The WHO Global Tuberculosis Report 2012, released last week, has made two key points — that much progress has been made in halting and reversing the tuberculosis epidemic, and that despite such progress much work remains to be done still. Easily, this is an encapsulation of the situation in India as well.
The government’s Revised National Tuberculosis Control Programme has done extremely well in expanding the scope of testing and treatment in India. This is an achievement that has been evinced by the numbers — about 1.5 million Indians are getting treated under the RNTCP’s successful DOTS regimen.
However, there is no room for complacency despite the achievements.
There are three areas that require immediate attention. The primary concern relates to the large number of patients who are being treated for TB in the private sector — there are an estimated one million of them, being treated with varying degrees of professionalism. There is often no follow-up to see if the patient completes the treatment. There is also a lot of misdiagnosis in the private sector, and people are being wrongly treated for TB.
This makes it necessary to reach out to them, to establish a standard of care for treatment. Essentially what is needed is flexibility and openness. Traditionally, the private and public health care sectors have not been partners. Covering patients in the private sector has become a priority area for the RNTCP. Notification of TB cases is now mandatory for the private sector.
The second major concern is detecting and managing drug resistant TB cases. So far, less than 10 per cent of cases with Multi Drug Resistant TB have been diagnosed. While it is estimated that there are at least 1,00,000 cases of new MDR-TB, only a few thousand cases have been detected. But efforts are on to remedy this situation. The number of laboratories running the molecular Line Probe Assay tests to diagnose MDR-TB across the country has increased. The recently introduced GeneExpert testing kit that detects resistance to rifampicin in a few hours, is making headway. Additionally, indigenous technology to test drug resistance is being developed. Once validated, it would help bring down the costs of diagnosis.
Managing such cases in an additional challenge. The DOTS Plus regimen runs for 24 hours, and the drugs are known to be very toxic. Ensuring compliance is very tough, and providing manpower to monitor and ensure that the drug course is completed is likely to be a huge challenge for the future.
Thirdly, the time has come to pay attention to the social determinants that influence treatment, and facilitate recovery. Over-crowding, under-nutrition, pollution, alcohol and tobacco abuse, are all factors at play. So far no effort has been made to tie up patients with TB and social support programmes. TB does affect people in the low socio-economic group where lack of nutrition is a serious complicating factor.
Also, if parents have TB, about 20 per cent of children drop out of studies for the duration of the treatment – which is six months, and two years, in the case of MDR-TB.
