Multidrug Resistant Tuberculosis (MDR-TB) in India

MDR-TB is a form of tuberculosis where the bacteria are resistant to rifampicin and isoniazid, two essential drugs in TB treatment. This form of TB carries a high risk of death, estimated at 30-40%. India has a significant burden of TB, contributing 27% of the 1,75,923 MDR-TB cases reported globally in 2023.

Challenges in Treatment

• The evolution of MDR-TB strains is often due to poor adherence to TB treatment and misuse of drugs, common in India.
• Traditional treatments for drug-resistant TB are lengthy (18 months or more) and involve toxic drugs, posing adherence challenges.
• Patients have long advocated for shorter and less toxic treatment regimens, which were often ignored by the health system.
• Side effects from treatments, such as hearing loss and depression, were often downplayed, exacerbating the stigma and discomfort for patients.

New Treatment Regimens

There is a need for shorter regimens to improve treatment completion rates and reduce economic burdens. The BPaL regimen, consisting of bedaquiline, pretonamid, and linezolid, is one such example, prescribed for 6 months.

• The Nix-TB trial in South Africa demonstrated the regimen's efficacy, and the ZeNix trial showed better tolerance with reduced linezolid doses.
• Although promising, adherence and drug-susceptibility testing are crucial for these new regimens.
• Adverse effects, such as sensory neuropathy from linezolid, need monitoring, and alternative regimens should be available.

Health System and Implementation

• Adequate training for physicians on managing these regimens is essential.
• Universal molecular diagnostics are needed to detect drug-resistant TB early.
• Effective public-private partnerships can improve access while preventing misuse of treatments.

Additional Considerations

• Shorter regimens might be costlier, but persisting with toxic alternatives is more detrimental.
• Community education and supportive services such as counseling are key to successful implementation.
• Addressing social, economic, and gender determinants is crucial for a holistic TB control approach.

Conclusion

While shorter regimens for MDR-TB are transformative, they are not sufficient alone. A broader systemic transformation addressing structural determinants is necessary for effective TB control.

Cervical Cancer and HPV Vaccination

January marks Cervical Cancer Awareness Month, emphasizing the importance of screening for cervical cancer, a leading cause of cancer among Indian women. The disease primarily stems from the Human Papillomavirus (HPV), responsible for 99.7% of cervical cancers globally.

HPV Vaccine: Prevention and Availability

• The HPV vaccine is the most effective preventive measure, stimulating immune responses to neutralize the virus.
• In India, the vaccine requires a prescription, despite recommendations for inclusion in the national immunization program by the National Technical Advisory Group for Immunisation (NTAGI).
• Some states like Punjab and Sikkim have incorporated the vaccine into their programs.

Vaccine Recommendations and Efficacy

• Recommended for girls aged 9–14 and children aged 12 to 13 years.
• Effective in preventing over 90% of cancers associated with HPV.
• Safe for immunocompromised individuals or those with HIV, with common side effects being mild fever and injection-site reactions.
• Approved vaccines in India include Gardasil, Cervarix, and Cervavac.

Prevalence and Incidence of Cervical Cancer

• 3rd most common cancer in India, with an incidence rate of 18.3% and mortality rate of 9.1% according to GLOBOCAN 2020.
• Highest incidence rate in Asia in Papumpare district, Arunachal Pradesh.
• Majority of cases diagnosed at advanced stages.

Challenges and Cost

• High costs and cultural perceptions impact vaccine uptake.
• Gardasil 9 costs ₹10,850 per dose; Cervavac, an Indian vaccine, costs ₹2,000 per dose.

Global Efforts and Recommendations

The World Health Organization and other global entities have committed significant funding ($600 million) to eliminate cervical cancer. Vaccination, coupled with screening and treatment, forms the path to eradication, particularly in low- and middle-income countries.