Scepticism shrouds India’s tuberculosis target
August and September were especially bad months for tuberculosis patients in Delhi.
Many of the 60,000 people who avail free medicines from nearly 200 DOTS (directly observed treatment short-course) centres in the city had to return empty-handed during that period, when a number of contractual National Health Mission (NHM) employees went on a 50-day strike. The few who managed to get the medicines did so by travelling an additional five-seven kilometres to associated clinics that functioned under increased pressure. DOTS is widely accepted as the best way to treat tuberculosis, but two of the pillars it is built around are the uninterrupted supply of medicines, and ensuring that the correct medicines are taken at the correct time.
“The NHM operates around 60% of the DOTS centres here, and even with permanent staffers and NGOs helping out, nearly two-thirds remained closed,” said an employee at a DOTS provider at a South Delhi clinic on the condition of anonymity. “The (medicine) compliance was less than 50%, but we’ll know more only after patients’ records are reviewed.”
With each DOTS centre providing medicines to anywhere between 100 and 300 patients, the strike resulted in thousands missing doses , having it without medical supervision, or continuing treatment even after the course had ended.
Interrupted treatment harms not only the patient’s health but also India’s goal to eliminate tuberculosis by 2025 (against the global target of 2030). The government, however, believes there is little cause for worry.
“Patients were given medicines for a week to 10 days (in advance), and they came back soon afterwards. We do not expect too much damage,” said Dr Ashwini Khanna, Delhi’s tuberculosis programme officer.
A senior health ministry official echoed his opinion. “We have created our own benchmark of reducing the new infection rate by 90% and deaths by 95%, with 2015 as the baseline, before 2025. Once this target is achieved, we will automatically reach a stage where new infections figure at less than one case per one-lakh population,” he said.
The World Health Organisation’s TB Report-2017 stated that India — with 2.79 million cases, 4.23 lakh deaths, and an average of 211 new infections diagnosed per 100,000 people — has the highest number of tuberculosis patients across the globe. Elimination, defined as restricting new infections to less than one case per 100,000 people, is possible only if patients get diagnosed and cured without any break in treatment. Interruptions can exponentially raise the patient’s risk of developing multidrug-resistant tuberculosis (MDR-TB), which is harder to treat.
Tuberculosis is a highly infectious disease that is cured by providing each patient proper medication at the right time for the full duration of the treatment. The drug regimen, called DOTS and provided free under the Revised National TB Control Programme (RNTCP), is based on the principle that a regular and uninterrupted supply of high quality anti-tuberculosis drugs must be administered to cure the disease and prevent the occurrence of the MRD-TB.
Missing prescription doses defeats the very purpose of DOTS therapy, which is meant to ensure strict compliance through supervised consumption of medicines. And yet, as many as 900,000 people with the disease are not getting proper treatment, which means they risk developing drug-resistance tuberculosis and infecting others.
Ten countries account for 76% of the gap between the incidence of tuberculosis and reported cases, with India topping the list at 25%, followed by Indonesia at 16% and Nigeria at 8%. Given the unfavourable scenario, not many medical experts believe India can achieve the target it has chalked out for itself.
“TB elimination by 2025 is a seductive mantra, but one that is unlikely to materialise soon. India not only has the most MDR-TB patients in the world but also the largest number of ‘missing’ tuberculosis patients. Several million people who have not been identified, notified or treated still remain off the radar,” said Dr Zarir F Udwadia, consultant chest physician at Mumbai’s PD Hinduja Hospital.
Udwadia said patients who are undiagnosed or treated late continue to spread tuberculosis in the country. “With each such patient infecting 10 or more healthy people a year in our extremely crowded environments, India has a potential epidemic on its hands,” said the doctor, who has done extensive work on MDR-TB.
WHO estimates that India has around 147,000 of the 490,000 people believed to be suffering from MDR-TB worldwide. More worrying is the fact that India also accounts for close to a third of the world’s 8,014 extensively drug-resistant tuberculosis (XDR-TB) cases, which are resistant to at least three of the six classes of second-line anti-TB drugs. “The unregulated private sector is our biggest challenge as many don’t notify cases or follow the standard TB treatment protocol. Nearly 60% patients go to the private sector for treatment before approaching the public sector, which makes tracking cases difficult,” said Dr Sunil Khaparde, deputy director general (TB), Union ministry of health and family welfare. To track missing cases, the health ministry has identified 189 high-focus districts where door-to-door screening is being done. “We are also focusing on creating awareness, so people with symptoms of the disease can get themselves tested,” said Dr Khaparde.
Nineteen high-burden states have also been asked to conduct universal drug-susceptibility tests on all diagnosed TB patients. “We have observed that the average period between the first time a patient coughs and the correct diagnosis of an MDR-TB case is 6.2 months. The GeneXpert test can diagnose it in a few hours, but – sadly – it is not as widely used as it should be,” said Dr Udwadia.
Ministry officials remain cautiously optimistic. “It may sound unlikely that India will be able to eliminate tuberculosis by 2025, but unlike earlier, at least we are talking about it now. We are reducing tuberculosis by 2% per year, while the need is to reduce it by 21%. It’s a good interim target to have, so we can curb the disease significantly,” said Dr Soumya Swaminathan, former director general of the Indian Council of Medical Research.
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