Tuberculosis remains the world’s deadliest infectious disease after AIDS. In 2011, 1.4 million people died from TB, and every year more than 8 million people get sick with the disease. These figures are often shocking to many who believe TB to be a disease from the past, and recent media reports have highlighted some of the reasons for these unacceptable figures.

India’s TB strategy isn’t working

On Saturday, The Wall Street Journal (WSJ) raised concerns that an emergency strategy to defeat drug-resistant tuberculosis (DR-TB) in India was instead encouraging more deadly and unstoppable strains. DR-TB refers to strains of TB bacteria that are resistant to any anti-TB drugs.

Geeta Anand reports that the strategy is treating at least some, if not many, DR-TB patients with medications that they are already resistant to. The results of such a strategy inevitably lead to the emergence of strains that have even greater resistance.  Indeed, there are a growing number of reports of extensively drug-resistant TB (XDR-TB), with the WHO reporting that are at least 77 countries with confirmed XDR-TB cases. XDR-TB is a form of TB that is resistant to isoniazid and rifampicin (the two most powerful anti-TB drugs) as well as any of the second-line anti-TB injectable drugs. Treatment of these strains are much more difficult, and costly, to treat. DR-TB strains can take up to two years or more to treat with drugs that are much more potent, toxic and expensive (MDR-TB drugs can cost up to US$5000, compared to US$20 for standard TB drugs).

The problem with India’s approach, which Mario Raviglione (Director of the World Health Organisation’s (WHO) Stop TB Department) refers to as ‘complete nonsense’, is that it tries to be one-size-fits-all. Patients are given the same six-drug cocktail, without testing to see which drugs they are resistant to.

Worryingly, the article points out that ‘India doesn’t have enough labs to test every patient for resistance, and likely won’t for years’.  Raviglione suggests:

‘if there aren’t enough labs to do that [thorough testing], Mumbai should conduct surveys to see which drugs its patients are most resistant to, then replace those in the standard cocktail’.

For now some patients are (relatively) lucky in that they are able to find private hospitals that can test their resistance, and subsequently pay out-of-pocket for a cocktail of drugs that is more likely to work for them. However for the vast majority of patients this will not be an option. TB health officials have been urging the government to change its strategy, before its simply too late for the millions of TB patients in India.

Countries awash with fake and substandard TB medication

The New York Times and Al-Jazeera have both reported on a recent study published in the International Journal of Tuberculosis and Lung Disease, which found that fake and poorly made antibiotics are being widely used to treat tuberculosis.

Researchers collected samples of the two frontline TB drugs (isoniazid and rifampicin) from pharmacies and markets in 17 countries where TB is common across Africa, Asia, South America and Europe.

From this sample, they found that nearly one in ten pills failed to meet basic quality standards, typically having too little of the active ingredient (the molecule that destroys the TB bacteria) present. Some of these were poorly made, while others had either corroded in transport or had been produced and distributed through criminal enterprises.

The study highlights that access to treatment is one of the main factors behind patients not receiving the supervised treatment and quality medicines that the WHO recommends. The cost of travelling to clinics is often very difficult for patients to bear, particularly because of the expense associated with travel and the high cost of in-patient treatment. Roger Bate, co-author of the study, says that in Zambia for example, ‘treatment through the tuberculosis program is three times more expensive than self-administering drugs purchased at local markets’.

The fact that the use of these drugs is widespread in at least 17 countries with high rates of TB must be addressed. As Lucica Ditiu has said:

“[By using substandard drugs to treat TB], in addition to the fact that the patient remains infectious and his treatment results will be really, really poor, you also develop a multi-drug resistant TB which is one of the worst forms of TB that unfortunately we have in this world. And that’s much more difficult to treat, it’s much more difficult to cure and is much more expensive.”

DR-TB strains of TB are a real and growing problem, and not just in the developing world. In the UK the number of DR-TB cases continues to rise, with 431 cases (8.4%) resistant to any first line drug reported in 2011, up from 342 in 2010 – an increase of 26%. It is encouraging that these stories are being featured in such prominent publications and media outlets, and we must continue to make parliamentarians and influencers take note of the growing epidemic and urge them to take  coordinated action to save millions of lives.

Click here for the NY Times article.

Click here for the Al Jazeera report.

Click here for the WSJ article.