Multidrug-resistant Tuberculosis In India Research Articles

Prevalence of multidrug-resistant tuberculosis (MDR-TB) in India: A mini systematic review and meta-analysis (2016–2022)

India carries the highest global burden of tuberculosis and multidrug-resistant tuberculosis (MDR-TB) (26%). There remains an uncertainty around the population-based estimates of MDR-TB in India. Applying a systematic review approach, we searched PubMed and Scopus to identify studies reporting the prevalence of MDR-TB among new and/or previously treated patients (cases) at any site in India and published during 2016–2022. Of 341 retrieved articles, we could select only 10 and excluded many as they were either unrelated or had limitations. From the meta-analysis of available studies, we found the pooled prevalence of MDR-TB among new cases as 3.9% (95% (CI 2.2–6.1) and as 13.4% (95% CI 8.8–18.7) among previously treated cases. Overall, it was 6.7% (95% CI 4.2–9.6). Albeit with a wider confidence intervals, the prevalence figures calculated from the present study are comparable to those reported by the National Anti-TB Drug Resistance Survey. Among selected studies, the majority were from North India and the recent data on prevalence are lacking for other Indian regions. This mini-review highlights the need for the Indian National TB Elimination Program to make provisions for regional periodic prevalence surveys for careful designing of MDR-TB control strategies.

The epidemiologic impact and cost-effectiveness of new tuberculosis vaccines on multidrug-resistant tuberculosis in India and China

BackgroundDespite recent advances through the development pipeline, how novel tuberculosis (TB) vaccines might affect rifampicin-resistant and multidrug-resistant tuberculosis (RR/MDR-TB) is unknown. We investigated the epidemiologic impact, cost-effectiveness, and budget impact of hypothetical novel prophylactic prevention of disease TB vaccines on RR/MDR-TB in China and India.MethodsWe constructed a deterministic, compartmental, age-, drug-resistance- and treatment history-stratified dynamic transmission model of tuberculosis. We introduced novel vaccines from 2027, with post- (PSI) or both pre- and post-infection (P&PI) efficacy, conferring 10 years of protection, with 50% efficacy. We measured vaccine cost-effectiveness over 2027–2050 as USD/DALY averted-against 1-times GDP/capita, and two healthcare opportunity cost-based (HCOC), thresholds. We carried out scenario analyses.ResultsBy 2050, the P&PI vaccine reduced RR/MDR-TB incidence rate by 73% (UI:66–76) and 72% (UI:65–77), and the PSI vaccine by 29% (UI: 27–31) and 47% (UI: 37–58) in China and India, respectively.In India, we found both USD 10 P&PI and PSI vaccines cost-effective at the 1-times GDP and upper HCOC thresholds and P&PI vaccines cost-effective at the lower HCOC threshold. In China, both vaccines were cost-effective at the 1-times GDP threshold. P&PI vaccine remained cost-effective at the lower HCOC threshold with 49% probability and PSI vaccines at the upper HCOC threshold with 21% probability. The P&PI vaccine was predicted to avert 1.0 million (UI: 0.6–1.3) and 0.8 million (UI: 0.5–1.4) second-line therapy regimens in China and India between 2027 and 2050, respectively.ConclusionsNovel TB vaccination is likely to substantially reduce the future burden of RR/MDR-TB, while averting the need for second-line therapy. Vaccination may be cost-effective depending on vaccine characteristics and setting.

Health System and Policy Perspectives of Multidrug-resistant Tuberculosis (MDR-TB) Control in India

