MUMBAI:

, which kills around 1,000 people a day in India, has acquired a deadlier edge. A new entity—ominously called Totally Drug-Resistant

(TDR-TB )—has been isolated in the fluid samples of 12 TB patients in the past three months alone at

. The hospital’s laboratory has been certified by the

(WHO) to test TB patients for drug resistance.

While

first reported TDRTB cases three years ago, India seems to be only the second country to report this deadly form of the disease. TDR-TB is the result of the latest mutation of the bacilli after Multi-Drug-Resistant TB (MDR-TB ) and Extremely Drug-Resistant TB (XDR-TB ) were diagnozed earlier.

Even more worryingly for Mumbai, 10 of the 12 TDR-TB cases are from the city, while the other two are patients from Ratnagiri and UP. One of the 12 patients has since died. India sees around 3- 4 lakh deaths for all forms of TB each year, while the world saw 1.7 million deaths in 2009.

As the full form of TDR-TB suggests, none of the known TB combination drugs work on the patient. All 12 showed resistance to 12 drugs. "The TB bacilli have obviously mutated. The emergence of TDR-TB has grave implications for public health," said Hinduja Hospital’s Dr Zarir Udwadia, whose observations have been published in the latest issue of the US-based Clinical Infectious Diseases (CID) peer review journal. His team started isolating TDR-TB cases among patients with pulmonary TB in October 2011.

Dr Amita Athawale, who heads KEM Hospital’s chest department, said TDR-TB was a reality in India. “The cases we clinically isolate are just the tip of the iceberg," she said. TB is one of the biggest killers in India, along with heart attack.

Among tuberculosis patients, drug resistance develops mainly because patients fail to complete the 6- to 9-month first treatment phase. "They feel better within a couple of months of taking the drugs and so they stop taking them. However, the TB germs in the body are not completely vanquished and they again multiply," said a senior BMC public health official.

VIRULENT STRAIN IN THE AIR

* Tuberculosis is one of the most fatal diseases in Mumbai, accounting for nearly 15% (8,953) of the deaths in 2010

* Left untreated, each person with active TB can infect 10 to 15 people a year TB is a contagious disease. Like the

, it spreads through the air Patients resistant to all first-line and second-line drugs are classified as having Totally Drug-Resistant TB (TDR-TB )

* An estimated 1.7 million people died from TB worldwide in 2009

* About 3 lakh to 4 lakh die of TB each year in India It is believed that more than half the city’s TB patients seek treatment in the private sector

‘Deadlier strain arose due to health system’s failure’

From the emergence of Multi-Drug-Resistant tuberculosis (MDR-TB ) in 1992 to the arrival of Extremely Drug-Resistant TB (XDR-TB ) a few years ago, the TB bacilli have now reached a totally resistant form. The new, deadlier form is Totally Drug-Resistant TB (TDR-TB ). “A hundred years ago, TB patients were sent to the sanatorium for treatment. With the emergence of these various drug-resistant strains, we have come full circle to the idea for sanatoria. We have little to offer these patients except for drastic surgery and medication for some relief,’’ said Dr Zarir Udwadia, of Hinduja Hospital , Mahim. His team’s observations have been published in the latest issue of the USbased Clinical Infectious Diseases (CID) peer review journal.

Udwadia says the emergence of TDR-TB is the failure of the overall health system. "The public sector only provides second-line drugs to 1% of the patients who have drug-resistant TB. The private sector has many doctors who badly manage patients. These factors have obviously worsened drug resistance." An earlier study by the group showed that barely 5 of 106 doctors in Dharavi prescribed the right drugs for drug-resistant patients.

The CID report, written by Udwadia , Rohit Amale and Camilla Rodrigues of Hinduja Hospital says, “A careful audit of their (patients) prescriptions revealed that these patients had received erratic, unsupervised second-line drugs, added individually and often in incorrect doses, from multiple private practitioners.”

TDR-TB was reported three years ago in Teheran, the Iranian capital, when 15 patients were found to have bacilli resistant to all first- and second-line drugs. A worrisome aspect of the Hinduja Hospital findings is that the average age of the 12 patients – six men and six women – is just 32.3 years.

While the minimum period of suffering has been two years, one patient (who cannot be named due to confidentiality clauses) is the 35-year-old wife of a farmer from Deveria, UP. She has been ill for over five years. While the patient is very ill, her husband told TOI, “We began treatment in a local hospital for a year before moving to Lucknow and then Kanpur for treatment.’’ She has been on an MDR-TB drug regimen for over two years. “I have sold major portions of my farm in this period and have taken up work in Mumbai,’’ he added.

Hinduja Hospital doctors are awaiting a CT scan before deciding whether a lung surgery can provide some relief to the woman.

Drug Susceptibility Testing (DST) performed at Hinduja Hospital showed that each of the 12 patients was resistant to all first-line drugs (isoniazid, rifampicin , ethambutol, pyrazinamide and streptomycin) and second-line drugs (ofloxacin, moxifloxacin, kanamycin, amikacin, capreomycin, paraaminosalicylic acid and ethionamide ) that were tested.

GERMS GET RESISTANT

Drug-resistant TB can be caused by: a) inconsistent or partial treatment; b) when patients do not take all medicines regularly for the required period because they start to feel better; c) because doctors and health workers prescribe the wrong treatment regimens; or d) because the drug supply is unreliable

A particularly dangerous form of drug-resistant TB is Multi-Drug-Resistant TB (MDR-TB ). It is caused by bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs

India reportedly has the highest burden of MDRTB , with some estimates pegging it at 3 lakh. Barely 1% are covered by the govt’s free drug plan

Drug-resistant TB requires chemotherapy with second-line anti-TB drugs that are costlier than first-line drugs, and which produce reactions that are more severe, though manageable

MDR-TB treatment continues for 24 to 27 months and could cost up to Rs 2 lakh

The emergence of Extremely Drug-Resistant TB (XDR-TB ), particularly in settings where many TB patients are also infected with HIV, poses a serious threat to TB control. The patient is resistant to one more drug Patients resistant to all 1st-line and 2nd-line drugs are classified as having Totally Drug-Resistant TB (TDR-TB )

AIR THREAT

Tuberculosis (TB) is a contagious disease. Like the common cold, it spreads through the air. It can affect any part of the body, but only people with TB in their lungs are infectious

When infectious people cough, sneeze, talk or spit, they spread TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected

But people infected with TB bacilli will not necessarily become sick. The immune system ‘walls off’ TB bacilli, which, protected by a thick waxy coat, can lie dormant for years. When the immune system is weakened, the chances of becoming sick are greater

Left untreated, a person with active TB can infect 10 to 15 people a year

INDIA A HOTSPOT

Overall, a third of the world is infected with the TB bacillus, but not all are sick 5 to 10% of people infected with the TB bacilli (but who are not infected with HIV) become sick or infectious at some time in their life. People with HIV and TB infections are more likely to develop TB 1.7 million people died of TB in the world in 2009. About 3 to 4 lakh die each year in India

KILLER IN MUMBAI

TB caused 15% (8,953) of the deaths in Mumbai in 2010 BMC has 28,000-plus listed patients. Thousands more seek pvt sector treatment As of Dec 31, 2011, 298 patients were under treatment for MDR-TB. Three tested positive for XDR-TB. Results of 27 tests are awaited