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competent host. Am J Respir Crit Care whom reside in overcrowded slums. The AIDS in adults in Med 1999;160:1366–8. Since 1990, a resurgence of TB has has adversely affected the 6. Ward MS Lam KV, Cannell PK, Herrmann occurred, characterized by a 70% to epidemic within the population of RP. Mycobacterial central venous catheter tunnel : a difficult problem. Bone 140% increase in the rate of TB- children with TB. HIV infection in Marrow Transplant 1999;24:325–9. related deaths among adults aged 25– young adults has resulted in a large 7. Telenti A, Marchesi F, Balz M, Bally F, 44 years (3). A vital factor contribut- number of HIV-infected infants, the Bottger EC, Bodmer T. Rapid identification ing to this phenomenon is HIV infec- result of a lack of any large-scale pro- of mycobacteria to the species level by tion. A recent review of autopsy gram aimed at preventing vertical polymerase chain reaction and restriction enzyme analysis. J Clin Microbiol reports from Mumbai showed that 85 transmission. To combat the growing 1993;31:175–8. (59%) of 143 adult patients with AIDS problem with HIV-infected infants, 8. Roth A, Reischl U, Streubel A, Naumann were diagnosed with pulmonary TB India’s National AIDS Control Orga- L, Kroppenstedt RM, Habicht M, et al. (4), indicating that the is the nization is performing feasibility stud- Novel diagnostic algorithm for identifica- most common opportunistic infection ies for implementing interventions to tion of mycobacteria using genus-specific amplification of the 16S-23S rRNA gene for persons with AIDS. Commensu- prevent mother-to-child transmission spacer and restriction endonucleases. J Clin rate with the increase in TB cases is a of HIV infection. Clinical trials with Microbiol 2000;38:1094–104. surge in the prevalence of multidrug- nevirapine are currently being con- resistant TB in adult patients. Two ref- ducted at five major public hospitals erence mycobacterial laboratories in in Mumbai. Address for correspondence: Jorge Luiz Mello Sampaio, Fleury–Centers for Diagnostic Medi- private hospitals in Mumbai have Multidrug-resistant TB frequently cine, Microbiology Section, Av. General Wal- reported a high prevalence of multi- develops in adult AIDS patients (7). domiro de Lima 508, São Paulo, Brazil 04344- drug-resistant TB strains; 56 (11%) of Accordingly, many pediatric AIDS 070; fax: 55 11 50147601; e-mail: jorge.sam- 521 cases in 1991–1995, and 58 (58%) patients in Mumbai are also develop- [email protected]. of 100 cases in 1994–1995 (5,6). ing primary multidrug-resistant TB. The crisis of multidrug-resistant Since most families cannot afford anti- TB in adults in Mumbai has been well retroviral therapy, HIV-infected chil- Children and documented (7). However, little atten- dren in whom TB is diagnosed are tion has been directed at children also prescribed a four-drug TB treatment Multidrug-Resistant affected by the resurgent TB epi- (consisting of , , in demic. We think that TB is developing , and ) and Mumbai (Bombay), in more children in Mumbai today co-trimoxazole for Pneumocystis cari- than a decade earlier. Moreover, close nii pneumonia prophylaxis. Although India proximity to adult patients with multi- deaths in these children are being drug-resistant TB makes children attributed to AIDS, we think that To the Editor: India has the high- prone to developing primary multi- many of these deaths are related to est number of tuberculosis (TB) cases drug-resistant TB, a vulnerability doc- multidrug-resistant TB. in the world. Each year in India, over umented in a South African study (8). To combat the TB epidemic, the 2 million new cases of TB are diag- Similarly, disseminated TB is occur- Revised National Tuberculosis Con- nosed, and approximately 500,000 ring in large numbers of children liv- trol Program directly observed treat- persons die of the disease (1). During ing in overcrowded slums in Mumbai ment strategy has been implemented the last decade, multidrug-resistant TB with a consequent high death rate (9); as part of a public health program. has burgeoned in India, resulting in an we attribute many of these deaths in However, most patients receive treat- extremely large number of multidrug- children to primary multidrug-resis- ment from private physicians and thus resistant TB cases, second only to the tant TB. However, this conclusion is remain outside the purview of the number of cases noted in Latvia (2). difficult to document, as most affected strategy. Private physicians seldom Since 1993, in response to this epi- children are sputum-negative for acid- refer their patients to centers offering demic, the government of India has fast bacilli. Contact tracing to detect directly observed treatments because implemented the Revised National the adult source of infection is rou- of potential for loss of income (3). In Tuberculosis Control Program, which tinely undertaken; often we can trace 1991, Uplekar and Shepard (10) is based on directly observed treat- the source of infection. Because the reported that 100 private physicians in ment (short course) principles (1). facilities for culture and susceptibility the Dharavi slums in Mumbai pre- Mumbai (formerly Bombay), testing are not available at affordable scribed 80 different anti-TB regimens; India, is a densely populated metropo- rates, proving that the adult contact most were both inappropriate and lis with a population of approximately has multidrug-resistant TB is not fea- expensive. Since private physicians 12 million, 4.8 million (40%) of sible in most cases. have not yet been involved in the gov-

