Dr Srinivas Rao Ghattamaneni is a senior MSF MDR-TB/HIV doctor who recently returned from Ukraine after serving there as a tuberculosis (TB) specialist. In Ukraine, MSF (Medecins Sans Frontieres or Doctors Without Borders) is providing drug-resistant TB (DR-TB) treatment in a prison setting, which, due to poor ventilation, is considered to be one of the most vulnerable spots when it comes to the spread of the disease.
Thirty-six-year-old Dr Srinivas Rao has been working with MSF since 2009. He started his career with MSF as a field doctor for MSF’s project in the border areas of Andhra Pradesh, Telangana and Chhattisgarh. Having worked for this project in different capacities for three years, Dr Srinivas went on to work as a TB doctor in MSF Uzbekistan treating patients with MDR-TB (multi-drug-resistant TB) or XDR-TB (extremely-drug-resistant TB) for a year. From March-December 2015, he worked in Swaziland where he played a pivotal role in operational research on DR-TB and was responsible for treating patients who needed emergency critical care.
Dr Rao’s most recent project was located in Ukraine where he went as a Project Medical Referent and worked in the prison to administer MDR-TB/XDR-TB treatment. Before joining MSF, he worked as a casualty medical officer in Durgabai Deshmukh Hospital and Kamineni Hospital, Hyderabad. He completed his MBBS from Ukraine and can speak English, Russian, Hindi and Telugu.
In an interview with India Medical Times, Dr Srinivas Rao shared his experience while treating TB patients in Ukraine prison.
Please tell us about your career so far, how did you end up with the MSF organization?
In 2004, I finished my medical studies in Ukraine and returned to Hyderabad to pursue internship. Back home, I worked with semi-corporate (co-owned by both public and private health sectors) and corporate hospitals to garner experience as a casualty doctor. I have also worked as a duty doctor at hospitals in Hyderabad.
I joined Doctors Without Borders or Medecins Sans Frontieres (MSF) in 2009 as a medical doctor in a primary healthcare project in my hometown, Bhadrachalam. In this region — bordering Andhra Pradesh, Chhattisgarh and Telangana — MSF runs mobile clinics to reach the remote populations to administer primary healthcare. As a professional, I always wanted to work for people who are medically neglected. Also, since I am a native of Andhra Pradesh, I know the context, diseases and most of the challenges faced by the people. As a doctor with MSF, I knew that I would be able to deliver medical services to those who need it the most. During my time in this project, I saw many anaemic pregnant women and malnourished children visiting our facilities and getting the required medical help. This particular region is notorious for high malaria cases and MSF has been actively treating patients through mobile clinics for over 10 years.
Tell us more about MSF and its activities. How does it help in healing beyond the horizon?
MSF is an international, independent medical humanitarian organisation, which delivers medical aid to people who need it the most. We deliver aid in over 65 countries worldwide, in conflict, disasters as well as those who have no or limited access to critical healthcare services. Our work in Nepal entailed setting up of an inflatable hospital within hours of the devastating earthquake. This hospital was equipped with all possible equipment to cater to the affected population. MSF also played a pivotal role in administering treatment during the 2014-15 Ebola outbreaks in West Africa. When it comes to treating people who are in need, MSF doesn’t consider borders or horizon. As doctors, we treat on the basis of medical need and nothing else.
In India, we work in Andhra Pradesh, Jammu & Kashmir, Bihar, Chhattisgarh, Delhi, Manipur, Maharashtra and Telangana.
You just returned from Ukraine treating prisoners, please share your experience with us.
The project in Ukraine is a complex project, which entails effectively diagnosing and appropriately treating MDR and XDR TB in prison and pre-trail detention centres. I was mainly managing the programme’s medical activities, but I also played the dual role of being an on-site doctor for a few months. It is a challenging project as we are targeting a specialized group of people confined to special setting – prisons. Being confined for a long-time also results in certain psychological problems in some of them. Further, getting diagnosed with TB as well as the prolonged treatment is a challenge for them given the deep-rooted stigma associated with the disease. Such issues made it challenging for us to administer treatment that too in a limited amount of time as we were not allowed to stay longer in the prison premises and had about four to five hours each day to cater to medical and psychosocial needs.
As with many TB patients, adherence was a challenge with prisoners too. For instance, MSF administers Directly Observed Short Course (DOTS) therapy to treat TB, wherein the drugs are to be taken under supervision. However, often patients, in this case in a prison, refused to take the treatment, as they detest supervision. This is why MSF also provides psycho-social support in order to help the patients to deal with the long and painful treatment, as well as to increase adherence.
