Sunday, March 23, 2014

India: MSF Calls For `Rational’ Antibiotic Use In Treating TB


MSF Briefing Report


# 8395


Tomorrow (March 24th) is World TB Day, and the focus this year is on multidrug-resistant tuberculosis (MDR TB) (see ECDC/WHO: World TB Day - Focus On MDR & XDR Treatment Outcomes), a growing concern around the world, but no more so than in India where more than 25% of all new TB cases reported in 2012 are to be found.


On Friday, Médecins Sans Frontières (MSF) released a sharply worded statement admonishing the Indian government for failing to regulate the sale and use of antibiotics for the treatment of Tuberculosis.


They warned that the inappropriate prescribing of antibiotics risks fueling the expansion of drug-resistant TB in that nation. The following excerpts come from a press release from MSF.


Patients in India suffer the consequences of poor regulation of TB drugs

March 21, 2014

The Ministry of Health must act to stop drug resistance from spiralling

New Delhi/Mumbai, March 21, 2014: Immediate action from the Indian government is needed to prevent the unregulated sale and inappropriate prescription of tuberculosis (TB) drugs in the private healthcare sector, a practice that has had a significant role in the emergence of drug-resistant TB in the country, warned the international medical humanitarian organisation Doctors Without Borders/Médecins Sans Frontières (MSF) in a statement released today in advance of World TB Day.

“It is the patients who suffer the consequences of poor regulation of TB drug formulations in India. An increasing number of our patients are being diagnosed with drug resistant TB (DR-TB). We encounter a spectrum of resistance patterns which range from mono-drug-resistant TB all the way through to extensively drug-resistant TB (XDR-TB),” said Dr Simon Janes, medical coordinator with MSF in India. “This makes it even more difficult for treatment providers like MSF and the government’s TB Control Programme to accurately diagnose and treat the different forms of drug-resistant tuberculosis.”

Read the briefing report

DR-TB infections are on the rise in India. The rising incidence has made the disease more difficult and considerably more expensive to treat. The conditions for emergence of drug resistance are increasingly being linked to poor drug regulation in India.

India has the largest private TB drug market, with rampant proliferation of first-line TB drugs in a wide variety of dosages and combinations.

Lack of oversight from the drug regulatory authority - the Drug Controller General of India (DCGI) - has made even basic treatment of drug-sensitive TB difficult to monitor. In the face of so many different formulations available in pharmacies across the country, ensuring the correct prescription of first-line TB drugs in the private sector is almost an impossible task for the Central TB Division (CTD).

As a result, poor compliance to World Health Organization (WHO) treatment guidelines is common among private doctors. TB patients being treated by private doctors in India might be facing a grave risk of developing drug-resistant TB due to irrational prescribing practices or indiscriminate use of non-WHO-recommended drug regimens.

“In our experience of working in India since 1999, we have seen prescriptions from private health providers that were completely inappropriate. For example we have seen many prescriptions that prescribe three out of the four first-line TB drugs in combination with a quinalone (antibiotic)”, said Dr Homa Mansoor, the TB Medical Referent for MSF India. “The alarm on drug resistance has been sounded, and the Health Ministry must act now to address this public health crisis."

(Continue . . . )


This coming week will no doubt bring many more reports on the challenges, and the progress being made, in the battle against TB.  For more on World Tuberculosis Day, the WHO has released the following brochure:

Reach the 3 million: Find. Treat. Cure TB

WHO. Stop TB Partnership. The Global Fund to Fight AIDS, TB and Malaria

Publication details

Number of pages: 17
Publication date: March 2014
Languages: English



While currently the biggest antibiotic-resistance crisis in India, TB is far from being the only concern.


Three and a half years ago The Lancet published a study (see NDM-1: A New Acronym To Memorize)  by Walsh, Toleman, Livermore, et al. that sounded the alarm on the emergence and growing prevalence of the NDM-1 enzyme on the Indian sub-continent.


Of particular concern, this NDM enzyme is carried by a plasmid – a snippet of portable DNA  - that can be easily transferred to other types of bacteria (see Study: Adaptation Of Plasmids To New Bacterial Species).


Six months after the first Lancet article - in April, 2011 - the same researchers published another study that found the NDM-1 enzyme in 4% of New Delhi’s sampled drinking water sources, and 30 per cent of the sewage tested. Most alarmingly, the researchers also identified 11 new species of bacteria carrying the NDM-1 gene, including strains which cause cholera and dysentery.


The rise of antibiotic resistance - including these emerging NDM enzymes - has long been linked to the overuse and misuse of antibiotics. A practice that is still widespread in many parts of the world, but has been particularly rampant on the Indian sub-continent.


After years of delay and debate, India this month finally placed restrictions on the sale of antibiotics without a prescription (see Times of India report 46 drugs under strict prescription norm), although pharmacists are already chaffing under the rules (see Pharmacists oppose sales record rule), and it remains to be seen just how effective these new rules will end up being.


Short of seeing an extremely high mortality influenza pandemic, it is hard to envision a looming medical crisis more dire than the growing threat of antimicrobial resistance. The World Health Organization, the ECDC, and the CDC all consider the spread of antibiotic resistant organisms to be a major public health concern.


For a more complete look at the complex issues of antibiotic resistance, and the dearth of new drugs on the horizon, I can think of no resource better than Maryn McKenna’s superb book (and recent winner of the 2013 June Roth Memorial Book Award, American Society of Journalists and Authors)  Superbug: The Fatal Menace of MRSA.

Superbug (MRSA) Book

And while I dabble in the issues of antibiotic resistance, undoubtedly the best coverage can be found on Maryn’s Superbug blog.