1360 Emerging Infectious • Vol. 8, No. 11, November 2002 LETTERS ernment-run Revised National Tuber- multidrug-resistant TB to develop. We 5. Chowgule RV, Deodhar L. Pattern of sec- culosis Control Program, the situation suggest that this case is not unusual ondary acquired to antitu- today remains the same. and that many children in Mumbai are berculosis drug in Mumbai, India—1991– 1995. Indian J Chest Dis Allied Sci Although children are included in dying of multidrug-resistant TB 1998;40:23–31. the national control program, they do because directly observed treatment 6. Udwadia ZF, Hakimiyan A, Rodrigues C, not receive the benefit of directly strategy regimens are unavailable. Jillisgar T, Mehta A. A profile of drug- observed treatment strategy. The The multidrug-resistant TB crisis resistant tuberculosis in Bombay. Chest Revised National Tuberculosis Con- on Mumbai’s children warrants imme- 1996;110:228. 7. Udwadia ZF. India’s multidrug-resistant trol Program does not provide drugs in diate attention and action. We suggest tuberculosis crisis. Ann N Y Acad Sci syrup form or permit breaking of tab- that the directly observed treatment 2001;953:98–105. lets, making the administration of strategy should be made child-friendly 8. Schaaf HS, Gie RP, Kennedy M, Beyers N, accurate pediatric doses impossible. with anti-TB drugs made available in Hesseling PB, Donald PR. Evaluation of Most children with TB are also spu- suitable pediatric formulations. Pri- young children in contact with adult multi- drug-resistant pulmonary tuberculosis: a tum-smear negative for acid-fast vate physicians require education and 30-month follow-up. Pediatrics bacilli. Doctors must rely on clinical involvement in the treatment strategy. 2002;109:765–71. acumen when deciding whether or not BACTEC (BD Diagnostic Systems, 9. Karande S, Bhalke S, Kelkar A, Ahuja S, to start TB treatment. This lack of a Sparks, MD) culture and susceptibility Kulkarni M, Mathur M. Utility of clini- method for definitive diagnosis of TB testing to detect multidrug-resistant cally-directed selective screening to diag- nose HIV infection in hospitalized children in children makes treatment centers TB should be made available at in Bombay, India. J Trop Pediatr reluctant to enlist pediatric cases; as a affordable rates. Transmission of HIV 2002;48:149–55. result, these children attend general to newborns would be reduced by uni- 10. Uplekar MW, Shepard DS. Treatment of pediatric outpatient clinics every 28 versally implementing a prevention tuberculosis by private general practitio- days to obtain their TB medication. program for mother-to-child transmis- ners in India. Tubercle 1991;72:284–90. 11. Karande S, Kelkar A, Jagiasi A, Kulkarni Directly observed treatment strategy is sion at subsidized rates. Immediate M. Acquired multidrug-resistant tuberculo- not followed in the general outpatient action on these suggestions will lower sis in an immunocompetent adolescent. clinics. Hence, compliance with treat- the incidence of both TB and multi- Pediatr Infect Dis J 2002;21:577–8. ment depends on the motivation and drug-resistant TB and reduce the num- perseverance of the parents. Fre- ber of deaths from these diseases. Address for correspondence: Dr. Sandeep B. quently, one or more of the drugs is Bavdekar, A2-9, Worli Seaside Cooperative Sunil Karande*† out of stock, and parents must use Housing Society, Khan Abdul Gaffar Khan and Sandeep B. Bavdekar‡§ their own small resources to purchase Road, Worli, Mumbai 400 018, India; fax: 91- 22-414 34 35; e-mail: [email protected] the necessary medication. To avoid *Lokmanya Tilak Municipal Medical Col- long waits in the crowded general lege, Mumbai, India, †Lokmanya Tilak pediatric outpatient clinics, some par- Municipal General Hospital, Mumbai, India, Certificate of Knowledge ents intermittently purchase the anti- ‡Seth Gordhandas Sunderdas Medical Col- in Travel TB drugs from local chemists, who lege, Mumbai, India, and §King Edward VII Examination Memorial Hospital, Mumbai, India supply the drugs without a current pre- The International Society of Travel scription. This practice leads to fre- References Medicine (ISTM) will offer its first quent defaulting and inadequate 1. Agarwal SP. TB across the globe (2). international Certificate of Knowledge treatment. Tuberculosis in India—the past and pros- in Travel Medicine examination on May Since children in general have pects for the future. Scott Med J 7, 2003, before the opening of the 8th paucibacillary TB, secondary multi- 2000;45:11–3. ISTM Conference in New York City, on May 7–11. Those passing the exam will drug-resistant TB is considered less 2. Pablos-Mendez A, Raviglione MC, Laszlo A, Binkin N, Rieder HL, Bustreo F, et al. receive a Certificate in Travel Health. likely to develop in them, even when Global surveillance for antituberculosis- The exam is open to all licensed travel the treatment is inadequate. However, drug resistance, 1994–1997. World Health medicine practitioners, including physi- Karande et al. (11) describe a 12-year- Organization– International Union against cians, nurses, and pharmacists. old boy in Mumbai with secondary Tuberculosis and Disease Working To obtain more information on prep- aration for taking the exam, registration, multidrug-resistant TB. He had Group on Anti-Tuberculosis Drug Resis- tance Surveillance. N Engl J Med and a Candidate Bulletin of Information, received multiple courses of inade- 1998;338:1641–9. please access the ISTM website at quate treatment with various anti-TB 3. Hira SK, Srinivas Rao AS, Thanekar J. www.istm.org. Applicants may also con- treatment regimens for 9 years. The Evidence of AIDS-related mortality in tact Brenda Bagwell, ISTM Secretariat, TB gradually progressed in severity Mumbai, India. Lancet 1999;354:1175–6. P.O. Box 871089, Stone Mountain, GA, 30087-0028. USA. Telephone: 1-770- and was disseminated with the bacte- 4.Lanjewar DN, Duggal R. Pulmonary pathology in patients with AIDS: an 736-7060; fax: 1-770-736-6732; e-mail: rial load increasing sufficiently for autopsy study from Mumbai. HIV Med [email protected] 2001;2:266–71.

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