Tuberculosis in India – Fighting the epidemic

I'm cutting and pasting material re:TB that I received today as an attachment to an email from Karishma Saran, Program Assistant, Global Health Strategies, New Delhi. There is much merit in this material. But note my comments in blue! I think these people don't understand KEY aspects of health policy, and are chanting slogans against private doctors when the reality is that all doctors can do better. In particular, my take is that doctors tend to treat patients as fools and refuse to explain the necessity of taking the proper dose of drugs in the case of TB. That means patients often get off the required dosage before TB is cured.

TB in India

TB is one of India’s greatest public health challenges. India has the highest burden of TB in the world, accounting for one-fifth of the global incidence – 2 million cases annually. TB kills close to 280,000 men, women and children every year, and is one of the leading causes of death in India. A communicable disease, TB spreads through the air; if left untreated, a person with active TB can infect 10-15 people every year.1
 
TB is the cause of extensive economic losses and individual, family and community suffering.  The direct and indirect costs of TB, in the case of India, stand at $23.7 billion annually.2 Moreover, TB continues to be highly stigmatized, often leading to discrimination within both the community and the workplace. It also disproportionately affects the poor and disadvantaged leading to loss of livelihood and creating a cycle of poverty.

India’s TB Strategy

The Revised National Tuberculosis Control Programme (RNTCP) under the Ministry of Health is the primary body coordinating TB prevention, control and treatment in India. The strategy of Directly Observed Treatment, Short-course (DOTS), recommended by the World Health Organisation (WHO) based largely on research done in India, has been successfully implemented under the RNTCP, leading to approximately 9 out of 10 patients being cured. For the past four years, the programme has consistently achieved the global benchmark of 70% case detection and 85% cure of new smear positive patients.

However, despite these successes, TB continues to affect people at an alarming rate in India. For more effective TB control, India must ensure universal access to high quality TB diagnosis and treatment for all 

India’s Key Challenges for TB Control

Ineffective TB Diagnostics: The most widely used method of TB diagnosis in India (sputum smear microscopy) misses more than half of all cases.3 Ineffective and inaccurate diagnostics not only lead to patient suffering but also speed the spread of the infection. Alternatively, if patients are misdiag­nosed with TB, they can undergo six months of unnecessary toxic treatment.
 
In the private sector, ineffective TB diagnostics is a lucrative market. [Sanjeev: This is a below the belt attack on the private sector that I don't agree with! I don't see any reason why private doctors are particularly incompetent. BOTH government and private sector doctors fare equally in this regard.] Patients in the private sector are commonly subjected to serological (antibody) tests that have poor sensitivity and specificity for TB diagnosis. Therefore, false-positive and false-negative results are common, leading to patient suffering and loss of resources. [Sanjeev: This just reaffirms my general points, made recently, about the seriously deficiencies in the medical profession.]
 
There are new and more effective diagnostic technologies approved by the WHO that have been introduced globally. [Sanjeev: It would have been nice to know what are theese techniques] India needs to make immediate efforts to improve techniques for diagnosing TB in the public sector by introducing new technologies [Sanjeev: why the PUBLIC SECTOR!!]. It also needs to regulate private sector’s indiscriminate use of ineffective diagnostics. [Sanjeev: Once again, the public sector is apparently to be given special benefits while the private sector must be regulated! I suggest that we totally eliminate the public sector in health services and regulate and fund health care according to the model outlined in BFN.]
 
Irrational use of anti- TB drugs outside the RNTCP: With a large population accessing the medical services outside the RNTCP sphere, large-scale distribution of anti- TB drugs has become rampant. This has harmful implications for patients.  All drug-resistance in TB is man-made, caused by inappropriate use of anti-TB drugs. That means providers who use non-standard regimens, prescribe non-quality assured drugs, make patients pay for drugs which they may not be able to afford, and provide treatment without ensuring patient adherence through supportive supervision. Though there are clear regulations around the sale and dispensation of over the counter sale of anti- TB drugs, they remain weakly implemented. [Sanjeev: I've read somewhere that the problem is that doctors don't educate their patients properly. Patients are not stupid. Doctors need to spend more time to educate their patients].
 
