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Treating drug-resistant tuberculosis in a low-intensity chronic conflict setting in India

E. Armstrong,M. Das,H. Mansoor,R. Babu,P. Isaakidis

Published 2014 in Conflict and Health

ABSTRACT

IntroductionThe eastern part of India has been affected by an ongoing low-intensity conflict between government forces and armed Maoist groups, known as Naxalites. Since 2006, Médecins Sans Frontières (MSF) has been providing primary health care services in the conflict-affected region along the Andhra Pradesh-Chhattisgarh border. In 2011, treatment for drug-resistant tuberculosis (DR-TB) was included in the services provided. This report aims to describe MSF experiences of providing treatment to DR-TB patients in a mobile primary health care outpatient clinic, in a low-intensity conflict setting in India.Case descriptionA total of thirteen patients were diagnosed with drug-resistant TB (DR-TB) between January 2011 and October 2013. An innovative treatment model was developed which delegated responsibility to non-TB clinicians, including primary-care nurses and nurse-aids who were remotely supported by a TB-specialist from the MSF DR-TB project in Mumbai. Individualised regimens were designed for each patient based on WHO guidelines. Of these 13 patients, 10 patients had an outcome, of whom seven (70%) patients were cured. One patient became lost to follow-up prior to treatment initiation, one patient died prior to starting treatment and one patient refused treatment. Three patients were on-treatment, were clinically improving and were culture-negative at the end of their intensive phase of treatment.Discussion and evaluationDrug-resistant tuberculosis diagnosis and treatment is a highly specialised and technical subject which requires continued patient follow-up. However, our study demonstrates that it is feasible to manage DR-TB patients in a conflict setting, using a primary-care model with remote expert support. Long-term commitment and sustainability are essential for continued care, even more so in similar conflict settings. Loss to follow-up in patients remains a programmatic challenge and community involvement may play a key role.ConclusionManaging DR-TB in a primary health care programme is feasible in a low-conflict setting with an appropriate treatment model. Ambulatory strategies and standardised treatment regimens should be considered to further simplify treatment delivery and allow for scale-up when needed.

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