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 DRPrevalence of primary DR TRC Studies 1956 - 2001TRC Studies 1956 - 2001

Prevalence of primary DRPrevalence of primary DR TRC Studies 1956 - 2001TRC Studies 1956 - 2001

0

2

4

6

8

10

12

14

16

18

YEARS

H

S

SH

R/H

Prevalence of Primary Drug Resistance TRC Studies – (1974 -2001)

0

5

10

15

20

XII 74-77

XIII 77-80

XIV80-85

XV 85-86

XVI 86-90

XVII90-95

XVIII95-98

XIX 98-00

XXI2001

per

cen

tag

e

MDR

RIF

STREP

INH

After the introduction of rifampicin in Controlled Clinical Trail at TRC

*

Drug resistance in cases detected in Drug resistance in cases detected in prevalence surveys in India 1968-2003prevalence surveys in India 1968-2003

0

5

10

15

20

25

1968-70 1971-73 1973-75 1976-78 1979-81 1981-83 1984-86 1991-92 1994-96 1999-01 2001-03

Year

Per

cen

tage

H

S

HRSH

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%

Level of MDR in ‘New’ in different Level of MDR in ‘New’ in different sites in Indiasites in India

3.3%

3.2%

3.0%

3.0%

2.7%

2.5%

2.2%

2.0%

1.7%

1.2%

1.0%

0.9%

0.7%

0.5%

0.0% 0.5% 1.0% 1.5% 2.0% 2.5% 3.0% 3.5%

TAMILNADU (389) (1995)

RAICHUR (244) (1989)

HOOGLY (350) (2003)

NORTH ARCOT (282) (1999)

AFMS (2562) (1995-99)

RAICHUR (278) (1999)

BANGALORE (366) (2002)

NORTH ARCOT (2779) (1985-89)

NORTH ARCOT (350) (1989-90)

MYSORE (203) (2001)

JABALPUR (273) (2002)

PONDICHERRY (2127) (1985)

MAYURBHANJ (343) (2002)

WARDHA (197) (2001)

Percent MDR

(population covered 8.1%)(population covered 8.1%)

TRCNTI

DRS in MDP area

85

73

15

27

10 13

1.7 2.20

10

20

30

40

50

60

70

80

90

U n T re a te d

fully sens.

Any Res.

Any H

HR

Drug resistance among Drug resistance among newly diagnosed casesnewly diagnosed cases

MDP area N=1603 Bangalore city N=271

59 60

41 4037

27

12 13

0

10

20

30

40

50

60

70

R e tre a tme n t c a se s

Fully densitive

Any Res.

Any H

HR

Drug susceptibility among previously Drug susceptibility among previously treated casestreated cases

MDP area N=443 Bangalore city N=226

9.8 9.3 9.7

2.7

41.8

34.0 35.037.6

21.7

9.8

16.0

0.9 1.1 1.03.5

41.3

10.812.611.2

8.0

0

5

10

15

20

25

30

35

40

45

1999 2000 2001 2002 2003

per

cen

tag

e

H (New)

HR (New)

H (Re Rx)

HR (Re Rx)

Drug resistance trend in MDP area

New 144 326 367 389 371

Re Rx. 46 98 100 103 93

Drug Resistance in Patients With HIV / TB in South India

62.2

13.6

36.8

13.2

27

4.2

13.5

84.4

0

10

20

30

40

50

60

70

80

90

% o

f P

ati

en

ts

suseptible to all Any resis.

Res. To H MDR

New cases-167 Treated cases-37

Swaminathan S et al IJTLD 2004

Drug Resistance pattern of referred samples 2001-04

Susc. 32.5%

Res. 1 or more 67.5%

(n 2816 patients)(n 2816 patients)

Drug Resistance pattern of referred samples 2001-04

(n 2816 patients)

43.2

67.5

1

29.9

6.5

24.6

9.7

53.2

0

20

40

60

80

100

S H R E K Th Ofl. HR

Drugs

( % )

Drug Resistance pattern of referred samples

2001-04 (n 2816 patients)

29 6

2011

23

30 36

40

337

1214

26

16

68

49 44

14

40

0

10

20

30

40

50

60

70

80

90

100

HR HRS HRE HRSE Any HRRes.

per

cen

tag

e

Column 4

O

Eth

K

N 355

385 176 582 1498

Resistance pattern of PZA among MDR TB

5647

63

3

31 33

66

40 43

100

7380

0

20

40

60

80

100

120

Z E S K TH OF

Anti TB drugs

% o

f res

ista

nce

RF (51)

TRC (15)

PZA Resistance among New Cases At TRC – Chennai(1995-99)

PZA

Sensitive Resistant Total

MDR 1 3 4

Non MDR 191 17 208

Both 129 20 212

MDR TB in SEAR

4

1.3

0.9

15.5

20.5

20.2

0 5 10 15 20 25

Treated

New

Thailand (2000 – 02)

172

1505

Nepal (2000 – 02)

177

755

Myanmar (2003 – 04)

166

733

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 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

DRS – Key findings in IndiaDRS – 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 : 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