TDR-TB: The Indian Government Denies It

An update to the news two weeks ago of totally drug-resistant tuberculosis, TDR-TB, being identified in India (and earlier in Italy and Iran): The Indian government has announced that it doesn’t exist, and is putting pressure on the physicians who identified it to say they made a mistake.

Because, of course, that’s going to keep a disease from spreading.

A news story published Friday in BMJ, datelined New Delhi, reports:

Sections of India’s medical community have decried what they see as an attempt by the Indian health ministry to underplay the country’s first report of totally drug resistant tuberculosis and to censure the hospital that reported the infection last month…

The health ministry, which independently examined the patients’ records, has said that the term “totally drug resistant” tuberculosis is “misleading” and has not been endorsed by the World Health Organization. It has classified the cases as extensively drug resistant tuberculosis. In a statement, the ministry also said that the Hinduja Hospital had not received accreditation from the government to conduct drug sensitivity tests for second line drugs.

…Pulmonary and public health specialists believe the government’s response, particularly its focus on the terminology of resistance, seems intended to turn the spotlight away from India’s growing problem of drug resistant tuberculosis.

“This seems like an attempt to question the messenger,” said Bobby John, a doctor and president of Global Health Advocates, a non-government public health organisation that has been tracking India’s national tuberculosis control programme. (Byline: Ganapati Mudur)

A couple of things seem to be going on here. (For a recap of TDR’s emergence, see these three posts. Indian physicians have since flagged additional patients, and the state where TDR was first identified has created an isolation sanatorium in a small town.)

Regarding the allegation that it’s not really TDR: It is correct that the World Health Organization has asked that people stick to using the acronym XDR (extensively drug-resistant), because the WHO has internationally agreed-upon definitions for XDR and MDR (multi-drug resistant) and no such definition for TDR. Those definitions set standards for labs to test against. The WHO’s objection is that the hospital which identified the first patients in India — which is a WHO-collaborating hospital — did not test the patients’ bacterial strains against every possible drug and concentration, and so there might yet be a drug to which their infections might respond.

Fair enough, from the lab point of view. But from the political one, this is clearly blame-shifting. Within India, media reports are quite clear about what is really going on: The health ministry is looking for leverage to silence these physicians in order to spare the country further embarrassment. The paper and website Daily News & Analysis India is taking the physicians’ side:

Dr Zarir Udwadia, chest physician who did the TDR-TB study at the Hinduja Hospital, said: “There are 27 WHO-designated Intermediate Reference National Labs in the country. Hinduja lab is one of them. We expect the government authorities to admit that a decade of neglect of MDR-TB patients has resulted in TDR-TB.”

This is unfortunately reminiscent of the Indian government’s response to the discovery of NDM-1, the gene and enzyme that confers almost total antibiotic resistance on very common bacteria. From the time NDM-1 became big news in 2010 (which was several years after the gene was first identified, in a paper that got little notice at the time) and as recently as a few months ago in the wake of an international conference, the official response has been that NDM-1 is at best no big deal and at worst a Western plot to besmirch the reputation of India’s burgeoning medical-tourism industry.

For people who have been watching global health for a while, the current situation in India recalls the embarrassing emergence of another stigmatizing disease: SARS, which in early 2003 emerged from Guangdong province in China, first infecting a dozen travelers in Hong Kong, and then sweeping the world. As the epidemic burgeoned, it became clear that SARS had actually begun in fall 2002, but the Chinese government had attempted to suppress any news of the epidemic from being repeated beyond its borders. It failed to control either the epidemic or news of it, which eventually leaked out via the early-warning list ProMED. (How the news of SARS got out is retold in my book Beating Back the Devil; here’s a link to the chapter.)

Last week I happened to have a conversation with a public-health official who was very involved in the international SARS response and was on the ground in Hong Kong while the epidemic was cresting there. “China really learned the lesson of transparency” thanks to SARS, he said, noting the country’s rapid, from-the-top response to the recent polio outbreak in Xinjiang.

That is great news — and yet, for China to learn it, almost 8,000 people were infected with SARS, almost 800 died, and China earned a footnote in textbooks as the country which proved diseases spread whether news of them does or not. Wouldn’t it be better for India’s reputation — not to mention safer for the world — if India studied China’s lesson, instead of repeating China’s mistake?



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