Despite the lack of reliable information on multidrug-resistant tuberculosis (MDR-TB) epidemiology, research shows an increasing trend of MDR-TB incidence in India. Of several determinants attributable to the rising trend of MDR-TB, health systems and policy (HSP) determinants play a pivotal role. With this article, an attempt has been made to unravel the HSP challenges for the control of MDR-TB and recommend strategies to overcome that. Ten different strategies have been recommended in this article that includes operations research (OR), molecular epidemiological studies, drug susceptibility test (DST), surveillance system, advocacy communication and social mobilisation (ACSM), nutrition and livelihood support, contribution of private practitioners (PPs), human resources for health (HRH), social determinants of health and information systems. Methods of OR with the right technical expertise can help in decision-making and evaluation of the TB control programme. Molecular epidemiological studies further help identify the right strain and can help in institutionalising the right therapeutic regimen. Similarly, the DST allows extended treatment strategies, including second-line drugs. A proper surveillance system can enable the availability of the right information for public health decision-making. Communication enables and empowers the community in accessing health services and helps policymakers take informed decisions. Nutrition and livelihood support are essential in TB control as it mostly affects the poor and people in the productive age group. Further, tapping PPs is equally important as more than 50 per cent of TB patients visit them. Proper orientation of the PPs about the TB control programme is non-negotiable given these facts. The HRH issues are pertinent—staff members lack the required motivation owing to delay in payment of salaries and the lack of job promotion. The HRH form the backbone of any health system, as the mere presence of drugs, technologies and infrastructure do not suffice for the provision of healthcare. Attention on the neglected social determinants of health is required as well. Finally, all these suggestions need to be implemented in coordination with each other to bring down the scourge of MDR-TB in India.

Cost effectiveness of decentralised care model for managing MDR-TB in India

BackgroundIn India, multidrug-resistant tuberculosis (MDR-TB) patients are usually treated in hospitals. Decentralised care model, however, has been suggested as a possible alternative by the World Health Organization (WHO). In the “End TB Strategy”, the WHO highlights, as one of the key targets for 2035, that ‘no TB-affected families should face catastrophic hardship due to the tuberculosis’. Removal of financial barriers to health-care access and mitigation of catastrophic expenditures are therefore considered vital to achieve the universal health coverage (UHC) goal. Since forgoing healthcare due to the financial constraints is a known fact in India, decentralised care as an intervention choice (as against hospital-based care) might enhance equity provided it is an affordable choice. Thus, an economic evaluation was conducted, from the perspective of the national health system in India, to assess the cost-effectiveness of decentralised care compared to centralised care for MDR-TB. MethodsThis study uses a decision-analytic model with a follow-up of two years to assess the expected costs of the decentralised versus the centralised approaches for MDR-TB treatment. A published systematic review of observational studies yielded the MDR-TB treatment outcomes, which included treatment success, treatment default, treatment failure, and mortality parameters. It was observed that these parameters did not vary significantly between the two alternatives. Treatment costs included the following costs: hospital admission costs, clinic costs, visits to laboratory and MDR-TB centre, drug therapy, injections and food. Costs data of drugs, diagnosis, hospital stay and travel to public facilities, based on a simple market survey, were taken from a recently published study on MDR-TB expenditures in the Chhattisgarh state of India. Potential cost savings related to the implementation of decentralised MDR-TB care for all patients who initiated MDR-TB treatment in India were additionally estimated. ResultsEstimated average expected total treatment cost was US$ 3390.56 for the hospital-based model and US$ 1724.1 for the decentralised model for a patient treated for MDR-TB in India, generating potential savings of US$1666.50 per case, with ICER US$ 2382.68 per QALY gained. One of the primary drivers of this difference was the significantly more intensive (thus expensive) stay charges in the hospital. If the costs and treatment probabilities are extrapolated to the whole country, with 48114 MDR-TB patients initiated on treatment in 2017, decentralised care would have additional 1058 patients cured, gain additional 3824 QALYs, and avert 2165 deaths, as compared to centralised care, in India. At various scenarios of coverage rates of decentralised and centralised care the cost difference would range between 23% and 94% for the country. ConclusionOur study provides evidence of cost savings for MDR-TB patients if patients choose decentralised treatment in comparison to suggested hospitalisation of these patients for centralised treatment with similar outcomes. The economic evaluation presented in this study expected significant efficiency gains in choice of two treatment options and the cost savings may improve equity. In India, treatment of MDR-TB using decentralised care is expected to result in similar patient outcomes at markedly reduced public health costs compared with centralised care.

Predictors of unfavourable treatment outcome in patients with multidrug-resistant tuberculosis in India.