Other challenges that hampered effective treatment were the crowded prison cells and no ventilation, which deterred infection control. Often, after a TB prisoner is released, he or she may need hospitalisation and follow-up until the completion of the treatment. However, the patient’s home may not be in proximity to MSF’s programme, in which case the distance becomes a challenge. With the help of local social workers, we support the TB patients to adapt to the community (by helping them to acquire social identity cards, preparing useful documents, talking to family to secure support for the patient, following up with medical doctors to update a patient chart for side effects and adherence issues, regular counselling over phone etc) for continued treatment post the release.
While following a standard protocol for TB treatment, MSF also distributes food, hearing-aid and glasses; organizes tournaments (chess, football) and movie screenings and also helps in creating volunteer groups to support other DR-TB patients as an incentive to strengthen TB treatment.
As far as diagnostics are concerned, we use GeneXpert to diagnose DR-TB, although sometimes shortage of cartridges is an issue, and for culture and drug susceptibility test (DST) we identify gaps in lab supplies. There also exist gaps in drug supply. MSF tries to support and fill these gaps. The same applies to HIV diagnosis and initiation of treatment wherein reagent shortage is common.
MDR-TB and XDR-TB are a nightmare to all the physicians, how did you manage those cases?
TB is curable, but managing MDR and XDR-TB is extremely challenging and complex. It requires a lot of patience since the treatment is prolonged and includes numerous side effects. Management of XDR-TB is even more complicated with less than 30 percent of success rate due to lack of effective drugs, long duration of treatment and severer side effects. TB patients need close follow up since the beginning of the treatment and timely management of side effects is also very crucial. Treatment of both these strains should be patient centred and comprehensive including psychosocial support, incentives and financial support if needed. We have been following this strategy for a very long time and after the treatment we follow up for over two years to monitor relapse. Hence, before I take on a patient, I try to know everything about him or her, including the environment at home, any issues at home which may influence the treatment as well as the financial health of the household.
If this protocol is not followed stringently, the patient may default treatment, given the severity of side effects, lose trust in treatment, get demotivated and worst of all develop further resistance to TB. Building trustful relationship with patients since the beginning and providing the assurance that TB is curable is key in TB management. Dispelling stigma within the family and community will greatly benefit one to complete treatment without frustration and discrimination.
At MSF, we follow a standard protocol to treat TB patients and always seek expert opinion for complicated MDR or XDR -TB cases for optimal regimen with the available drugs. If a patient is HIV co-infected, then MDR and/or XDR -TB management becomes even more complicated and challenging, as both the diseases need to be managed simultaneously and carefully. In co-infection, patients might experience pill burden (too many tablets to be consumed in a single dose; an MDR-TB patient consumes 14,600 pills during his or her treatment span of two years, this excludes HIV or other medications), other infections (as the immunity of a patient is at an all-time low) and worst of all, drug interactions (especially with HIV and TB drugs). So, when I treat MDR and XDR patients I have to be extremely careful, especially since there may be co-morbidities to manage (diabetes, hypertension, Hepatitis B and C) and closely monitor adherence as well as side effects.
Since MSF has its own supply of drugs we always manage to provide all essential drugs to patients when it comes to side effects and co-morbidities management. In most of MSF TB projects, we provide new drugs like Bedaquiline and Linezolid for XDR-TB patients in order to prevent mortality and decrease XDR-TB transmission.
MDR and XDR -TB management is not a single medical person’s responsibility. At MSF, it is a team-work. From the diagnosis until the end of treatment, stringent patient follow-up is conducted by an MSF team comprising a doctor, counsellor and an outreach team member. In case of any medical complication, the doctor also suggests ways to manage the patient. MSF provides free diagnosis, treatment and drugs; counselling is provided regularly and home assessment is conducted by the outreach team. Follow-up also includes regular contact screening (considering TB is airborne and highly contagious); monthly food parcels, other incentives such as transport money and books. For instance, in Uzbekistan where I served as a TB specialist, we offered plastic cards, which are widely accepted as a form of money. In Swaziland, MSF pays $15 per month to a patient’s peer supporter to look after the affected. MSF trains the peer supporters to give support to MDR/XDR -TB patient for the entire duration of the treatment as well as organize support groups among TB patients to share and express their concerns, experiences and support for each other. However, it is critical that the doctor is aware of the patient’s history, requirements, his or her economy, such that tailor-made incentive packages can be created and offered. One has to play the dual role of a doctor as well as a counsellor.
