Tuberculosis treatment faces drop-outs test in Mumbai
In most cases, the reasons for dropping out are social, economic or personal.mumbai Updated: Mar 26, 2018 10:28 IST
Every year around 2,000 tuberculosis (TB) patients drop out of treatment in Mumbai. These patients not only put their own lives at risk, but also expose healthy people around them to the disease, and often with drug-resistant forms that are more difficult to treat. In most cases, the reasons for dropping out are social, economic or personal.
While officials from the government’s Revised National Tuberculosis Control Programme, where diagnosis and treatment are offered free, actively chase these patients – called loss to follow-up cases – the job of persuading them to resume treatment is a tough one.
In Kajupada, Kurla, an area where 80% of residents live in slums, 30-year-old Ganesh, a chronic alcoholic who weighs only 35kg, spends most of his day sleeping on the second floor of a small shanty, which he shares with his elder brother and the latter’s family – wife and a 10-year-old son – who live on the ground floor.
An electrician, Ganesh was diagnosed with TB during Diwali last year. His incessant coughing and drastic weight loss were the first signs of the disease. At a local municipal health post, he was diagnosed with a drug-sensitive TB – an easily treatable form – and was prescribed medicines, a course that he was supposed to take for six months, two tablets a day.
However, in three months, after the cough subsided and Ganesh felt relief, he stopped taking the medicines. “I am feeling better now, so I have stopped taking the medicines,” he told the local health officials, who were tracking his intake of medicines.
When Ganesh failed to update the officials about his daily intake of medicines through the phone call system, as per the Directly Observed Treatment short-course (DOTS) 99 programme, the local health officials had to visit Ganesh and put him back on medication.
Under DOTS 99, patients make a free call each time they take their medication, so that providers can monitor adherence records, without the patients having to visit them.
Ganesh, along with TB, is also battling alcoholism, which is a double whammy for the District Tuberculosis Officer (DTO) and health officials, as they never find him in a state where they can convey the seriousness of his disease to him.
“We have been visiting him every week. He takes the medicines after we tell him, but stops again,” said Rajkumar Kumbhar, a civic official in the area.
Until now, the health officials have visited him thrice to put him back on treatment, but Ganesh keeps dropping out. His family, too, has given up.
“We give him his meals upstairs. We have asked him not to come down anymore as he is drunk most of the times,” said Chayya, his sister-in-law.
In January 2017, when Ganesh finished a month of skipping his daily medicines, he was termed as a ‘loss-to-follow-up patient’, as per the new RNTP guidelines.
Currently, there are 1,500 patients on treatment in Kurla, of which 23% have dropped out of treatment in 2016. However, in 2017, the numbers fell to 12 % as more health workers were visiting the loss-to-follow-up patients in the ward. Most of the patients who drop out of treatment have drug-sensitive TB, which is worrying for health workers, as these patients eventually go on to becoming multi-drug-resistant cases.
Doctors said other loss-to-follow-up patients such as Ganesh could be tricked into believing that their health is recuperating within the first two weeks of taking the medicines, but without completing the stipulated dose, the TB bacilli in their body is multiplying and possibly acquiring resistance. In fact, in the area where Ganesh lives, there are a staggering 46 MDR cases and 13 XDR cases.
Ganesh’s own health is at risk and loss-to-follow-up TB patients like him pose a big public health hazard to the general public, said doctors.
“Once the patient stops taking medicine, they may feel better, but they still harbour the bacterium. This increases the chances of the bacterium becoming resistant to more and more drugs, making it a challenge to treat the patient,” said a senior doctor, who works at the civic-run Sewri TB hospital.
“But, what is more worrisome is that the patient may then infect healthy individuals with a strain that is already drug resistant.”
In Prabhadevi, 35-year-old Ramesh, a newspaper vendor was taking treatment for drug-sensitive TB. However, he stopped taking the medicines, the day he stared feeling better. His drug sensitivity tests, which tell which drugs would work for a patient, revealed that he had acquired Extensively Drug Resistant (MDR) TB, a form of TB which is resistant to at least four of the core anti-TB drugs. XDR-TB patients can be cured, but with the current drugs available, the likelihood of success is much lesser than in patients with ordinary TB or even MDR-TB, says the WHO.
The fear of taking 15 tablets and a daily injection has now deterred him from even starting his course of medication. Three months have passed, but he has not resumed treatment. “They told me my report was bad. I stopped the medicines. I was scared. I thought my health was improving, but the report said something else,” Ramesh told HT.
But, during that period, Ramesh was going about his normal life, meeting people, showing up at work, where he may have infected other people.
In his case, counselling by the local district TB officials helped, and they were successful in putting him back on medicines. In cases where patients are not traceable, what can the DTO’s do? They can’t do much.
An internal analysis by the ward officer showed that 35% patients stop treatment because they migrate out of the city during the period of treatment; 24% just refuse to take treatment; 20% are alcoholics; 16% opt for private treatment; and 5% have adverse drug reaction.
DTOs said most loss-to-follow-up patients are men who migrated to the city for work. In a quest to find cheap accommodation, workers move from one slum to another, leaving the health officials only guessing about their whereabouts.
“Sometimes the addresses are incorrect, sometimes they would have moved out of the city, how do we track them in that case?” said Vikram Chavan, a TB home visitor, whose job is to look for loss-to-follow-up cases.
In Chandivali, the TB home visitors have not been able to trace a 35-year-old patient, Mumtaz Shaikh, for the past month. When the health officials visited her at the address she had provided, they found her family had relocated to a slum near the airport, but none of the neighbours knew where they had gone. She has started taking TB medicines in November 2017, but in two months, she moved to her village in Karnataka, without informing health officials.
“When patients move without informing the health officials, how do we trace them?” said Dr Yashodhara Sonawane, district TB officer, L-ward.
As civic officials continue to grapple with the problem of loss-to-follow-up cases in the city, they are hopeful that new initiatives under the RNCP, including providing ration to TB patients, will incentivise treatment for patients and decrease the number of loss-to-follow-up cases.
Dr Daksha Shah, the TB officer at Brihanmumbai Municipal Corporation (BMC), said it is only in the past three years the programme has intensified their efforts in finding these cases.
“We now have 50 counsellors under the programme to educate these patients about the harmful effects of stopping treatment. Moreover, many loss-to-follow-up patients, when they realise that their heath is deteriorating, come back to the programme, but they are still termed as loss-to-follow-up. To tackle loss-to-follow-up cases, we need to counter problems related to social factors, stigma, lack of better family support , alcoholism and rapid migration,” she said.