Setting: India has one of the highest global rates of multidrug-resistant tuberculosis (MDR-TB), which is associated with poor treatment outcomes. A better understanding of the risk factors for unfavourable outcomes is needed. Objectives: To describe 1) the demographic and clinical characteristics of MDR-TB patients registered in three states of India during 2009-2011, 2) treatment outcomes, and 3) factors associated with unfavourable outcomes. Design: A retrospective cohort study involving a record review of registered MDR-TB patients. Results: Of 788 patients, 68% were male, 70% were aged 15-44 years, 90% had failed previous anti-tuberculosis treatment or were retreatment smear-positive, 60% had a body mass index < 18.5 kg/m2 and 72% had additional resistance to streptomycin and/or ethambutol. The median time from sputum collection to the start of MDR-TB treatment was 128 days (IQR 103-173). Unfavourable outcomes occurred in 40% of the patients, mostly from death or loss to follow-up. Factors significantly associated with unfavourable outcomes included male sex, age ⩾ 45 years, being underweight and infection with the human immunodeficiency virus. Adverse drug reactions were reported in 24% of patients, with gastrointestinal disturbance, psychiatric morbidity and ototoxicity the most common. Conclusion: Long delays from sputum collection to treatment initiation using conventional methods, along with poor treatment outcomes, suggest the need to scale up rapid diagnostic tests and shorter regimens for MDR-TB.

Financial Implications in Management of Multidrug Resistant Tuberculosis in India

Financial Implications in Management of Multidrug Resistant Tuberculosis in India

Multidrug-resistant tuberculosis in India: looking back, thinking ahead

Multidrug-resistant tuberculosis in India: looking back, thinking ahead

The making of a public health problem: multi-drug resistant tuberculosis in India

This paper examines how actors construct the public problem of multi-drug resistant tuberculosis (MDR-TB) in India. MDR-TB has been framed by the World Health Organization as a pressing, global public health problem. The responses to MDR-TB are complicated as treatment takes longer and is more expensive than routine TB treatment. This is particularly problematic in countries, such as India, with high patient loads, a large and unregulated private sector, weak health systems and potentially high numbers of MDR-TB cases. This paper analyses how actors struggle for control over ownership, causal theories and political responsibility of the public problem of MDR-TB in India. It combines Gusfield's theory on the construction of public problems with insights from literature on the social construction of diseases and on medical social control. It highlights that there are flexible definitions of public problems, which are negotiated among actor groups and which shift over time. The Indian government has shifted its policy in recent years and acknowledged that MDR-TB needs to be dealt with within the TB programme. The study results reveal how the policy shift happened, why debates on the construction of MDR-TB as a public problem in India continue, and why actors with alternative theories than the government do not succeed in their lobbying efforts. Two main arguments are put forward. First, the construction of the public problem of MDR-TB in India is a social and political process. The need for representative data, international influence and politics define what is controllable. Second, the government seems to be anxious to control the definition of India's MDR-TB problem. This impedes an open, critical and transparent discussion on the definition of the public problem of MDR-TB, which is important in responding flexibly to emerging public health challenges.

New diagnostics for multi-drug resistant tuberculosis in India: Innovating control and controlling innovation

Among the challenges for tuberculosis control is the emergence of multi-drug resistance, which has led to the search for new diagnostic solutions worldwide. The focus of this article is the interplay between innovation of diagnostics for multi-drug resistant tuberculosis in India and control through standardization of operational and technical processes. Innovation in diagnostics is closely related to processes of standardization. As a form of social ordering, standardization not only controls patients, bacteria, artefacts, health-care staff and medical providers, but also the diagnostic process as such. On the basis of qualitative fieldwork, I analyse the innovative efforts of a demonstration project for a new test by an international NGO and the development of tests by smaller players. The main argument is that a balance is needed between the extremes of controlling the diagnostic process through standardization in such a way that it becomes exclusive for particular local settings or expertise, and innovating a diagnostic test without standardizing operational processes, which is not programmatically feasible. These negotiations between innovation and control can be found in situated assessments, yet require flexibility in standardization.