Drug-resistant TB:This is a TB disease type that shows no response to first line anti-TB drugs. It develops when the TB drug regimen is poorly administered, or when patients stop taking their medicines before the disease has been fully treated. Multidrug-Resistant TB (MDR-TB) is defined by resistance to the two most commonly used drugs: Isoniazid and Rifampicin. More than 5% of the world’s TB cases may be MDR, and 5% of those may be Extensively Drug Resistant-TB (XDR-TB), a virtually incurable form of TB
 
MDR-TB can transform into XDR-TB through inadequate or interrupted treatment with second-line anti-TB drugs. The treatment for MDR-TB is extremely complex, expensive and has terrible side effects. India and China are currently home to 50% of the globe's multidrug-resistant TB (MDR- TB) cases, 4 and this represents a growing challenge for India’s TB Control.
                                      
HIV-TB co-infection:TB is the leading cause of mortality in people living with HIV/AIDS. In 2009, an estimated 2.39 million people in India are living with HIV/AIDS, while an estimated 4.85% of TB patients are also HIV positive. 5There are selected pockets especially in states like Tamilnadu, Andhra Pradesh and Maharashtra, where the co- infection rate is high. A vital problem faced by patients continues to be the lack of access to Anti Retroviral Treatment (ART) drugs. People living with HIV/AIDS (PLHAs) also suffer the inconvenience of two separate testing centers, and the need for multiple testing appointments, the cost of transport, and lost income may prohibit many from getting their TB test done early.
 
Socio- Economic Impact:TB primarily affects people in their most productive years of life. Almost 70% of TB patients are between the ages of 15 to 54 years. The disease is common among the poorest and most marginalized sections of the community. It also takes a disproportionately large toll on young females, with more than 50% of female cases occurring before 34 years of age. Thus, the disease has considerable socio-economic consequences. The vast majority (more than 90%) of the economic burden of TB in India is caused by the loss of life rather than by morbidity. This is because TB mortality incurs a greater loss in the number of life-years compared to TB morbidity– despite the fact that there are many more prevalent cases than deaths.
 
Weak regulatory mechanisms: The lack of effective regulation has led to extensive misuse of serological antibody tests in the private sector – an estimated $15 million are spent on these tests every year.6 This leads to misdiagnosis and delayed treatment. Further, only a fraction of estimated TB cases are identified by private practitioners. There is an urgent need to create appropriate regulation for the private sector for TB control in India. Only when regulations are tighter, for reporting as well as treatment, will there be a possibility to reverse the epidemic. [Sanjeev: I think this post, for all the utility it offers, is turning into a diatribe against the private sector, and excuses the public sector of its even greater failures. This article does not represent a balanced position.]
 
What can you do?
 
As your blog is widely read by the Indian public you can be a TB spokesperson and support the creation of awareness around this issue by frequently blogging about this issue.

Conclusion

TB is easily cured if accurately detected and treated on time. [Sanjeev: I'm no longer sure! First the writer says that there is Drug-resistant TB, then he says treating TB is easy!] However, it continues to be a public health challenge for India. As responsible citizens, we appeal to you to take steps to counter the growing menace of TB in India. Every patient is vital and needs to be protected from this disease.
 
References
1.       TBC India http://www.tbcindia.org/key.asp
2.       Directorate General of Health Services, Ministry of Health and Family Welfare, ‘TB India 2011, RNTCP Status Report’ 2011 http://www.tbcindia.org/pdfs/RNTCP%20TB%20India%202011.pdf
3.       Stop TB Partnership, www.stoptb.org/global/research/funding.asp
4.       Kounteya Sinha, ‘India, China account for 50% of global MDR-TB cases’, Times of India, March 20, 2010 http://articles.timesofindia.indiatimes.com/2010-03-20/india/28117115_1_xdr-tb-mdr-tb-patients-mdr-tb
5.       Directorate General of Health Services, Ministry of Health and Family Welfare, ‘TB India 2011, RNTCP Status Report’ 2011 http://www.tbcindia.org/pdfs/RNTCP%20TB%20India%202011.pdf
6.       Madhukar Pai, National Med J India, 2011