India Faces Shortage Of Drug-Resistant TB Drugs: What's the Impact On Ground?

Linezolid. Clofazimine. Cycloserine.

These are the three life-saving tuberculosis (TB) drugs that India is currently short of.

What started in 2022 with the shortage of Rifampicin, a drug used for treating drug-sensitive TB patients, has now turned into a full-blown shortage of drug-resistant TB drugs, and it’s concerning.

FIT reached out to experts to understand the consequences of this drug shortage.

Drug-Resistant TB Drugs: What Does This Even Mean?

Usually, drugs or antibiotics like isoniazid and rifampin are used to treat tuberculosis, which is a bacterial infection that mainly targets the lungs.

However, there are certain tuberculosis-causing organisms that these drugs are not effective against. 

According to the United States Centers for Disease Control and Prevention (CDC), multidrug-resistant tuberculosis (MDR TB) is “caused by an organism that is resistant” to potent TB drugs.

In such cases, the patients have to rely on stronger drugs like Linezolid, Clofazimine, and Cycloserine to fight against TB.

According to the World Health Organization’s Global Tuberculosis Report 2022, India had the highest share of MDR TB cases in 2021, accounting for 26 percent of the global cases. 

As of March 2021, this number stands at 1,24,000, according to the Government of India’s annual report. 

Why This Is Concerning?

To put it simply, taking anti-TB drugs is a matter of life and death for those suffering from tuberculosis. 

Ganesh Acharya, a TB/HIV survivor and activist based in Mumbai, explains to FIT that when a TB patient doesn’t take their medication for even a few days, their body starts becoming resistant to it.

In people suffering from MDR TB, the worry is even bigger. These patients are already taking drugs for drug-resistant TB. So when their medication cycle is interrupted, there’s nothing that they can do to prevent the disease from becoming severe.

“People who have drug-resistant TB usually have to take 4-5 drugs on a daily basis for treatment. If they go off of any of these medicines, the effectiveness of the others also goes down. In such cases, it's not just the patient who is at risk. Community transmission also increases widely in such cases.”

Ganesh Acharya

Chapal Mehra, a public health activist, concurs. He says this is concerning because it can potentially lead to:

• People falling off the wagon of treatment and medication.

• People having to take loans or borrow money for treatment.

• With no guarantee for when the medicines will be available, financial and mental burdens on the patients might increase.

• Increasing severity of the disease might increase discrimination or the feeling of resentment towards the patients.

But, he also points out that we can't look at this drug shortage in isolation. It's just as important to see which sections of society it's impacting the most, whether these people have sources of income, who they're dependent on, etc, to get a bigger picture of the TB problem in India.

‘Don’t Push The Burden On States & Patients’, Say Activists

These drugs are supplied to patients by the Centre under the ambit of the National Tuberculosis Elimination Programme (NTEP). But due to this shortage, the Centre has been diverting requests for these drugs to the states.

Asha Frederick, Tamil Nadu State TB Officer, was quoted by The Hindu earlier in August as saying:

“The Union government has not supplied adequate doses of Rifampicin and some drugs used for treating people with Multidrug-resistant TB. The States have been asked to procure the drugs themselves but no additional funding has been provided.”

Acharya is also exasperated that the government authorities are expecting people to buy these drugs from private vendors. He asks,

“When the governments are unable to source these drugs, how can the patients do so in times of a shortage? How can people find them, and how can they afford them?”

He goes on to tell FIT that many of the patients he’s in touch are unable to continue their medication because of how expensive the drugs are. He says, “This is why marginalised communities are at a greater risk of TB. How can they spend Rs 10,000 per month on drugs alone?”

With this drug shortage, the disparity between those who can and cannot afford the medicines is also increasing.

Leena Menghaney, a lawyer working on medicines, law and, policy, who also heads Médecins Sans Frontières’ Access Campaign in India, says that with TB being one of the deadliest infectious diseases globally, “It's of utmost importance to ensure an interruption-free drug supply and treatment for patients.”

If the drug shortage continues any longer, it would have severe consequences on India’s goal to eliminate the disease by 2025, which is anyway ahead of the global goal to eradicate TB by 2030.

Why Do Drug Shortages Happen In The First Place & How To Prevent Them

“The shortages of essential medicines is not a new thing in developing countries. But it's important to record why these shortages happen. Are they occurring because the distribution of the drug is not done correctly or because the forecasting for the year is not accurate?”

Leena Menghaney

Menghaney explains that sometimes the distribution of drugs is so erratic in some centres that you have more drugs in a centre than patients and sometimes it's the other way round. 

Drug shortages also happen when procurement of medicines or their tender/finalisation is delayed at the national and state levels.

But there are certain things that can be done to prevent drug shortages, small and big steps waiting to be taken. 

For one, Menghaney says, “We need efficient procurement systems in our healthcare programmes.”

But, she also suggests:

• Making the system more transparent so that people are at least aware when a shortage happens.

• Encouraging healthcare workers and patient groups to report their needs in an effective manner. 

• Effective forecasting from centres.

“Many times centres don't know there's going to be a shortage until it's too late. Only when multiple centres are low on supply do authorities realise that there's a drug shortage.”

Leena Menghaney

In addition to this, in their letter to the Health Ministry, the TB survivor have demanded that these steps be taken for prevention of drug shortages:

• Strengthen and streamline the drug forecasting, procurement, and supply chain mechanisms. 

• MoHFW to set up a Stock Monitoring Committee consisting of NTEP officials, supply chain experts, and TB community representatives. This committee should meet monthly to prevent and address shortages and stockouts of TB drugs in a timely, transparent, and accountable manner.