Further, MSF is also treating MDR patients with short course regimen (9-12 months), which showed very good results in Swaziland. Also, the World Health Organisation (WHO) endorsed short course regimen for eligible patients recently, which if rolled out in all countries, will decrease duration and subsequently the side effects and possible good adherence with less default rate. So, the future looks promising for MDR as well as XDR -TB with the new drugs.
What, according to you, would help prevent drug resistance in TB?
The most critical aspect to prevent drug-resistant TB is treatment adherence, although prevention is not only restricted to this aspect. Challenges begin at the diagnosis level. When a patient is suspected to have TB, the first step is to take into account the complete history of the patient and then prescribe a GeneXpert, which is a rapid diagnostic tool and can provide the test results within two hours. This test can also determine if the patient has DS-TB (drug-sensitive TB) or DR-TB (drug-resistant TB). Increased uptake and roll out of GeneXpert has been recommended and endorsed by the WHO. However, ineffective diagnostic techniques are being rampantly used to diagnose TB and patients are being repeatedly treated with wrong and ineffective regimens.
Further, the private health sector continues to remain the first point of care. Ineffective diagnosis, inappropriate treatment regimens, quacks, lack of quality drugs, over-the-counter selling of TB drugs are some of the examples in the private sector, which perpetuate transmission of TB.
Most commonly used antibiotics like Levofloxacin, Moxifloxacin, Amoxiclav and injectable(s) like Amikacin and Kanamycin are key dugs in treating MDR-TB. New antibiotic Linezolid is considered as a potential drug to treat XDR-TB patients. However, in the absence of proper diagnosis and over usage of the above mentioned antibiotics as well as over the counter selling of the drugs can prove harmful for TB patients. It only leads to developing the resistance and further complications.
If this wasn’t enough, TB patients once put on treatment do not adhere to the regimen. This is because of a variety of reasons. Firstly, after a couple of doses the patients start to feel better and hence treatment is interrupted. Secondly, stigma, which often leads to discrimination (patients try to hide the disease or don’t take the treatment to avoid discrimination), deters patients from going to the health facility to take medicines under supervision. Thirdly, patients have to visit the health facility regularly, (and every day if taking injections), which leads to loss of livelihood. In case patients are buying TB drugs every month from the private sector, then the treatment turns out to be a costly affair. This further perpetuates debt traps and in turn the vicious cycle of poverty. Further, crowded spaces and lack of ventilation also fuels TB transmission. It is estimated that one TB patient can potentially infect 10-15 people in a year.
Early diagnosis and uninterrupted treatment is key to control and prevent DR-TB. Countries need to strengthen their TB programmes, rollout sophisticated diagnostic techniques as well as correct treatment regimen of DR-TB. Additionally, raising awareness among the community about TB and how it can turn resistant is another very important step, which can be undertaken to reduce DR-TB transmission and burden.
At MSF TB projects, apart from providing incentives we also renovated the houses of the patients to ensure ample ventilation, sunlight and sanitation to avoid the family members from getting infected with TB. Educating the patient about his or her diagnosis is another important step to prevent developing resistance. As a doctor, I always explain the entire process — from the diagnosis to the ways of developing resistance due to non-adherence — to increase awareness about TB, and provide assurance that he or she will get support from a team.
TB is an ancient disease still having its head high among the human race. Do you think there’s a remote chance of getting rid of TB completely like small pox?
TB is a global public health challenge, so the solution has to be an international one too. The strengthening of TB programmes in high burden countries carries highest importance. Every disease has a different science. TB is curable. However, absolute eradication is a bit ambitious considering it is air-borne and highly contagious. As reiterated previously, the earlier it is diagnosed the sooner it is treated and hence transmission can be controlled. However, TB is not just one country’s problem. According to the WHO’ End TB Strategy, TB deaths are to be reduced to 95 percent by 2035. In order to achieve this goal, all countries must come together and prioritise TB as an emergency. There is an urgent need to roll out stricter policies to contain the spread of DR-TB. Increased allocation of budget to TB, rolling out diagnostic tools like GeneXpert, culture-based diagnostic methods like liquid medium culture and DST in labs, uninterrupted drug supply and procurement of new drugs, research and development of cost effective strategies (including vaccination) as well as a concerted effort to spread awareness about the disease (do’s and don’ts) need to be rolled out.
