Role of TRC in DRS for India & SEARRole of TRC in DRS for India & SEAR SNRL and ref. Lab of the WHO NRL for India

Renders assistance for the following: Preparation of generic protocol Developing laboratories for culture & DST Preparation of manuals and SOPs Training of laboratory personnel Instituting uniform methods for DST Ensuring quality thro’ QAP Supply of standard strains, drugs & reagents Periodic site visits

Earlier reports on combined resistance Earlier reports on combined resistance from India and their limitationsfrom India and their limitations

Case selection

Sample size

Methodology

Source of drugs

Definition of resistance

MDR TB in SEARMDR 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

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

*

DRS sites of India DRS sites of India (1985-2003)(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%)

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% 1.0% 2.0% 3.0% 4.0% 5.0% 6.0% 7.0% 8.0% 9.0% 10.0%

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 areaDrug resistance trend in MDP area

New 144 326 367 389 371

Re Rx. 46 98 100 103 93

MDR TB MDR TB (Gujarat, India Jan 2000 – Aug 2001)(Gujarat, India Jan 2000 – Aug 2001)

60

35

0

10

20

30

40

50

60

70

80

90

100

All patients Res. cases

N=822

N=482

Shah AR et al. Int J tuberc Lung Dis, 2003; 6(12): 1098.

3.9 %

12.4 %

Drug Resistance in Patients With Drug Resistance in Patients With HIV / TB in South IndiaHIV / 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 Drug Resistance pattern of referred samples 2001-04 referred samples 2001-04

Susc. 32.5%

Res. 1 or more 67.5%

(n 2816 patients)(n 2816 patients)

Drug Resistance pattern of Drug Resistance pattern of referred samples 2001-04 referred samples 2001-04

(n 2816 patients)(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 Drug Resistance pattern of referred samples

2001-042001-04 (n 2816 patients)(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

Few earlier studies on ADR in India

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

9.6

15

33.7

28.0

20.3

30.0

35.2

11.0

13.5

17.0

0 5 10 15 20 25 30 35 40

WARDHA (302) (1982-89)

Gujarat (1267) (1983-86)

Delhi (87) (1990-91)

Bombay (521) (1991-95)

T.Nadu (162) (1995)

Lucknow (183) (2001)

Gujarat (822) (2002)

NA Dt (560) (1986-88)

NA (S) (37) (1989-90)

Raichur (S) (111) (1989)

Percent MDR

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

TRCOthers

Year 2005 DRS sites of India Year 2005 DRS sites of India

Maharashtra, 102.8 millions (9.4%), I Qrt 2005

Gujarat, 53.8 millions (4.9%), I Qrt 2005

Orissa, 38.2 millions (3.5%), II Qrt 2005

Andhra Pradesh, 78.7 millions (7.2%), II Qrt 2005

Population being covered in 2005 = 25%

Resurvey – Tamilnadu DRS-Sikkim,2005-06

TRC Studies on Newer drugs and TRC Studies on Newer drugs and defining resistancedefining resistance

Studies carried out at TRCStudies carried out at TRC

DEFINITION OF RESISITANCE TO RIFAMPICINDEFINITION OF RESISITANCE TO RIFAMPICIN

MIC MIC : 128 : 128µg/ml. µg/ml.

PST (1% or more) : 40 µg/ml PST (1% or more) : 40 µg/ml

BACTEC BACTEC : 2 µg/ml : 2 µg/ml

Indian J. Med. Res. 2001, 114, 187-191.Indian J. Med. Res. 2001, 114, 187-191.

Studies carried out at TRC Studies carried out at TRC

In vitro activity of capreomycin and ciprofloxacin against S.Indian isolates of M.tb Indian J Tuberculosis 1993; 40: 21-25

In vitro activity of ciprofloxacin and ofloxacin against S.Indian isolates of M.tb Indian J Tuberculosis 1994; 41: 87-90

MIC of Lomefloxacin and Minocycline Against Drug-

Sensitive & resistant Isolates of M.tuberculosis Compared on L-J and 7H11 Media Int J Leprosy 1997; 65: 375-378

