Hindustan times interview - Battling through MDR and XDR TB 2016

Public hospitals are major pitfalls for country’s efforts to curb rising cases

Hindustan Times (Gurgaon) 22 Mar 2016 Sanchita Sharma sanchita.sharma@gmail.com

India’s revised national tuberculosis control programme (RNTCP) is thriving, but only on paper.Only those who cannot afford treatment in the private sector use it. With the government unable to monitor India’s unregulated private sector, which is the first point of diagnosis and care for the majority of the 2.2 million people diagnosed with TB each year, extensively drug resistant TB is spreading (XDR TB) rapidly.

Meena Dhadke, 30, is one such person who was diagnosed with “sensitive” TB — the kind that can be easily treated — in March but is getting treated at a private hospital in Mumbai. Her husband Ambaji Dhadke, 31, has been fighting XDR TB for two years and he weighs only 30 kg for his 5’ 6” frame.

“Her husband is a serial defaulter who stopped treatment five times in the past two years, which has made his infection impossible to treat,” says Dr Gaurav Ghatawat, the chest specialist at the charitable Fauziya Hospital in Kurla West, Mumbai, who is treating the couple.

Treating XDR TB involves having a cocktail of 12-15 drugs and injections that cause side effects such as appetite loss, stomach cramps, vomiting, diarrhoea, fever and depression. “He stops having medicines when he feels too sick to take them,” says Dhadke.

In the private sector, treating sensitive TB costs less than ` 1,500 a month, multidrug resistant TB costs around ` 5,000, and XDR TB costs close to ` 20,000 a month, yet Dhadke — who works in homes for a living — refuses to take her husband to be treated free at the government’s TB Hospital in Sewri East.

“Everyone who goes there dies, I want him to live,” she said. Sewri Hospital is known for poor infection control, which has led to several doctors and nurses working there developing XDR TB.

She struck gold by choosing Fauziya Hospital, where TB diagnostic and treatment protocols are followed, unlike at many other unregulated clinics and hospitals where irrational drug combinations are prescribed in wrong doses.

“Irrational fixed drug combinations containing important anti-TB drugs such as quinolones and linezolid are rampantly available in the market, which has worsened the prevalence of XDR in India,” said Dr Grania Brigden, TB and AMR ( antimicrobial resistance) advisor, access campaign, Medecins Sans Frontieres (MSF).

Keeping patients on course is the other challenge. For many, the compliance that the RNTCP’s directly observed treatment short-course (DOTS) regimen hopes to achieve by giving drugs under observation is threatened when they are too sick to go to a government centre.

“The biggest indicator of a good programme is whether people are choosing to use it... People go to DOTS centres as a last resort,” says a doctor in the government sector who does not want be named.

THE AVAILABILITY OF IRRATIONAL FIXED DRUG COMBOS CONTAINING IMPORTANT ANTI-TB DRUGS WORSENED THE PREVALENCE OF XDR

Hindustan times interview - Battling through MDR and XDR TB 2015

How resilient Mumbai is battling multiple drug resistant TB

Sanchita Sharma, Hindustan Times, New Delhi | Updated: Mar 28, 2015 17:37 IST

Bushra Mirza, 16, was diagnosed with tuberculosis (TB) two months ago. She was prescribed four medicines for nine months but she took them for a month because her coughing stopped. Now her hacking cough is back, and so is she, in the airless 8x8 room of pulmonary physician Dr Gaurav Ghatawat at the not-for-profit Fauziya Hospital in Mumbai's congested Kurla West neighbourhood. She is visibly underweight, weighing 35 kg for her 5-feet frame.

Dressed in a sequinned black burqa, Mirza tearfully looks at her GeneXpert test report that confirms the TB diagnosis. The doctor gently tells her that the only thing that can make her well is having all four prescribed medicines every day for the next nine months. She nods wordlessly. The message has finally sunk in.

Fauziya Hospital dispensary gives these medicines free and Mirza gets a fortnightly dose to ensure she is there next fortnight for a follow-up. If she misses an appointment, Anjali Mulik, who works as a counsellor at the TB clinic, will visit her at home and convince her to continue treatment.

Treatment works, as it did for Mohammad Ansari, 20, who works in the "garment line", his euphemism for hawking secondhand clothes on the streets. He hasn't missed a day of medication for two months. His cough is gone, he's full of energy and he's weight has gone up to 54 kg from 50 kg. Ansari was lucky he didn't have MDR (multiple drug resistant) or XDR (extensively drug-resistant) TB, which is resistant to the two most powerful anti-TB drugs, isoniazid and rifampicin, in addition to being resistant to fluoroquinolones (such as Ofloxacin or moxifloxacin) and to at least one of three injectable second-line drugs (amikacin, capreomycin or kanamycin). 

MDR-TB and XDR-TB usually take at least two years to treat with drugs that are more expensive and toxic.

Thane West-resident Haji Mohammad, 28, has MDR-TB, which killed his brother two years ago. Mohammad got symptoms four months ago but was misdiagnosed initially by private practitioners. He was diagnosed with MDR-TB two months ago and is now in hospital with severe drug-induced jaundice that has busted his liver. His weight is down from 50 kg to 35 kg in two months.

Ruksana Mohammad, 19, his wife of seven months, is beside himself with worry. Mohammad, who drives tempos and cars for a living, has been too sick to work since November and the family has already spent Rs 10,000 on his treatment. Though TB is treated free in government hospitals, she says his mother won't agree to him being admitted to Mumbai's sprawling Sewri TB Hospital, where treatment is free but the conditions are so depressing that the hospital makes news for patients going AWOL or attempting suicide, both successfully and unsuccessfully, than cure.

The problem is not the hospital but the disease. Most people who end up at Sewri are people like Mohammad with MDR- and XDR-TB who are in a government hospital simply because their families don't have the Rs 5,000-Rs 6,000 a month for medicine.

"The hospital is full of the living dead," says Ruksana with a shudder, "people there are only skin and bone and cough out blood all day. Then they die".

"Since the treatment for MDR and XDR takes two years and the progress is gradual, people think they're not getting better and choose to leave to try their luck with other cures," says Dr Ghatawat.

He has lost two patients to XDR-TB this year, with 15-year-old Farzana succumbing to it last month because she stopped medicines and got a tabeez (amulet) instead. That was three months ago. Last month, Farzana came back to hospital bleeding from the mouth but it was too late for the medicines to work. She died within 24 hours of being admitted.

Bustling Mumbai is undoubtedly India's most vibrant metropolis, but with 60% of its 13 million population living in slums, inevitable shortfalls in housing, sanitation and nutrition make people susceptible to infection.

So common are MDR and XDR now that Dr Ghatawat routinely does the GeneXpert test at a subsidised price of Rs 250, compared to the market rates of Rs 2,000. It's done free in government hospitals but only for suspected MDR and XDR cases.

He, like most doctors at Sewri, doesn't wear a mask on hospital rounds. "For patients to adhere to treatment, you have to get them to trust you with their lives. How can you do it if you speak from beyond a mask?" asks a Sewri doctor who did not wish to be named.