, M. Management and control of multidrug-resistant tuberculosis (MDR-TB): Addressing policy needs for India. J Public Health Pol 37, 277–299 (2016). https://doi.org/10.1057/jphp.2016.14

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Keywords

  • MDR-TB
  • policy
  • India
  • pathways to care
  • primary
  • acquired