New form of TB gives docs sleepless nights

Mumbai: Fifteen-yearold Vina's diagnostic report looks dismal. The lab report shows that the tuberculosis (TB) bacillus in her lungs is sensitive only to two drugs and resistant to eight others. 

    "The world may debate whether to call her TB an extremely, extensively 
or a totally drug-resistant form but the fact is how does one treat a child with only two drugs?'' says Ghatkopar-based Dr Amol Manerkar, who is treating Vina. "For all practical purposes,'' he adds, "the child's disease is totally resistant to drugs.'' 
    In the last two months, Mumbai has gained in terms of government attention (a special TB programme), money (the city's TB budget may increase 6 times) and infrastructure (new labs, machines), but the ground reality is grim, say doctors on World TB Day. 
WHO sticks to its stand 
    The World Health Organization, in a special meeting in Geneva, said it was too early to dub the new, severely drug-resistant forms of tuberculosis as totally-drug resistant TB. P 6 
Another H1N1 case in city 
T^he the grandmother city's first H1 of N1 a case Mulund in nine boy, months, is also suffering from the flu. Meanwhile, a one-year-old became Pune's eighth victim in 10 days. P 2 TB patients' woes worsen due to expensive drugs 
Victim Can Infect 10 Others In A Year: Docs 
Mumbai: Incidence of the new form of highly drug-resistant TB is growing across the city. Areas with a high population density-—such as Ghatkopar and Kurla—are particularly vulnerable. 
    Vina (name changed), who lives in Ramabai Colony in Ghatkopar (E), is only one of the three patients whom Dr Amol Manerkar diagnosed with severely drug-resistant TB in the Ghatkopar-Kurla belt in March. One of these new patients is only sensitive to 
one drug. TB is treated with a combination of drugs. "How can I ask this patient from a modest background to buy this one drug which is not only expensive but cannot guarantee a cure if taken alone,'' asks the doctor. 
    Mumbai's special TB programme had proposed that patients going to private doctors would also be able to access the government's free drugs. But private doctors say this partnership has not yet started. "I sent two of my patients who have severe drug resistance to government hospitals as they are too poor to afford to buy medicines privately. But they haven't been given any second-line drugs as the government is waiting to test them all over again,'' complains a doctor from Dadar. 
    In January, Hinduja Hospital had revealed that 12 of its patients had totallydrug-resistant TB (TDRTB). A central team visited Mumbai thereafter and said that it would be premature to label the cases as TDR-TB. However, the Union government gave the green signal for a pilot project in Mumbai to recognize each of the 24 civic wards as a TB district with special staff and infrastructure.
    The BMC has diagnosed 683 patients with drug-resistant TB. "As per our protocol, 347 of these patients are in category IV treatment and eight others in Category V treatment,'' says Dr Mini Khetrapal, who is Mumbai's first TB control officer. 
    She is hopeful. "We have increased the capacity in Sewri TB Hospital to treat drug-resistant TB from 44 to 90 beds. Within a couple of months, all these drug-resistant patients will be covered,'' she says, adding that medicines have already been given to all to ensure that their disease doesn't spread to others. 
    Soon, the BMC will kickstart an initiative of door-to-door surveillance in 10 wards that include Ghatkopar and Kurla. 
    "TB is a disease that spreads easily due to overcrowding. The government needs to strengthen its surveillance process to ensure that the disease doesn't spread,'' says a senior doctor at a south Mumbai hospital. 
    Dr Manerkar points out to hubs such as Thakar Baba colony in Kurla where people work in small, overcrowded shoemakingunits."If oneperson has drug-resistant TB, the airborne disease can spread to many others. After all, each TB patient can infect 10 others in a year,'' he says. 
TUBERCULOSIS OVER THE YEARS 
In mid-90s, multidrug resistant TB was first reported In 2006, extensively drugs-resistant TB (XDR) emerged In 2008, two cases were reported from Italy that had resistance to both first and second-line treatments In 2009, 15 TB patients in Iran were reported to be resistant to all anti-TB drugs tested, prompting researchers to coin new terms "extremely drug resistant" (XXDR-TB) and "totally drugresistant TB" (TDR-TB). In January 2012, four patients in India were described as having "totally drug-resistant" tuberculosis. Media subsequently reported a further eight such cases. In March, WHO said insufficient evidence to use term TDR-TB As per WHO nomenclature, multi-drug resistant tuberculosis (MDR-TB) is TB that is resistant to both of the main first line drugs, isoniazid and rifampicin WHO says extensively drug-resistant tuberculosis (XDR-TB) is MDR-TB with additional resistance to any of the injectables (amikacin, kanamycin or capreomycin), plus resistance to any fluoroquinolones 
NOT YET TIME 
WHO has given three technical reasons for its decision not to use the label of totally drug-resistant tuberculosis 1 Drug susceptibility testing (DST), key to defining new levels of drug resistance, lacks accuracy for several drugs used to treat multi drug-resistant (MDR) and extensively 
    drug-resistant (XDR)-TB 2 Insufficient correlation of DST results with clinical response to treatment for several drugs used to treat XDR-TB 3^Newdrugs are undergoing clinical trials and could prove effective against drugresistant strains