The staggering numbers are enough to tell India’s tuberculosis (TB)-control story: in 2012, 1.47 million people with TB, 14,059 with multidrug-resistant (MDR) TB and 131 with extensively drug-resistant (XDR) TB were treated free across 692 districts and 35 states and Union Territories. And, with an annual budget of R710 crore, the Revised National TB Control Programme (RNTCP) tested 55 million people and treated 15.8 million since its inception in 1997.
Now, the RNTCP, perhaps India’s most successful public health programme after Pulse Polio, is getting a booster shot with the health ministry’s proposed new Standards for Tuberculosis Care in India, which not only streamline diagnosis, treatment and care protocols but also include standards for social inclusion to help marginalised people and communities get treated.
Once the proposals get the Centre’s nod, patients will receive travel costs and coupons for food rations along with their “patient-wise boxes” that contain the full course of medicines customised according to the patient’s age, weight and diagnosis. Since treating TB takes six to nine months, MDR TB treatment takes 24-27 months and XDR TB up to 30 months, giving patients boxes with all their medicines ensures that people once placed under treatment keep having medicines uninterrupted, which reduces transmission, ensures cure and prevents the emergence and spread of drug-resistant TB.
Also ensuring better compliance to the complete treatment regimen, is Nikshay, a digital database to track and manage the treatment of mobile populations being treated free under the programme. It enables near real-time reporting of new cases and ensures optimal case management, especially in inaccessible areas and places where there is high mobility and patients often do not go back to the same health centre for follow-up treatment. A TB-infected person can infect 10 or more people in one year. India accounts for 26% of the 8.7 million global cases, followed by China with 12%.
TB, which continues to kills more people than AIDS, sexually-transmitted diseases, malaria, leprosy and tropical diseases combined, can easily be controlled using first-line drugs, with the cost of treatment per person beginning at R600. But if the person develops drug resistance, treatment costs shoot up substantially, with treating one person with XDR costing up to R2.7 lakh. Till March 2013, 25,727 people were being treated free for MDR TB, a sharp jump from 14,059 last year (2.2%), though it is still low compared to worldwide prevalence of 3.7% of new cases.
Treating uncomplicated TB involves using a six-month regimen of four first-line drugs: isoniazid, rifampicin, ethambutol and pyrazinamide. Treatment of MDR-TB (defined as resistance to isoniazid and rifampicin, the two most potent anti-TB drugs) is longer, and needs more expensive and toxic drugs. All TB drugs recommended by the World Health Organization (WHO) are currently out of patent-protection and freely manufactured by generic bulk drug companies. Currently, one dozen WHO–approved TB drugs are being manufactured in India, which helps meet shortages quickly, as it happened last month when the buffer stock of one paediatric TB drug dropped to two months, prompting emergency procurement that is refurbishing stocks till the end of 2013 by July 15.
Though TB was made a notifiable disease in May 2012, which makes it mandatory for all private hospitals and clinics to report cases to the government, the biggest challenge remains regulating the private sector, where doctors and quacks continue to prescribe medicines in wrong strengths and combinations. Add to this the high cost of treating MDR and XDR in the private sector and you have people stopping treatment soon after their symptoms disappear, which usually happens within the first couple of months. As much as standards for TB care, what is needed is better regulation of the private sector if it wants the TB-control programme to stay on track. For, without treatment, studies of the natural history of TB show around 70% infected died within 10 years, reports the Global TB Report 2012. And it’s for the Centre to ensure that everyone with this easily curable infection gets their ‘patient-wise box’ when and where they need it.