| Dr Evan Lee |
We cannot point a finger at one institution or organisation for the blame of drug-resistant TB. Government must set standards, but we also need to engage private medical practitioners, pharmacists, NGOs, patient groups and the like. Stakeholders need to work together to leverage one another’s unique skills and competencies.
TB is a complex disease, managed by complex processes. These range from the technical challenges associated with drug susceptibility testing, to training of healthcare providers to manage the required complex treatment regimens, to ensuring appropriate adherence to treatment and managing side effects and a myriad of socio-economic issues, to adequate follow up to be sure the patient has taken the last dose of medicine and is in fact free of the disease.
The complex healthcare system in India further adds challenges, with most people with cough or other TB symptoms visiting a private practitioner. Skills here range from international standards to low levels of TB-specific training.
TB in lungs is most common form, which is diagnosed by microscopy. But this technique does not show TB in other parts of the body. TB is a difficult to detect disease also because the frontline test most commonly used – smear microscopy – does not show whether TB is drug sensitive or drug resistant. So it is assumed the patient has drug sensitive TB and is put on the standard directly observed therapy, short course (DOTS) regiment. Therefore there is a need for capacity to test drug susceptibility- but this can take weeks to get a result. The new diagnostic device, GeneXpert, provides an alternative to the lengthy drug susceptibility testing process, but it tests for resistance to only one medicine (Rifampicin) not to the others. It is being introduced in selected sites in India.
The directly observed treatment-shortcourse DOTS regime requires that a patient must go to a certified DOTS provider, usually at a hospital three times a week to take medication under the supervision of a healthcare provider. Last year, the (Indian) government stated some pharmacists could be DOTS providers. If people go to the private sector, they might not get the right treatment for the right duration, so engaging the private sector is important to avoid creating resistance. Treatment of MDR-TB is carried out under DOTS-Plus guidelines, requiring administration of up to six different medicines for 24 months. All these medicines can have side effects, further complicating the management of the patient and creating the risk of treatment default. Preventing this situation, and ensuring that patients complete their treatment for MDR-TB therefore requires the engagement of several levels of the health system, from the community up to the referral hospital, and across the public and private sectors.
(The Eli Lilly and Company Foundation is responsible for the Lilly MDR-TB Partnership, an initiative started in 2003 to support the response to MDR-TB in India and other high-burden countries. In India, the company works with NGOs and associations representing medical professionals to train and support healthcare workers, including doctors, nurses, pharmacists, rural healthcare providers and community volunteers. Additional programmes engage journalists and communities to create awareness, detect TB early and provide support to those affected by TB in all its forms.)