THE TUBERCULOSIS SCARE IN NUMBERS

TB CASES IN MUMBAI

TB CASES STATE WISE

MULTI DRUG-RESISTANT TB CASES IN INDIA

TOP 4 STATES WITH MDR CASES (2013)

MDR CASES IN MUMBAI

MDR DEATHS IN MAHARASHTRA

EXTENSIVELY DRUG-RESISTANT CASES IN INDIA

EXTENSIVELY DRUG-RESISTANT CASES IN MUMBAI

TB HEAT

Situation is scary, say doctors, as Mumbai records 3,600% hike since 2011. Culprits are those who refuse medication.“I know the disease will kill me one day,” he said. “But the pain caused by the injections and swallowing 16 tablets daily is like dying each day.” The drugs cause Shinde dizziness, nausea and searing pain in the chest. He is often irritable, angry and frustrated. On several occasions, he has contemplated suicide.The labourer was diagnosed with TB two years ago, after which he was prescribed first-line medication – it is standard medical practice to administer antibiotics isoniazid, rifampicin, pyrazinamide andethambutol once a day as the primary offensive measure against the disease. Six months into his nine-month course, Shinde began to feel better. He stopped taking his medicines. As a result he developed resistance to all four first-line drugs in 2013 and was diagnosed with MDR-TB, which requires increased dosage of medication. “We tried to counsel him about the disease but he was not at all ready to take the drugs,” said Dr. Vikas Oswal, the physician tasked by the BMC to attend to TB afflicted residents of Govandi. As is the standard practice when a patient refuses medication or is remiss in completing his course, the city corporation sent Directly Observed Treatment, Shortcourse (DOTS) workers to Shinde’s home so that he may be convinced of the importance of not skipping his medication. “But he was not willing to take his medicines,” Dr. Oswal said. “We can do nothing about such cases.”To worsen an already fraught situation, if Shinde transmits his disease to others in Govandi, he will spread MDR-TB, creating a contagion of second-level pulmonary illness in the locality - infected carriers bear the risk of spreading the sickness each time they spit, cough or even speak; according to a 1998 American Journal of Infection Control study, a single sneeze can carry up to 40,000 TB-ridden droplets. “I know of the risks, but I still don’t want to take the medicines,” Shinde said. “The BMC provided me three handkerchiefs and advised me to always keep my face covered, but I can’t.” According to Dr. Oswal, in time, his patient will not only spread MDR-TB, but will develop Extensively Drug-Resistant (XDR) TB, which responds to even fewer medicines than MDR-TB.Shinde is not the only drug resistant patient in Govandi to be designated a defaulter. The BMC’s medical records, which Mumbai Mirror has reviewed, show that the neighbourhood is home to nine such cases. “Govandi and neighbouring Shivaji Nagar have a population of one lakh. Of the nine defaulters identified in these areas, seven cannot be traced,” said Dr. Pravin Chandure, District Tuberculosis Officer, indicating the difficulties of treating and counselling a transient population of TB patients.Although TB may infect any part of the body, it is most prevalent in the lungs and if the infection becomes active, it causes chest pain and a prolonged cough producing spittle. People ill with TB can pass the disease on to 10-15 other people through close contact. Without proper treatment up to two thirds of people ill with TB will die.According to the World Health Organisation (WHO), the disease is second only to HIV/AIDS as “the greatest killer worldwide due to a single infectious agent”. WHO statistics suggest that in 2012, 86 lakh people the world over fell ill with TB and 13 lakh died of the disease; India accounted for 20 lakh of the former and 3 lakh of the latter. A global study by the agency found that MDR-TB was present in virtually all countries surveyed. India reported 23,325 such cases in 2013, an increase from a 2011 figure of 4297. In Mumbai, 181 MDRTB instances were reported in 2011. That number rose to 6,701 in August (see below).“Govandi, Dharavi and Shivaji Nagar wards have the highest MDRTB cases in the city,” said Dr. Mini Khetarpal, BMC’s TB control officer. “In the last nine months 368 patients were registered as MDR positive and 27 patients as having XDR in Govandi and Shivaji Nagar area.”Dr. Oswal, who oversees Shinde’s treatment in Govandi’s Shatabdi Hospital, is particularly distressed by the situation. “Every day I see almost 15 new TB afflicted in my Out-Patient Department and a majority of them are drug resistant cases,” he said. “Earlier, I would treat single patients from a family, now I am treating entire clans for drug resistance. The situation has really become scary.”In 2012, India’s Central TB Division, part of the Union health ministry, sent a three-member factfinding team to Mumbai. A few months later, tuberculosis was declared a “notifiable disease”, a designation that requires private doctors to inform the health ministry of all tuberculosis patients they treat.In creating its strategy to combat the disease, the BMC appointed 24 District Tuberculosis Officers (DTOs) to oversee each of the city’s wards. Their mandate was trace every affected person in these neighbourhoods. “We were told strictly that the drug resistance cases can only come down if we can find out the defaulter list and put them on treatment,” said Dr. Pravin Chandure, the TB officer for M East Ward, which covers Govandi and Shivaji Nagar. Two years on, it is apparent that the method hasn’t been as effective as envisioned. The number of MDR-TB diagnoses in the city increased from 53 in 2010 to 6,000 in 2014. “I had instructed my 24 DTOs to make sure that not a single patient should miss their dose of medication and I don’t want a single defaulter in their area,” said Dr. Khetarpal. “But in MDR cases, 15 percent of patients are defaulters, the main reason being the side effect of the drugs prescribed.”Such is the anguish caused by the medication that four MDR-TB patients have committed suicide in Sewri’s TB Hospital in the last six months – it is the only facility dedicated to the treatment of the disease in Asia. “We have observed behavioural changes in patients. They develop psychological problem because of the medicine,” said Dr. Khetarpal. “We have now appointed two psychiatrists in the TB Hospital to identify such patents and administer anti-depression drugs.”Mumbai Mirror talked to one such patient interred in Sewri. The 26-year-old man, who requested that he remain unnamed, lives in Govandi and works as a driver in a transport company. He was diagnosed with MDR-TB in March 2013. When the bacillus invaded his lungs, pus accumulated in his chest - nine months on, the only manner in which he can breathe is if a tube is inserted into his lungs to drain the fluid. Incapable of withstanding the agony, he has pleaded with his mother to end his life on two occasions. He has been assigned a psychiatrist. “I can’t describe the pain,” he said. “I am stuck in this bed for the past nine months. The smell of pus is so foul that no one wants to meet me.”diagnosed withevery yearwho die ofever year2011 -2012 -2013 -2014 -(Till August)(Karnataka)(Tamil Nadu)(MP)(Raj)(AP)(Mah)2011 -2013 -2014 -West BengalGujaratRajasthanMaharashtra2011 -2012 -2013 -2014 -- 2013- (2013-2014)2011 -2012 -2013 -2014 -cases per year2574837827 * Till August