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Untreatable TB cases in India spur call for quarantine to prevent spread

By Adi Narayan
Bloomberg News

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Patients in India described as having an untreatable form of the lung disease may be quarantined to thwart possible spread, a health official said.

Authorities and World Health Organization doctors will meet in Mumbai today to discuss how to manage the patients. Among options is isolation at a facility in Jaysingpur, 400 kilometers (250 miles) south of Mumbai, said S.C. Gupta, Maharashtra state’s director-general for health services. If it’s deemed necessary, officials may seek to introduce regulations allowing authorities to forcibly quarantine the patients, Gupta said.

The cases have sparked concern that a highly resistant strain of TB is taking hold in a nation where about 3.8 new infections occur every minute. The country’s first instance of TB that isn’t curable with the recommended antibiotics was reported in India last month. Isolating those infected may prevent the bacterium from creating an unstoppable scourge.

“We are examining all the cases in detail now,” Gupta said in an interview from Mumbai. “In case it is required we can counsel them and try to motivate them, but we cannot compel them.”

India accounts for 26 percent of all TB cases worldwide, equating to at least 2 million new ones in 2010. The emergence of a highly resistant strain was “long expected,” given the ease with which antibiotics can be bought there, said Mario Raviglione, director of the WHO’s Stop TB program. Isolation of the patients is the necessary first step, he said.

Kneejerk Reaction

Quarantining the patients at an isolated site is a kneejerk reaction and is unlikely to be effective, said Yatin Dholakia, a chest physician and technical adviser to the state’s Anti-TB Association.

“The better thing would be to identify and isolate them in infectious diseases wards in Mumbai,” Dholakia said. “All TB cases are contagious, but the government is only focused on these few cases.”

TB spreads through the air similar to the common cold. When people who are sick with TB in their lungs cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected, according to a WHO fact sheet.

Unless the disease is suppressed by a cocktail of antibiotics, a patient will typically infect 10 to 15 others in a year, according to the Geneva-based WHO.

Medicines reserved for treating infections that don’t respond to first-line therapies are often available illegally without a doctor’s prescription in India. The inappropriate use of antibiotics makes them more susceptible to losing their potency, resulting in cases that aren’t readily treatable, according to the WHO.

‘Tip of the Iceberg’

“These patients may well be the tip of the iceberg,” the WHO’s Raviglione said in a telephone interview from Geneva. “When anyone can go to a pharmacy and buy these second-line drugs, then one can assume that many other cases like this exist.”

About 2.1 percent of the tuberculosis patients in India have a multidrug-resistant form that doesn’t respond to the standard six-month treatment with the drugs isoniazid and rifampicin, the WHO says.

These infections usually require a two-year course of medicines that are toxic and prohibitively expensive for most Indians. Only about 1 percent of Indian patients with an infection resistant to multiple medicines receive subsidized treatment, said Zarir Udwadia, a chest physician at Mumbai’s P.D. Hinduja National Hospital and Medical Research Centre.

Half of multidrug-resistant cases globally occur in India and China, leading to 150,000 deaths in 2008, the WHO estimates.

Not Always Fatal

Researchers led by Udwadia described the first four cases in a Dec. 21 paper in the journal Clinical Infectious Diseases. Bacteria cultured from the patients’ sputum didn’t die when exposed to any of the conventional first-line and second-line TB medicines, suggesting they were untreatable.

Infections caused by the highly resistant strain aren’t necessarily fatal. Patients may be managed with a cocktail of antibiotics administered for more than two years. Surgery to remove the most infected lung tissue may also help, Udwadia said.

“Most patients come to us when they are in dire straits and are weak and emaciated,” Udwadia said in a telephone interview. “They get worse week after week, month after month.”

The four patients described in Udwadia’s study were living in Mumbai shantytowns, including Dharavi, Asia’s second-largest slum.

‘Difficult to Treat’

Extensively drug-resistant, or XDR, TB doesn’t respond to three of the most powerful second-line medicines like kanamycin and amikacin. About 40,000 patients suffer from this form of the disease, the Stop TB program estimates.

“XDR is very, very difficult to treat,” Meenakshi Narasimhan, a tuberculosis specialist and director of the Institute of Thoracic Medicine at the Madras Medical College in Chennai, said in an interview. “We have to do a number of tests to find out exactly which drugs will work.”

Udwadia’s team described their new variant as “totally resistant” following the name given to a similar spurt of cases reported in Iran in 2009.

The term is “non standardized and misleading,” and the cases are still considered to be extensively drug-resistant, India’s health ministry said in an e-mailed statement today.

“Testing for resistance beyond XDR-TB is not advocated by the WHO,” and Mumbai’s Hinduja hospital is not accredited to diagnose the condition, according to the statement.

The WHO also has a similar position to that of the Indian government, according to a question and answer section on its website. Possible definitions for “totally drug resistant TB” will be discussed at a meeting of experts in March.






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