Studies carried out at TRCStudies carried out at TRC

Evaluation of various methods of susceptibility to ofloxacin in strains of M.tb Indian J Med Res 1999; 110: 186-189 Evaluation of bactericidal action of ofloxacin and sulbactam/ampicillin alone & in combination with R & H on M.tb invitro Antimicrob Agents Chemother 1996; 40: 2296-2299

A multi centre study of the early bactericidal activity of anti- tuberculosis drugs

J Antimicrobial Chemother 2000; 45: 859-870

Recent TRC studies on newer QuinolonesRecent TRC studies on newer Quinolones

1. Bactericidal action of Gatifloxacin, Rifamicin and isoniazid on Logarithmic –

and Stationary – Phase Cultures of Mycobacterium tuberculosis. Antimicrob.

Agents Chemother.2005, 49:627 – 631

2. Moxifloxacin and Gatifloxacin in a new acid model of persistent

M.tuberculosis. Antimicrob. Agents Chemother.2005

3. In vitro activity of fluoroquinlones against M.tuberculosis. J.

Chemotherapy.April,2005 (Accepted)

4. In vitro definitions of MIC of gati and moxifloxacin by different test methods.

FEMS Microbiology.2005

5. Bactericidal action of Moxifloxacin, Rifampicin and Isoniazid on Logarithmic –

and Stationary phase cultures of M.tuberculosis. J Antimicro.Agents and

Chemother. (2005 Communicated)

6. Analysis of Fluoroquinolone resistance in clinical isolates of M.tuberculosis

from India. J. Clinical Microbiology,2005 ( Communicated)

In vitro definition of resistance to gatifloxacin & Moxifloxacin

No. of strains : 50 (Sens. 30; Res. 20) Methods used : Abs.conc. - LJ PST - LJ, 7H11 & BACTECRESULTSRESULTS

MIC of GATI LJ : 1 μg ml

Critical conc. LJ & 7H11 : 0.5 μg/ml

BACTEC : 0.25 μg/ml

MIC of MOXI LJ : 1 μg /ml

Critical conc. LJ : 1 μg/ml

7H11 & BACTEC : 0. 5 μg/ml

No of strains : 55 (oflox-Res 33; Susc 22)

Method of testing : MIC

Drugs tested : Spar, Oflo, Cipro, Lome,moxi & Gati

Media used : LJ & 7H11

RESULT : Fluoroquinolones exhibited cross resistance

at different levels.

MIC of quinolones were in the order of GTFX = MOXI >

SPFX > OFLX > CFLX > LMFX

TRC Study

J.Chemother,2005

Determination of MIC & Cross Determination of MIC & Cross resistance in resistance in M.tbM.tb

TRC study findingsTRC study findings

In vitroIn vitro MIC studies MIC studies

Quinolones showed low and similar MIC on both drug sens & resist. population of M.tb

Cipro showed higher mean MIC than Ofloxacin

Almost 100% cross resistance was seen

Ofloxacin MICs were lower than other quinolones tested

PST on LJ showed 2mg/l as a criterion of resistance for Ofloxacin

Absolute Concentration Method (Ofloxacin) :8mg/l

TRC study findingsTRC study findings

In vitroIn vitro simulation experiment with ofloxacin simulation experiment with ofloxacin

Showed high EBA either alone or in combinations on

exponential growth

Expect high bactericidal activity in the early phase of the

Rx

Comparatively low level of SA against stationary phase

growth

However, it enhanced activity in combination with H, R &

HR

Definition of resistance to QuinolonesDefinition of resistance to Quinolones

OFLO : NCCLS 2.0 µg/ml (7H10 & 7H11) TRC 8 µg/ml ACM (LJ) 2 µg/ml PST (LJ)

GATI : TRC 1 µg/ml – LJ; 0.5 & 0.25 (7H11 & BACTEC)

MOXI : TRC 1 µg/ml – (LJ); 0.5 (7H 11 & BACTEC)

Standardisation of DST to newer drugsStandardisation of DST to newer drugs

• NCCLS (2002) Guidelines :

7H10 & 7H 11: Capreo, Eth, Kan, Oflo, PAS, RBU & Strep

BACTEC : PZA

• Canetti etal (1969)& Various TRC Publications LJ : INH, Capreo, Amikacin,Rif,RBU, Kan, Eth, Cyclo

