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In the early weeks of January 2012, a report of four cases of tuberculosis from Mumbai, India, stirred up a storm.1 India bears a giant's share of the world's multidrug-resistant tuberculosis (MDR-TB) burden, but these cases were different even though they came from a centre (Hinduja Hospital and Research Center) which has been reporting on the alarming escalation in drug-resistant TB in Mumbai over the last two decades. The four patients described in this report were resistant to all first-line (isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin) and second-line drugs (kanamycin, amikacin, capreomycin, ofloxacin, moxifloxacin, ethionamide and para-amino salicylic acid) to which they were tested. That the report came from Mumbai's most reputed mycobacterial laboratory, accredited for drug susceptibility testing (DST) by the Revised National TB Control Program (RNTCP), and serving as the de facto reference mycobacterial laboratory for the city added to the veracity of this report. The choice of the term ‘Totally Drug-Resistant’ for these four cases was found unpalatable by the Indian health authorities, who initially denied the very existence of ‘totally drug-resistant tuberculosis (TDR-TB)’. This, despite there being reports of strains with similar extreme patterns of resistance, from Italy and Iran in the past, none, however, having stirred up the hornet's nest of attention among media and health organisations as the Indian report did.2 ,3 The government's response of initial denial served only to stir up matters further. WHO, though more measured in its response, at a meeting of experts (TDR-TB: a WHO consultation on the diagnostic definition and treatment options) on March 20-21st, 2012, in Geneva, decided that there was not enough evidence to support the creation of yet another category of resistance (TDR), but admitted that patterns of resistance even more extreme than Extensively Drug-Resistant TB (XDR-TB) were being encountered, and were …
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