MDR-TB in Pakistan Directly Linked to Noncompliance

From the Daily Times of Pakistan by Urooj Zia

KARACHI: Medication for Multi-Drug Resistant Tuberculosis (MDR-TB) is generally smuggled into Pakistan from parts of India, sources in the federal health department and medicine-vendors in Karachi told Daily Times.

MDR-TB is a “higher form” of TB, and is a lot more difficult to cure than regular TB, mostly because the bacteria in this case have become resistant to most drugs used in the first line of treatment for (regular) TB. Medication for regular TB is provided free by the government, under the WHO-sponsored DOTS programme, run by the National TB Control Programme (NTP).

MDR-TB develops mainly due to non-compliance with the first line of treatment, which lasts around six to eight months. A number of patients, however, stop taking medication after the first three months (around the same time that TB symptoms disappear). “The bacteria are still there, though. They just become dormant, which is why the symptoms disappear. People think they’re cured, and stop taking the medication. The treatment during the next few months, however, works towards killing these bacteria, so the disease doesn’t make a comeback,” doctors said.

Once a patient drops out mid-treatment, the disease comes back with a vengeance, in the form of MDR-TB. These bacteria are resistant to the first line of treatment, and a different combination of drugs has to be used to combat them. These drugs are extremely expensive in Pakistan. Treatment generally lasts around two- to two-and-a-half years, and the total cost of medication alone comes up to around Rs 200,000,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, said.

Moreover, even a patient who has never contracted TB before can contract the drug-resistant form of the disease, if infected directly by a person suffering from MDR-TB. Four major drugs are used to combat MDR-TB – Cycloserene, Oflobid (a wide-spectrum antibacterial), Pas, and Ethomid.

Each of these medicines costs less than Rs 10 in India. After being smuggled into Pakistan, however, the cost increases to between Rs 50 and Rs 75 per capsule. An MDR-TB patient is expected to take at least two of each daily for the duration of the treatment. The total cost of treatment depends on the combination of drugs being used – all four medicines are not used at the same time.

Interestingly three of the four medicines are also produced locally in Pakistan, “but they are produced by multi-national companies (MNCs), so the difference in cost isn’t much,” a shopkeeper at the Medicine Market in Katchhi Gali # 2 (behind M.A. Jinnah Road) told Daily Times. “MNCs have their own costs of production to look at too.” “Locally-produced” versions of Pas, however, cost Rs 375 for a box of 50 tablets (Rs 7 per tablet). Ethomid costs Rs 476.85 for a pack of 30 tablets (Rs 16 per tablet), and Oflobid costs Rs 115 for a pack of 10 tablets (Rs 11.5 per tablet).

A cheaper variant of Ethomid is sold under the trade name “Marbital.” These are available at Rs 175 for 100 tablets (Rs 1.75 per tablet). Both versions are “legal” – the more expensive Ethomid is produced in Lahore, while the cheaper Marbital is produced in Karachi.

Cycloserene is produced in Seoul, Korea, and is marketed by a firm in Karachi. It is available at Rs 59 for a pack of 30 tablets (Rs 2 per tablet).

These are the prices that are generally applicable. “Most of the time, the supply of the locally-produced medicines falls short in the market, and drugs smuggled in from India have to be used,” medicine-vendors said. “That is when prices shoot up. If a patient has to take these medicines for two years, he or she will find the cheaper versions readily available for merely three to four months out of a total of 24. The rest of the time, the patient’s family will have to search hard and long for even the Indian versions of the medicines. This is how the treatment costs for MDR-TB shoot up. The government should subsidise the production of these medicines, so they are readily available, at cheaper rates.”

Another factor pharmacy salespeople and owners brought up was the fact that the availability of these medicines in rural areas is next-to-zero.

The WHO has a programme for treating MDR-TB. This programme is referred to as DOTS+. It is yet to be implemented in Pakistan, however. “Right now, we are concentrating on implementing the DOTS programme completely. We have been advised by the WHO to not touch MDR-TB as a programme yet,” Sindh TB Control Programme director, Prof. Iqtedar Ahmed, told Daily Times. “Keeping our human resources, financial resources, and technical resources in mind, our first priority is the first line of treatment for TB (under the DOTS programme). Our next target is paediatrics (incidence of TB in children under the age of 12).”

The National TB Control Programme has started to work on a protocol for implementing a programme for MDR-TB too, Prof. Ahmed said, adding however, that implementation will take time. “It could take anywhere from two to six months, I can’t be sure at this time,” he said.

The incidence of MDR-TB is equal all over the country, he added. “According to WHO reports, the incidence of the disease in Pakistan is somewhere around two to three percent. It is higher in more populated areas, and lower in relatively more affluent suburbs, where a lesser number of people share the same living space.”

The problem with the government sponsoring MDR-TB treatment is that the prognoses (results) of the treatment are around 50 percent, Prof. Ahmed said. “At the end of the day, looking at financial constraints, it is more feasible to spend that money on the first line of treatment, so that the disease is nipped in the bud.”

He did agree, though, that some level of coverage should be given to MDR-TB by the federal and provincial health departments.