Why are India's programmes to control drug-resistant tuberculosis not working?

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The success rate of the ambitious Revised National Tuberculosis Control Programme (RNTCP), driven by the Government of India, is appaling, reports a study. The study was conducted by a team of researchers from the World Health Organization (WHO), National AIDS Control Organization, Bill & Melinda Gates Foundation, Public Health Foundation of India and Central TB Division of the Ministry of Health and Family Welfare, Government of India. It reveals that RNTCP has a success rate of a mere 34.5% and details some of the challenges the country faces in tackling drug-resistant tuberculosis.

Tuberculosis (TB) is a bacterial, air-borne infection mainly affecting the lungs. The disease is rampant among poor communities with inadequate housing. It is socially fraught with a very high stigma, driving affected individuals away from timely treatment. With the tuberculosis bacteria, Mycobacterium tuberculosis, becoming resistant to many antibiotics in use to fight the disease, multidrug-resistant TB (MDR-TB) has raised its ugly head. India has the highest number of individuals with MDR-TB, contributing to one-fourth of the global burden. 

The researchers of the current study, published in the journal PLoS ONE, believe that a systematic evaluation of programmes designed to tackle drug-resistant TB can help in identifying factors that limit their success rate.

“The magnitude of patients to be managed in India also makes it critical that the treatment outcomes of MDR-TB patients and the factors affecting them be systematically evaluated to guide the national programme to take informed decisions on policies and strategies to improve treatment outcomes of subsequent cohorts of patients,” say the researchers.

The study, a first of its kind, analysed medical records of 3712 MDR-TB patients registered and treated under the RNTCP program in India from 2007 to early 2011. Among them, information about the outcome of the treatment was available for only 60.9% of the patients at the time of conducting this study. Of the 2264 patients, only 34.5% were successfully treated, 28.4% succumbed to the disease, 29.6% were lost to follow up and 7.5% experienced failure of treatment or developed XDR-TB—extensively drug-resistant tuberculosis.

However, why is the success rate of the MDR-TB control program not satisfactory? According to the researchers, it was difficult to treat most patients because of their poor health. Many had prolonged treatment history and other chronic diseases. The delay in the diagnosis made it worse, and by the time they were diagnosed with MDR-TB, more than half of the patients had developed cavities or hollow spaces in the lungs. These factors, coupled with missed doses or treatment interruptions, poor nutritional levels and body-mass index due to poverty or other reasons, caused further progression of the disease to untreatable stages.

“India’s initial MDR-TB treatments under RNTCP experienced poor treatment outcomes, no better than the already low global average", remark the researchers. They advocate a systematic, multi-pronged approach to address the factors associated with poor treatment outcomes revealed in the study.

The early findings from this study have facilitated the necessary national policy refinements such as early diagnosis of  MDR-TB by improving access to the diagnostic tests, introducing counselling services across India and enhanced monitoring and evaluation of the TB patients, say the researchers.

“A highest political commitment to invest in a robust national strategic plan, systematic vigilant scale-up of the new interventions with evidence-guided course correction will remain the key to ending TB and drug-resistant-TB in India”, they conclude.



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