• TRC: Lomi, Cipro,Oflo,Gati & Moxi

• Developing SOP for country’s requirement

Type Geometric mean LJ 7H11 Sensitive(46) 63.97 26.73(SHR)

Resistant (46) 65.92 23.82(SHR/HR) Total (92) 65.01 25.23

MIC of S/A against sensitive and MIC of S/A against sensitive and resistant isolates of M.tuberculosisresistant isolates of M.tuberculosis

Microbios 89 135-141 1997 TRC study

SuggestionsSuggestions

Role of IQC and EQAP

Res. Pattern of strain Results obtained

Drug Pattern No. of tests

Agreement

No. %

S 

R

S232369

217367

93.599.5

HRS

381299

376286

98.795.7

RRS

384307

382305

99.599.3

E RS

282384

272383

96.599.7

K R S

46169

44168

95.799.4

OflRS

38219

36219

94.7100.0

TOTAL

TRC:IQC IN DST (June’98–Dec 2001)

Res. Pattern of strain Results obtained

Drug Pattern No. of tests

Agreement

No. %

S 

R

S334329

334323

10098.2

HRS

567138

567137

10099.3

RRS

417294

416292

99.899.3

E RS

268458

258457

96.399.8

K R S

28266

27261

96.498.1

OflRS

67296

63292

94.099.8

TOTAL

TRC:IQC IN DST (Jan’2003 – Dec 2004)

The role of DST in DECThe role of DST in DEC

Failures of category II cases under DOTFailures of category II cases under DOT

Tests should be very simple & rapid for

Primary culture

Identification &

DST

DST in DECDST in DEC Drug resistance surveillance

The tests should be as per global DRS guidelines

Identification Growth rate. Growth in 500 micrograms of PNB medium Niacin test / NO3 reduction test

DST Indirect economic variant of PST Other methods

Review of simple & rapid tests DST Review of simple & rapid tests DST for DECfor DEC

DirectDirect Primary culture

Sputum swab method Sputum deposit after processing by Petroff’s

Identification Growth in 500 micrograms of PNB medium

DST Standardization of direct PST only for H & R Absolute concentration method Resistance ratio method

? RIF. Resistance as an indicator of MDR TB

Direct methods

MABA

Nitrate reductase assay

MTT Assay

MODS

PhaB & Others

Role of speedier pheneotypic methods

DEFINITION OF RESISTANCE ON LJDEFINITION OF RESISTANCE ON LJSIMPLIFIED VARIANT – PST*SIMPLIFIED VARIANT – PST*

-----------------------------------------------------------DRUGS CONC.(µg/ml) PR (%)------------------------------------------------------------------------ INH 0.2 1 Strep. 4 10 Thioacetazone 2 10 ETH 20 10 Kana 20

10 Cyclo 30 10 Vio 30 10 Capreo 20 10 PZA 100 10 Emb 2 10 Rif 40 1-----------------------------------------------------------------------Only one conc. of drug Canetti et al. Bull. WHO. 1969

DRS – Salient ObservationsDRS – Salient ObservationsDRS – Salient ObservationsDRS – Salient Observations Among new cases : No evidence of an increase in the

prevalence of resistance

Reports on higher prevalence of ADR ( TRC findings, Gujarat, N.Arcot, N.Delhi, Tamilnadu ,Bombay, UP.)

TRC studies :Low level prevalence of MDR TB

TRC studies : Paediatric & Extra-pulmonary cases• low level resistance to H (5-10%)

• low level resistance to S (2-14%)

• absence of MDR TB

Compared to global situation

• a lesser prevalence of primary resistance

• a much higher level of acquired resistance is

observed

Issues to be consideredIssues to be considered Steps and Time Tables

Preparation of SOP

Culture system and methodology

Training

Organizing EQAP for second line drugs

IQC Measures (Drugs, Techniques, Periodicity, Monitoring)

Role of Speedier methods for DST of 2nd line drugs

Role of simpler phenotypic methods for detecting MDR TB

Rif. Resistance as an indicator for detecting MDR TB

DST for PZA – Its relevance

Multi - centric approach for defining resistance to various 2nd line drugs by different test systems