The problem of tuberculosis in India is multifaceted: Years of inequitable distribution of health care services helped an epidemic grow, and while public health response to tuberculosis has greatly improved in the past two decades, drug resistance is greatly complicating these positive strides.
In Part 1 of "India and Multi-Drug Resistant Tuberculosis," we looked at tuberculosis in India, and how drug-resistant strains (collectively known as MDR-TB) are occurring more and more. In Part 2, we will take a look at the Revised National Tuberculosis Control Program's 2012 response plan for tackling MDR-TB in India. The Revised National Tuberculosis Control Program, or RNTCP, is fighting to limit tuberculosis in India, and especially to stop the spread of MDR-TB before it can become its own epidemic. The RNTCP's response plan to stopping multi-drug resistant tuberculosis consists of five mains points:
"MDR Prevention through sustained high-quality DOTS implementation"
DOTS is an acronym for Directly Observed Therapy, and the term refers to a tuberculosis control strategy developed by the World Health Organization. DOTS protocol includes aspects of doctor-patient interaction such as detecting tuberculosis cases and standardizing treatment. On a national level, DOTS calls for government commitment to solving the problem of tuberculosis, and a system of data in order to assess treatment results. The strategy has proved useful in a number of nations; Mexico, for example, has reported great success since beginning the DOTS program in 1996 and training over 5,000 health care providers in how to use it. The RNTCP notes a few challenges for DOTS implementation in India - overcrowded care clinics, a lack of communication and data sharing between public and private clinics, and poor data records in general. To combat these issues and better implement DOTS protocol, the RNTCP wants to increase access to tuberculosis diagnosis and treatment, especially amongst already-treated patients who are likely to be MDR-TB. Also important according to the RNTCP is furthering the use of DOTS in private clinics, and engaging in more public campaigns to explain what multi-drug resistant tuberculosis is, and how to stop it from spreading.
"Improve capacity for rapid diagnosis of M/XDR TB"
There are many reasons why rapid diagnosis of tuberculosis is important in stopping the spread of MDR-TB - quicker diagnosis means quicker access to the correct drugs and less time for the disease to strengthen, and better diagnostic methods can lead to great improvements in data collection for health care professionals monitoring the success of different tuberculosis treatments. Therefore, a major goal of the RNTCP is to maintain and create more "Culture and Drug Susceptibility testing Laboratories" across India. These laboratories will provide quick diagnoses to patients, and aid the nation as a whole by contributing to trend reports on MDR-TB (tuberculosis resistant to the most common drugs known as first-line treatment drugs) as well as XDR-TB (tuberculosis resistant to both first and second-line drugs). Hiring more lab personnel and providing better staff training is another aspect of diagnostic laboratory improvement. Within these labs, the RNTCP also wants to experiment with new, rapid diagnostic tests such as the GeneXpert. This tool tests throat mucus; analyzing a genetic sequence of the disease to quickly check for first-line drug resistance. Because the test does not require much training to use, and because results are available in under two hours, this sort of rapid diagnostic test has the potential to greatly improve MDR-TB diagnosis and ensure that patients are not treated with a drug for which they have already developed a resistance.
"MDR TB treatment and XDR-TB Prevention"
This sub point calls attention to the importance of basic techniques in treating drug-resistant tuberculosis and preventing new strains of the disease which are resistant to even more drugs. Effective treatment during the very first contraction and diagnosis of tuberculosis is key; if the disease is properly treated the first time, resistant molecules will not have the chance to regroup and grow even stronger. Likewise, MDR-TB must be properly treated with second-line drugs to ensure that XDR-TB does not develop. Proper treatment means prescribing drugs to which a patient is not resistant, and making sure that the patient takes those drugs regularly and finishes the entire dose. To best treat MDR-TB and prevent XDR-TB, the RNTCP is recommending a network of DOTS centers specifically devoted to caring for MDR-TB and XDR-TB patients. These sites would be equipped with a good supply of second-line drugs, and have the necessary knowledge to manage drug-resistant tuberculosis patients. The RNTCP has already published MDR-TB guidance in a public domain online, and would like to engage in even more public campaigns to increase awareness of proper MDR-TB treatment and prevention techniques.
"Evaluate the extent of the threat of second line drug resistance / XDR-TB"
XDR-TB, or a form of tuberculosis that is resistant to both first and second-line drugs, has the potential to do a huge amount of harm. If the disease can develop faster than the drugs to fight it, India and other nations will face a major health crisis. The RNTCP is again working toward better data collection and assessment methods, so that medical researchers and public health organizations know where to focus their skills. If data shows that XDR-TB is indeed a growing problem, more resources can be put toward finding drugs that can fight the disease in a XDR-TB patient.
"Review the supply and availability of second line anti-TB drugs in India"
Along with the previous sub point, this tenant of the RNTCP plan involves preventing drug resistance to second-line antibiotics (XDR-TB) by building awareness and improving drug administration practices. The RNTCP wants drug standards published and distributed, so that clinics (both public and private) follow important guidelines such as not selling to patients without a prescription, and monitoring a patient to ensure that once prescribed, the entire dose of drugs is taken. With appropriate vigilance and comprehensive standards across the country, India should be able to treat MDR-TB patients without creating the same problem of drug resistance that led to these stronger tuberculosis strains in the first place.