When XDR-TB spread in Mumbai, “lots of togetherness” led to a path of solutions

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Mumbai

credit: Khetarpal, Challenges of Urban TB & Approaches to Integrate Pulbic and Private Sector, Municipal Corporation of Greater Mumbai

In Mumbai, the challenges to controlling the spread of drug-resistant TB are as dense, diverse and sprawling as the place itself. A small dot on the map, it is a “mega city,” as Mumbai TB officer Dr. Minni Khetarpal notes. It is the economic capital of India, the most urbanized region, and an epicenter for tuberculosis and HIV. With 60 percent of the population crammed into crowded slum settlements, the city also is home to a wide range of cultures, languages and ethnicities. More than a third of the population are migrants, including street children and sex workers. The public health department makes the directly observed treatment for tuberculosis that is endorsed by the World Health Organization available, but unregulated, and in slum areas, unqualified, private practitioners make less effective treatment easy: take the pills, and go home.

In such an environment, how do you get accurate and timely diagnosis and treatment to the people who need it most, and curtail the spread of totally drug-resistant strains of disease?

“We are working like an army,” Dr. Khetarpal said. She attended a working meeting in Washington, DC last week, on public private mix models for controlling TB and gave a presentation on Mumbai’s efforts. Afterward, she talked to Science Speaks about the efforts in her city that have tackled climbing rates of drug-resistant TB and seen payoffs in public perceptions of the disease and resources dedicated to it. “Only because we are working together we are able to reach so many people,” she said.

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A newspaper photo celebrates the involvement of Bollywood icon Amitabh Bachchan (on left) with Dr. Minni Khetarpal, (right)

She credits Mumbai Executive Health Officer Dr. Arun Bamne with leading an effort that, with support from USAID and international agencies has involved the city’s mayor, its administrator, as well as community and corporate-based support, and, not least, Bollywood cinema icon, “Big B” Amitabh Bachchan’s role as the face of the city’s TB control program. “We can’t have only the funding agencies doing the work,” Khetarpal said.

She flipped through headlines inspired by the panic of 2012 when 1,679 cases of multidrug-resistant tuberculosis were diagnosed, and 32 cases of extensively drug resistant cases were recorded for the first time. ” . . . facility dealing with resignations, transfer requests,” one headline says, “Worried docs want out of TB hospital.”

For all of that, Khetarpal, appointed to Mumbai TB officer in early 2012,  says sincerely, “It’s a very exciting time in TB control.”

The municipal response that began immediately, she said, included engagement with private practitioners. “The behavior of the doctors (in the private sector) is very difficult to change,” she said. But she added, for the poorest people, the nearest practitioner is the first resort, and, “unless we reach out to the poorest, unless we are able to reach them, we will not succeed against TB.”

The systematic approach to “slum TB control” included identifying the highest risk areas, listing the private practitioners in those areas, enlisting the aid of more than 4,000 providers of directly observed treatment. Where 650 private facilities provided directly observed treatment in 2012, 1,631 do now. Initial house to house screening of more than 6,500 people led to more than 1,400 diagnoses of multi-drug resistant tuberculosis, according to a September 2012 report.

“We are now able to diagnose and put patients on treatment, curtailing the spread of drug-resistant tuberculosis,” Khetarpal said.

Among the resources the program now has to correctly diagnose TB and determine if it is drug-resistant, are 16 GeneXpert machines — six in public laboratories, 10 in private labs. “We have put the diagnostics in place,” Khetarpal said, “In two years that is a big achievement.”

Among the positive press the city’s efforts generated by March 24, 2014 — World TB Day — was a report on a new directory of doctors and nonprofits offering effective TB diagnostic and treatment services.

Challenges remain in a place that serves as a crossroads for speakers of dozens of languages, health challenges, and causes of marginalization, she acknowledges. Among them continued efforts to design and implement improved environments for infection control.

“Now we can see the path,” she said. “We have not reached the destination, but we know which way to go.”

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