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

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

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

4. Prevalence of primary DR TRC Studies 1956 - 2001

5. Prevalence of Primary Drug Resistance TRC Studies – (1974 -2001) After the introduction of rifampicin in Controlled Clinical Trail at TRC *

6. Drug resistance in cases detected in prevalence surveys in India 1968-2003 H S HR SH

7. DRS sites of India (1985-2003) North Arcot – 1985-89 (2%), 1989-90 (1.7%), 1999 (3%) Pondicherry - 1985 (0.9%) Tamil Nadu - 1995 (3.3%) AFMS – 1995 - 1999 (2.7%) Bangalore - 2002 (2.2%) Mysore - 2001 (1.2%) Raichur - 1989 (3.2%), 1999 (2.5%) Wardha - 2001 (0.5%) Jabalpur - 2002 (1%) Mayurbhanj - 2002 (0.7%) Hoogli - 2003 (3%) Nawgong - 2003 Population covered = 8.1%

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

9. DRS in MDP area

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

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

12. Drug resistance trend in MDP area New 144 326 367 389 371 Re Rx. 46 98 100 103 93

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

14. Drug Resistance pattern of referred samples 2001-04 Susc. 32.5% Res. 1 or more 67.5% (n 2816 patients)

15. Drug Resistance pattern of referred samples 2001-04 (n 2816 patients)

16. N 3553851765821498

17. Resistance pattern of PZA among MDR TB

18. PZA Resistance among New Cases At TRC – Chennai(1995-99) PZA SensitiveResistantTotal MDR134 Non MDR19117208 Both12920212

19. MDR TB in SEAR Thailand (2000 – 02) 172 1505 Nepal (2000 – 02) 177 755 Myanmar (2003 – 04) 166 733 Percentage

20. 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

21. 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

22.  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

23. 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

24. Year 2005 DRS sites of India Maharashtra, 102.8 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, 2005-06

25. 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

26. DRS – Key findings… Among Patients with Treatment History : Urban & Rural Settings : 10 -12% Among Chronically ill : Almost 50% Compared to global situation a lesser prevalence of primary resistance a much higher level of acquired resistance is observed