New Delhi: Drug-resistant tuberculosis (DR-TB) remains a formidable challenge in India’s fight against TB, with multidrug-resistant (MDR-TB) and extensively drug-resistant (XDR-TB) cases on the rise. Despite advancements in treatment, gaps in diagnosis, access to new drugs, and patient adherence continue to fuel the spread of resistant strains. In this exclusive interview with Rashmi Mabiyan Kaur, Dr. Sandeep Nayar, Principal Director and HOD, Chest and Respiratory Diseases at BLK-Max Super Speciality Hospital, sheds light on the growing burden of MDR-TB and XDR-TB, the role of new medications like Bedaquiline and Delamanid, and the urgent need for policy reforms to strengthen India’s TB elimination efforts. Edited Excerpts:How common are MDR-TB and XDR-TB in India, and what are the major reasons behind their rise? Are certain populations more vulnerable to drug-resistant TB? What factors put them at higher risk?
TB caused by Mycobacterium tuberculosis strains resistant to both Isoniazid (INH) and Rifampicin, with or without resistance to other first-line anti-TB drugs, is classified as MDR-TB. Extensively drug-resistant TB (XDR-TB) includes cases that, in addition to MDR-TB criteria, are also resistant to fluoroquinolones and key drugs like Bedaquiline or Linezolid. The emergence of drug resistance is a major threat to global TB elimination efforts. Drug resistance surveys in several states indicate that MDR-TB prevalence in India is around 2–3% among new cases and 12–17% among reinfection cases. In 2023, India accounted for 27% of the global MDR-TB burden, followed by the Russian Federation (7.4%), Indonesia (7.4%), China (7.3%), and the Philippines (7.2%).The main causes of MDR-TB include inappropriate prescriptions, poor-quality anti-TB drugs, interruptions in treatment, and failure to complete therapy. Delayed recognition of drug resistance and lack of access to effective medications further contribute to transmission and the development of resistance. People with weakened immune systems, such as those with HIV, malnutrition, diabetes, and a history of TB, as well as prisoners, refugees, homeless individuals, smokers, and drug addicts, are at a higher risk of developing drug-resistant TB.
What are the biggest challenges you face while treating DR-TB patients?
Treating drug-resistant tuberculosis presents several challenges, including limited treatment options, long and complex regimens, poor patient compliance, and the risk of further resistance. The high cost of therapy and the limited availability of second-line drugs further complicate treatment. While most of these drugs are available in government institutions, many patients in the private sector struggle to procure medications like Bedaquiline and Pretomanid.
How have Bedaquiline and Delamanid changed the treatment outcomes for MDR-TB and XDR-TB patients?
Bedaquiline has been a game-changer, significantly reducing the duration of treatment. However, its administration requires strict monitoring due to potential side effects. The introduction of new oral regimens, such as the six-month BPaLM and the nine-month regimen, appears promising. Currently, these drugs are available only in government healthcare settings, but expanding their availability to the private sector would greatly enhance treatment access and outcomes.
Is India doing enough to scale up access to new TB drugs under the National TB Elimination Program (NTEP)?
Newer drugs like Bedaquiline, Pretomanid, and Delamanid have been introduced under the NTEP for managing drug-resistant TB. However, more needs to be done to ensure these treatments reach all eligible patients. A significant portion of TB patients seek care in the private sector, and enabling them to access these medications would be a crucial step in scaling up treatment efforts.
How important is nutrition in TB recovery, especially for DR-TB patients? Have you seen cases where malnutrition led to poor treatment outcomes in DR-TB patients?
Nutrition plays a vital role in TB recovery. Malnourished individuals are more susceptible to TB, and the disease further exacerbates malnutrition. Poor nutritional status is linked to higher mortality and relapse rates, making nutritional support a key aspect of treatment, particularly for drug-resistant TB patients.
What policy changes or improvements in the healthcare system would help tackle drug-resistant TB more effectively?
Strengthening case-finding efforts, ensuring drug availability in remote areas, and actively involving the private sector will be instrumental in tackling drug-resistant TB. Rapid diagnostic kits should be made accessible even in peripheral healthcare settings to facilitate early diagnosis and treatment. Public awareness campaigns aimed at reducing stigma will also play a key role in improving treatment adherence and coverage.
