India and Multi-Drug Resistant Tuberculosis - Part 1

Posted on Feb 14, 2013 by Ailee Slater (G+)

Counterfeit handbags and counterfeit sunglasses may be a bane to the fashion industry, but they're probably not going to kill anyone. Counterfeit drugs, on the other hand, just might. Thanks to a study published last week in the International Journal of Tuberculosis and Lung Disease, we now know that counterfeit tuberculosis drugs are shockingly common, and they are helping to create more dangerous and drug-resistant forms of tuberculosis.

The study was conducted by a U.S. research team, investigating the quality of the most commonly used tuberculosis drugs in 19 cities around the world. Researchers purchased the drugs (two first-line antibiotics known as isoniazid and rifampicin) from local pharmacies and markets, then tested how these medications matched quality control standards. The U.S. team found that 9.1 failed the basic quality control test, and nearly 50 percent had no active ingredient - the drugs were actually missing the molecule needed to kill the tuberculosis.

Some of the drugs tested came from legitimate manufacturers, and their quality issues stemmed from poor make or damage while in transit. Others, however, were complete counterfeits - the result of criminals making and selling fake tuberculosis drugs. One of the biggest problems with counterfeit or low-quality tuberculosis antibiotics is the fact that these pills are creating drug-resistant strains of the disease. If a drug has too little of the active tuberculosis-killing ingredient, treatment will not work. Instead, the patient will often be left with a more powerful form of the disease, resistant to whatever active ingredient they have been exposed to. If this patient attempts tuberculosis treatment later on, they will not be able to benefit from even a high quality, high dosage of the active ingredient to which their particular strain of tuberculosis is now immune. Drug-resistant strains of tuberculosis are unfortunately becoming more and more common; in fact, there is a name for the condition - multi-drug resistant tuberculosis, or MDR-TB for short. MDR-TB is a problem for health care workers around the world, however some countries are of particular concern.

India has had a long and ugly struggle with tuberculosis; small surprise that in the U.S. quality control study, India had the second highest failure rate of tuberculosis drugs, with just over 1 in 10 pills found to be faulty. There are between 3.1 and 4.3 million people living with tuberculosis in India, accounting for more than a quarter of total tuberculosis cases in the world. Doctors do not always have the tools to properly diagnose and treat patients, and patients themselves are often without the resources, financial or otherwise, to seek medication or even just a diagnosis.

Still, the country has made great strides in the last two decades - establishing quality microscopy centers to better diagnose and record cases of tuberculosis; improving treatment using strategies set up by the World Health Organization; improving and standardizing training manuals for health care providers; and initiating more joint tuberculosis/HIV programs. Now, most health care professionals agree that multi-drug resistant tuberculosis is where the government of India ought to focus its attention. Multiple editions of the India Journal of Tuberculosis published in 2012 contained editorials calling attention to the rising problem of MDR-TB. In July, for example, author  D. Behera writes that three percent of new tuberculosis cases are multi-drug resistant, and 12-17 percent of patients seeking tuberculosis re-treatment will likewise be suffering from a drug resistant strain.

Behera urges policy makers to focus their attention on infection control practices - dealing with hospital overcrowding and ensuring that health facilities are properly disposing of medical waste are two ways to avoid the further spread of drug-resistant tuberculosis strains. Published in October 2012, another editorial from the India Journal of Tuberculosis also discussed the issue of MDR-TB. In it, authors Vinaya S. Karkhanis and Jyotsna M. Joshi make the frightening comparison between the drug-resistant tuberculosis of today and the tuberculosis of a pre-antibiotics era - both are diseases capable of spreading, with no easy cure in sight. Karkhanis and Joshi make special note of the fact that improper tuberculosis treatment is a huge factor in creating drug resistant strains; when patients have only sporadic access to drugs, or doctors incorrectly prescribe medication without following tuberculosis program guidelines, MDR-TB can result.

There are a few reasons why India might be particularly susceptible to MDR-TB. Poverty in the country is endemic, and in fact editorial author Behera points out that treating MDR-TB costs around $2000 USD, as opposed to treatment for traditional tuberculosis which comes with a price tag of less than $10. This high cost of treatment leads people to abandon their drug regimen, producing stronger forms of the disease. Of course, we have already seen how high costs can push consumers toward cheaper yet lower quality counterfeit drugs, which again produce drug-resistant strains due to low amounts of the active, tuberculosis-killing ingredient. India's Tuberculosis Control Program reports other issues with the nation's approach to treating the disease. Because there is little information coming from the private sector as to how many cases of MDR-TB are occurring and how these cases are treated, it is difficult for public health groups to monitor the country's overall trends and provide adequate recommendations to health care centers.

Due to the lack of good records in both private and public health settings, patients may be given medication erratically, or put on a dosage of the same drug more than once. This non-standard course of tuberculosis treatment can cause MDR-TB to develop and spread. The upside to all of this is that public health officials in India are working hard to fight multi-drug resistant tuberculosis. Since 1992 the government has developed an initiative known as the Revised National Tuberculosis Control Program, or RNTCP. Just last year, RNTCP released a document outlining their response plan for tackling MDR-TB in India. The plan includes five main points, ranging from better implementation of tuberculosis strategies from the World Health Organization, to preventing new strains of tuberculosis resistant to even more types of drugs, as well as an increase of MDR-TB screening to better diagnose and treat patients. In 'India and Multi-Drug Resistant Tuberculosis - Part 2' we will take a closer look at this MDR-TB response plan from the Revised National Tuberculosis Control Program of India.