Failure to deter or eradicate TB drug resistance occurred because of:
- Poor management in both public and private sectors in India.
- Private practice lacked regulation as well as qualified physicians and specialists in TB.
- And the MOST significant reason...Patients were administered anti-tuberculosis drugs without susceptibility testing to screen for selective drug resistance, known to occur from (previous) improper treatment.
India’s Revised National Tuberculosis Control Program (RNTCP) was known for its singular success, starting in 1996 with a directly observed treatment short-course (DOTS) program, but patients who failed treatment did not receive susceptibility testing that would have revealed MDR-TB, leading to the correct therapy. Instead, treatment with a single drug (streptomycin) was added to their first-line drugs, to which the TB had already developed resistance. This action was responsible for the resistance resulting in the XDR-TB, as well as strains resistant to all known drug treatments. Patients, having little recourse, often traveled widely looking for cures while spreading resistant strains throughout the country and beyond.
In 2012, the Indian government initially denied the existence of TB resistance to all known drugs until the WHO discussed the nomenclature at a special meeting in Geneva, where the incidence of cases beyond the resistance of XDR-TB was announced. Incomplete susceptibility testing clouded the interpretation of results by some private-care physicians. The RNTCP agreed to require mandatory notification of MDR- and XDR-TB by all clinics and laboratories in Mumbai, as well as enforcement of the DOTS program throughout India. Since then, the RNTCP has met regularly and published updated requirements for India's public health program, including mandatory reporting and use of specific drug regimens (some not yet approved for use in the US or Europe).