Drug Resistance Pattern of Tuberculosis in India- Status Report Tuberculosis Research centre (ICMR)

Earlier reports on combined resistance from India and their limitations Case selection Sample size Methodology Source of drugs Definition of resistance

Role of TRC in DRS for India & SEAR  SNRL and ref. Lab of the WHO  NRL for India

Prevalence of primary DR TRC Studies

Prevalence of Primary Drug Resistance TRC Studies – ( ) After the introduction of rifampicin in Controlled Clinical Trail at TRC *

Drug resistance in cases detected in prevalence surveys in India H S HR SH

DRS sites of India ( ) North Arcot – (2%), (1.7%), 1999 (3%) Pondicherry (0.9%) Tamil Nadu (3.3%) AFMS – (2.7%) Bangalore (2.2%) Mysore (1.2%) Raichur (3.2%), 1999 (2.5%) Wardha (0.5%) Jabalpur (1%) Mayurbhanj (0.7%) Hoogli (3%) Nawgong Population covered = 8.1%

Level of MDR in ‘New’ in different sites in India (population covered 8.1%) TRC NTI

DRS in MDP area

Drug resistance among newly diagnosed cases MDP area N=1603 Bangalore city N=271

Drug susceptibility among previously treated cases MDP area N=443 Bangalore city N=226

Drug resistance trend in MDP area New Re Rx

Drug Resistance in Patients With HIV / TB in South India New cases-167Treated cases-37 Swaminathan S et al IJTLD 2004

Drug Resistance pattern of referred samples Susc. 32.5% Res. 1 or more 67.5% (n 2816 patients)

Drug Resistance pattern of referred samples (n 2816 patients)

N

Resistance pattern of PZA among MDR TB

PZA Resistance among New Cases At TRC – Chennai( ) PZA SensitiveResistantTotal MDR134 Non MDR Both

MDR TB in SEAR Thailand (2000 – 02) Nepal (2000 – 02) Myanmar (2003 – 04) Percentage

A baseline prevalence of these populations at the state level required through Well designed state level surveys Separate sampling for new & re-treatment cases Planning for trend analysis among re- treatment cases DRS: Indian initiative

DRS: Indian Initiative  India has developed a national plan to conduct nationwide surveillance of DR in different states  DRS protocol as per international guidelines developed and implemented for three states this year (Gujarat, Sikkim and Maharashtra)  DRS protocol under development for two more states for next year (AP and Orissa)  Gradual expansion & re-survey of states over time, as has been done in China - eg: Tamilnadu State

 Another objective of nationwide surveillance of drug resistance in India Strengthening of laboratory networks through; The implementation of an EQAP for smear microscopy QA of culture & DST in state laboratories DRS: Indian initiative

DRS: Requirements for India  Human & financial capacity are being addressed enhanced before proficiency testing can take place & a nationwide survey could be implemented Three national reference laboratory (NRLs) 16 intermediate reference laboratories (IRLs)  IRLs to be established in the remaining 18 states

Year 2005 DRS sites of India Maharashtra, millions (9.4%), 2005 Gujarat, 53.8 millions (4.9%), 2005 Orissa, 38.2 millions (3.5%), 2005 Andhra Pradesh, 78.7 millions (7.2%), 2005 Population being covered in 2005 = 25% Resurvey – Tamilnadu DRS-Sikkim,

DRS – Key findings in India Among new cases : No evidence of an increase in the prevalence of resistance TRC studies :Low level prevalence of MDR TB TRC studies : Pediatric & Extra-pulmonary cases low level resistance to H (5-10%) low level resistance to S (2-14%) MDR TB - Almost Nil

DRS – Key findings… Among Patients with Treatment History : Urban & Rural Settings : % Among Chronically ill : Almost 50% Compared to global situation a lesser prevalence of primary resistance a much higher level of acquired resistance is observed