In spite of widely acknowledged achievements of the Revised Tuberculosis Control Programme (RNTCP) being carried out by the Central TB Division of the Ministry of Health and Family Welfare (MoHFW), Govt of India, even now in 2018, tuberculosis (TB) continues to be a serious public health problem in the country. Under RNTCP, over the last ten years, more than 80 million people have been tested, 15 million TB patients detected and treated and millions of lives saved across the country. Nevertheless, in 2013, India still reported 1.24 million new and relapsed cases of TB, by far the largest TB burden of any country, and over 2,70,000 Indians died of TB in that year (WHO, Global Tuberculosis Report 2014). Some estimates calculate deaths twice as high. WHO’s Global TB report further states that TB case notification in India is only 58%. It is a matter of concern that one third of TB cases is not diagnosed; or diagnosed but not treated; or diagnosed and treated but not reported to RNTCP. In fact, WHO estimates that 1 million Indians with TB are not even notified. Therefore, even the most basic aspect of TB control, that is credible statistics about incidence of disease in the country need to be strengthened. For this, simpler but more sensitive and specific diagnostic assays need to be in place. An imported cartridge-based nucleic acid amplification test (CBNAAT) system (GenExpert) is being evaluated or assessed at different sites in India; however, the cost of its maintenance under high ambient temperature in Indian field conditions, plus the cost of proprietary consumables required (cartridges), severely limits its wide application in the country. DBT is playing a crucial role by supporting R&D of alternate, indigenously developed assay system(s) suitable for rapid diagnosis of TB as well as detecting possible mutations in the Indian isolates of MDR TB. Studies in NER may provide an opportunity to assess the available prototype(s) in this endeavour. Even more alarming is the emergence of multi-drug resistance (MDR) strains of Mycobacterium tuberculosis (Mtb) now posing a huge organizational and financial challenge to the public health system of India. In the existing control programme, it takes nearly 200 days before a patient of MDR TB can get the specifically recommended treatment!
All these problems are perhaps even more prevalent in North Eastern Region (NER) of India where relatively higher incidence of HIV in certain states (such as Mizoram, Manipur & Nagaland) further aggravates the situation. In a focussed study on detection of MDR-TB in NER, Singhal and colleagues (2014, IJMR) reported that MDR-TB among the MDR-TB suspects was as high as 32.7%. Although there is apparently little data available in public space, it is commonly believed that incidence of MDR TB is the highest in Sikkim, a state in NER.
It is now widely realized that the most glaring flaw in the RNTCP has been to administer DOTS without the requirement of carrying out drug sensitivity tests (DST) on the infecting strain of Mtb. Efforts are now underway to incorporate DST in the programme. However, genotypic characterization of Mtb strains isolated from cases of MDR-TB would need to be done in order to understand the dynamics of evolution of multi-drug resistance in the region. Strains isolated from patients co-infected with HIV & TB, a common phenomenon in NER, seem to present altogether new challenges in terms of their drug sensitivity and evolutionary fitness.
The scenario in NER is further aggravated by the more intimate contact of humans with their livestock (cattle, pigs, sheep/goats, poultry, fish etc.) potentially leading to infections with non-tuberculous mycobacteria (NTM), masquerading as TB. Most NTMs are tolerant to anti-tuberculosis drugs; consequently, NTM infections are likely to be mis-classified as MDR TB, thus adding to the confusion. So there is an urgent need to map the incidence and prevalence of NTMs in NER, as well.
In order to mitigate the TB situation in NER, a Brainstorming Workshop was organized to discuss various public health dimensions of the Multi-Drug Resistant Tuberculosis (MDR-TB) in northeast India. Twenty-three experts from all over the country met at Guwahati on 19-20 August 2016 for the meeting. Based on the Recommendations of the meeting, a new comprehensive programme has been launched on various aspects of molecular characterization of MDR tuberculosis in NER. Twelve multicentric projects have been conceptualized and are at different stages of implementation. These projects include TB experts from leading TB research institutes like AIIMS-New Delhi, ICGEB, NITRD-New Delhi, CDRI-Lucknow, and state units of RNTCP of all eight states of the Northeastern region.