World TB Day: Tuberculosis fight in Mumbai sees improvement
In the past three years, TB care in the public health sector has seen an improvement not only in diagnostic facilities, but also in outlay of new treatments.mumbai Updated: Mar 26, 2018 10:26 IST
The city continues to remain the country’s tuberculosis (TB) capital with 45,675 new cases of drug-sensitive TB and 4,891 cases of multidrug-resistant TB reported between 2015 and 2017 by the civic body’s public health department.
In the past three years, TB care in the public health sector has seen an improvement not only in diagnostic facilities, but also in outlay of new treatments, especially Bedaquiline, the newest anti-TB drug to be introduced after four decades, globally, said doctors. However, with challenges in finding ‘missing cases’ - cases that are not documented by the government – Prime Minister Narendra Modi’s announcement of eliminating the disease by 2025 looks far-fetched to most city TB specialists.
Faster and more advanced diagnostic tests help
In the past year, the number of GeneXpert machines – which tell if a patient has drug-resistant TB within two hours, have increased from six to 28, which is good news for the city’s TB care programme, said doctors.
GeneXpert can find out if a patient has resistance to one of the most powerful anti-TB drug – Rifampicin. It is one of the most crucial tests to ensure the patient is put on the correct medications right from the start.
“Easy access to GeneXpert is one of the most welcomed advancements in TB care, as we get to know if a patient is resistant or not on the same day of diagnosis,” said Dr Yashodhara Sonawane, district TB officer, Kurla, which is a high-burden TB area.
From 2017, sputum samples of patients are collected from all nearby health posts, and sent to the district TB office for the GeneXpert test. The results are out by evening, and are sent to the doctors immediately.
However, it is only over the past year that this test is being performed on the first day for all patients who are diagnosed with the infection. Until a year ago, the test was performed on the first day only if the patient belonged to a high-risk group, such as HIV, diabetes or if the patient’s sputum didn’t convert to ‘negative’ despite being on first line medications. This approach in the past, doctors said, could have added to the burden of drug-resistant cases
While the use of GeneXpert for all TB patients is hailed as a positive development by doctors, this was not the case traditionally, said Dr Yatin Dholakia, secretary and technical advisor to Maharashtra State Anti-TB Association.
He said that in the past, the approach of not performing the GeneXpert test for all patients could have theoretically added to the burden of drug-resistant TB. “GeneXpert has four slots, which is a limitation. Only 12 to 16 tests can be performed per day per machine. Currently, the test is conducted only in wards with high TB burden, although it should be done to all patients as soon as they are diagnosed with TB under RNTCP (Revised National Tuberculosis Control Programme),” Dholakia said.
A patient with drug-resistant TB is infected with bacteria that are inherently resistant to or have developed resistance to Isoniazid and Rifampicin, two of the most effective anti-TB drugs. Poor adherence to treatment is a significant contributor to the increase in burden of drug-resistant cases, doctors said.
Increased notification from private sector
On March 16, a notification by Union health ministry stated that doctors, health workers and pharmacists could be jailed for up to two years for failing to report TB cases.
However, Mumbai over the past three years has witnessed a significant increase in the number of TB cases notified by the private health sector to the state government via a non-government organisation (NGO).
In 2017, 20,000 new TB cases were notified by the private sector as against around 3,000 cases in 2014. This, doctors said, was important as 70% patients in the city first visit the private sector for treatment.
“If private practitioners don’t report cases to the government, we will not know the correct picture of the disease burden,” said Dr Vikas Oswal, a chest physician practicing in Govandi, another high-burden area. He, however, said that there are no processes in place to notify the disease directly to the government. “Till now, a third party which is an NGO was notifying the disease on behalf of private practitioners. But with that Public Private Interface Agency (PPIA) withdrawn, will private physicians who see around 80 patients a day have the time to notify the disease?” Oswal said.
PPIA was a joint initiative between RNTCP and the international PATH foundation to document TB cases in the private sector.
Decentralisation of treatment facilities
Facilities for treating drug-resistant TB have also seen decentralisation over time – from six in 2016 to 14 this year. Earlier, all MDR patients visited the civic-run Sewri TB hospital for treatment and follow up.
“Many MDR patients visit hospitals at the cost of their daily wages. Having a centre near their house will improve access and adherence to treatment,” said Dr Daksha Shah, who heads the TB treatment under RNTCP. “Decentralisation of facilities will significantly reduce out-of-the-pocket expenses for patients.”
Scaling up Bedaquiline
With rising number of Extensively Drug Resistant (XDR) TB cases, access to Bedaquiline has also improved with a total of 170 patients in the city currently on the drug.
The news of patients not being able to access Bedaquiline came to the fore when an 18-year-old woman from Patna reached out to the judicial system to get access to the drug. She was initially denied the drug because she was not a domicile of Delhi. While she eventually came to Mumbai for her treatment last year, she has been on oxygen as her lung tissues are scarred, said Dr Zarir Udwadia, chest physician, Hinduja Hospital, Mahim, who was treating her.
The sale of the drug is restricted in India, with the government issuing the drug only at six centres — two centres in Delhi, one each in Mumbai, Ahmedabad, Chennai and Guwahati on a trial basis since March 2016. The drug is administered to patients who have acquired severe resistance or the infection has spread such that the lung tissues are damaged.
This year, four new out-patient department services were started at civic-run Sewri TB hospital to evaluate more patients for Bedaquiline. “Initially, the access was slow, but now we have scaled up. We are also waiting for the outcome among patients who were put on the drug last year before we increase the number of patients. As present, we are facing shortage of manpower to monitor complications,” said Dr Alpa Dalal, honorary TB specialist at the TB Sewri hospital.
Elimination of TB by 2025?
A 2016 study published in the scientific journal, the Lancet, by Dr Nimalan Arinaminpathy of the School of Public Health at Imperial College London had found that more than one million TB cases may be missing from official statistics in India.
“The PM’s announcement shows political will, and will add momentum to the programme. But realistically speaking, it is an impossible target. TB has been there for centuries. Even if we find active cases, identifying all the latent cases is a difficult proposition,” said Dr Dholakia. “Latent TB cases surface at least two-three years, or even later, when a patient’s immunity is compromised.”