India’s TB control programme needs to engage the private sector
Most people in India think that tuberculosis (TB) is an old disease with little or no relevance in 2013. But, in fact, India reports over two million TB cases every year. It kills 280,000 men, women and children and is one of the leading causes of death in the country.
With the emergence of drug-resistant version, TB is becoming difficult to diagnose and treat. The most common form of drug-resistant TB is multi-drug resistant TB (MDR-TB), one that is resistant to isoniazid and rifampicin, two of the most important first-line antibiotics. More severe forms of resistance have been reported, including extensively drug-resistant TB and totally drug-resistant TB in Mumbai.
A 2012 Global TB Report by WHO estimated that 66,000 cases of MDR-TB emerge annually from the notified cases of pulmonary TB in India. Since the private sector in India does not routinely report all TB cases, the true figure may be higher, especially in urban hot spots.
Drug-resistance is generated by mismanagement of TB. If the treatment of patient is incorrect, interrupted or incomplete, the TB bacteria can become resistant to drugs. Drug resistance can also emerge when doctors prescribe the wrong treatment, the incorrect dose, or length of time for taking the drugs. MDR-TB requires extensive treatment (at least two years) with multiple, toxic, expensive drugs and outcomes are poor. So prevention must be priority.
Patients in India often seek care from informal and private sector providers, and delay in diagnosis is common. Research has shown India’s private sector is a source of mismanagement of TB and hence, drug resistance. India’s Revised National TB Control Programme (RNTCP) needs to evolve an inclusive business model to engage the private sector to ensure better quality of care. It also needs to improve its quality of care for patients with MDR-TB. Currently, most patients in the public sector do not get tested for drug-resistance unless they do not improve with a full course of treatment. The programme needs to scale up access to adequate drug-susceptibility testing and second-line drug treatment. New WHO-approved molecular tests can give drug-susceptibility results within hours.
What can we do?
To begin with, individuals with cough for more than two weeks must get their sputum tested. Sputum testing is available free via thousands of designated microscopy centres run by RNTCP. If patients seek care in the private sector, they must demand sputum testing over blood tests. For extra-pulmonary TB, specimens must be collected from the site of the disease. Once diagnosed with TB, the patient should take medications exactly as prescribed. Patients who cannot afford to buy drugs must seek treatment in the public sector where drugs are given free. Doctors, healthcare providers, pharmacies and labs must ensure quick and accurate diagnosis of MDR-TB, follow treatment, monitor patients’ response and make sure therapy is completed. Similarly, labs should stop use of inaccurate diagnostics for TB. The government recently banned use of antibody blood tests for diagnosing TB. Other blood tests such as “TB-Gold” are not meant to diagnose active TB; they are meant to detect latent TB infection. One in three Indians is latently infected. Doctors should not use such tests to start treatment for active TB.
The Indian drug market is unregulated and pharmacies often dispense TB drugs without a valid prescription. Recently, the US Food and Drug Administration approved Bedaquiline, the first new TB drug in over 40 years. However, before any new TB drug enters India, mechanisms must be put in place to ensure it does not get abused. We cannot afford to lose new TB drugs to drug-resistance.
Madhukar Pai is professor at McGill University in Montreal, Canada
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