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Commentary
Drug-resistant tuberculosis: is India ready for the challenge?
  1. Soumya Chatterjee1,
  2. Husain Poonawala2,
  3. Yogesh Jain3
  1. 1 Division of Infectious Diseases, Allergy and Immunology, Saint Louis University, St Louis, Missouri, USA
  2. 2 Department of Immunology, National Institute for Research in Tuberculosis, Chennai, Tamil Nadu, India
  3. 3 Jan Swasthya Sahyog, Ganiyari, Chhattisgarh, India
  1. Correspondence to Dr Husain Poonawala; husain.poonawala{at}gmail.com

https://doi.org/10.1136/bmjgh-2018-000971

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    Summary box

    • India contributes to one-fourth of the global burden of multidrug-resistant tuberculosis (MDR-TB) with inadequate diagnostic infrastructure for drug susceptibility testing (DST).

    • A survey of anti-TB drug-resistance demonstrates high rates of resistance to first-line and second-line antitubercular drugs in new and previously treated cases of TB in India.

    • The survey is likely underestimating the burden of antitubercular drug resistance in India.

    • India needs more laboratories to meet the goal of universal DST.

    • A multipronged strategy investing in laboratory capacity, addressing isoniazid monoresistance, designing empiric MDR-TB regimens, involving the private sector and improving airborne infection control will be necessary to bring drug-resistant TB under control.

    Introduction

    Tuberculosis (TB) kills close to half a million Indians every year.1 Additionally, a million ‘missing’ undiagnosed or inadequately diagnosed cases go unnotified annually.2 Not surprisingly, drug-resistant tuberculosis (DR-TB) is a significant problem, and India now has the most number of cases of multidrug-resistant tuberculosis (MDR)-TB in the world, contributing one-fourth of the global burden.1 The treatment of MDR-TB requires the use of toxic drugs, is long and expensive and has substantially lower success rates than for drug-sensitive TB.1 In this commentary, we review the burden of drug resistance in India considering recent data from India3 and discuss areas of focus necessary to combat DR-TB.

    What is the burden of DR-TB in India?

    Globally, 4.1% of new TB cases are reported to be MDR.1 Concordant with previous surveys, the First National Anti-Tuberculosis Drug Resistance survey conducted by the Indian Government in collaboration with the World Health Organization (WHO) and the United States Agency for International Development (USAID) showed that close to 23% of new cases have resistance to any drug with MDR-TB detected in 3%.3 Monoresistance to rifampin was not seen and resistance to isoniazid (INH) was highest (any 11%, monoresistance 4%), followed by resistance to pyrazinamide (any 7%, monoresistance 4%) and …

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