Additionally, the recent endorsement by the WHO on the need to uptake a shorter (nine-month) DR-TB regimen needs to be considered by all countries. TB is a most common opportunistic infection among HIV infected people, so regular screening and prophylaxis for TB is recommended for these patients to stop developing active TB disease and further decrease mortality (TB is a leading cause of death among HIV patients).
The word TB is almost always associated with the respiratory system, but the extra-pulmonary cases are as bad too like the lymphadenitis for example. Tell us something about that and its way of treatment.
TB can affect any organ in the body. Extra-pulmonary TB or EP-TB occurs when TB develops outside the lungs (pleura, meninges, joints, spinal cord, lymph nodes etc). In a single patient both forms of TB can exist. EP-TB is more common in HIV co-infected patients but its occurrence is less common than pulmonary TB. The challenge with EP-TB lies in diagnosis and especially in children where the child’s contact history, contact screening, immunity, health of the lungs form the basis of diagnosis. We see EP-TB in the form of lymphadenitis but then lymphadenitis is very common among children due to other bacterial or viral infections. The most common form I have seen of EP-TB is in lymph nodes in HIV co-infected patients.
Once diagnosed, the treatment is not very different from the standard TB treatment except that the duration varies. For instance, TB meningitis, even if it is drug sensitive, is treated for 9-12 months. What also needs to be considered here is that every country has a different protocol when it comes to diagnosing and treating TB. Even the TB epidemiology varies from place to place — sometimes DR-EP-TB is also seen; plus a lot is dependent on the physician himself when it comes to case-to-case management. It is important to note that with the help of GeneXpert it becomes easy to determine drug resistance in EP-TB cases.
Another question that comes in every junior doctor’s or medical student’s mind is: “What if the patient coughs up on me while I’m examining him? Won’t I get TB?” And the other paranoid situation — a slight cold or cough for two days and they think “Oh my god! I’ve got TB”. As funny as it seems, it’s quite an issue to be addressed. Please help our readers in this regard.
One-third of the world is infected with TB but not all infected people are sick with active TB; we all run a risk of 10 percent, throughout our lifespan, of developing TB in general population. The most vulnerable populations include HIV patients, children and pregnant women, people who have a compromised immunity, older population, smokers, and diabetics, amongst others. Especially in a country like India, which is so densely populated, 40-50 percent of various populations harbour the bacteria in the body. This is called latent TB infection (LTBI). Please note that harbouring the bacteria doesn’t mean that we have the disease. However, the moment one’s immunity weakens he or she can develop TB.
It’s true the healthcare workers are at great risk of exposure to TB. However, there are always chances that people get infected in other places too apart from hospital — imagine an undiagnosed coughing person in a closed movie theatre or airplane or in a bus. The more the TB bacteria coughed or sneezed, the more the risk of transmitting it to others; it mostly depends on the patient’s bacillary load.
MSF protocols warrant the staff to use Personal Protective Equipment (PPE) mandatorily. The patients need to wear surgical masks even if he or she is a suspected TB patient. Doctors in turn are supposed to wear respirators. Ventilated rooms, stringent infection control measurements, including ensuring that all windows of the room are open and that the wind must blow in the direction of the patient, are some of the examples of a hindered infection transmission. It is vital that healthcare professionals are trained in protecting themselves. They should also be in a position to teach the community some cough etiquettes.
You had finished your medical studies in Ukraine. How was your experience when you got back here? Did you face any difficulties?
India is my home. As a professional, I had no difficulties in getting back to this life. I am quite used to it. Also, when I returned I was in a learning phase. I focused on my internship and learned a lot as a casualty doctor in Hyderabad.
Would you like to say something to our readers?
I am grateful when I see undergraduate MBBS students’ will to devote their time and energy to people who needs it the most. I would urge you all to know more about MSF India and join our cause of delivering medical assistance to those who need it the most. You can donate. Our doors are always open to volunteer doctors who are looking for an adventure and are passionate about saving lives, no matter what. We also believe in speaking out and are vehemently pushing the international community to provide answers in light of consistent attacks on MSF or MSF supported hospitals around the globe. We also advocate for access to cheaper drugs. However, all this cannot be done alone, your support is solicited. Thank you!
by Usha Nandini