Not only is tuberculosis not going away, we are now seeing severe forms of multi-drug resistant tuberculosis (MDR-TB)
India accounts for a quarter of the 8.6 million cases of TB that occur worldwide. India also accounts for a third of the ‘missing 3 million TB cases’ that do not get diagnosed or notified. Not only is TB not going away, we are now seeing severe forms of multi-drug resistant TB (MDR-TB).
While the Indian government has done well to make TB treatment freely available, the public sector alone cannot control TB. What we need is large-scale engagement of India’s massive private health sector. Here are five good reasons to work with the private sector for TB control.
First, half of all patients with TB seek care in the private sector, and private healthcare providers are often the first point of care even for patients who are eventually treated in the public sector. TB patients get diagnosed after a delay of nearly two months, and are seen by 3 different practitioners (including informal providers)before a diagnosis is made. During this long process, TB patients can infect many others in their family and community.
Most poor patients begin seeking care in the informal private sector, including chemists and unqualified practitioners. So, if we want to diagnose TB early and prevent further transmission of the infection, then engagement of such first-contact private providers is the key. These providers must be educated about the importance of considering TB as the diagnosis in any patient with cough for two weeks or longer. Early referral for sputum tests which detect the TB bacteria can greatly help in reducing diagnostic delays,and help in initiating the right treatment before more harm happens to the patient and the community.
Second, there is plenty of evidence that quality of TB care in the private sector is suboptimal. Private doctors prefer blood tests for TB and these are known to be inaccurate and have not been recommended by any guidelines, including the World Health Organisation (WHO). Even if diagnosis is made correctly, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug combinations that are not recommended by the WHO or the Revised National TB Control Programme (RNTCP).
Correct treatment should be given in the form of right anti-TB drugs, in the right dosages, right combination, and the treatment needs to be taken for the full 6 months. If not, drug resistance can emerge, with poor outcomes for the patient and to the community. So, it is important for private practitioners to follow international and national guidelines and use the correct drugs and combinations.Adherence needed
Third, even if the correct TB treatment is started, it is important to make sure patients complete the full course of TB medications. Adherence will ensure cure and prevent drug-resistance. Every TB patient, preferably with close family members, should receive detailedcounselling from the doctor at the start of TB treatment, with emphasis on continuing the treatment till the disease is cured.
However, private practitioners struggle to ensure adherence in their TB patients. This results in patients stopping treatment early, or moving from one doctor to another. Doctors who manage TB patients have an obligation to monitor their patients periodically and keep them under supervision till the stipulated duration of treatment is completed.
Most private practitioners do not maintain medical records, and this makes it very difficult to follow-up patients during therapy.
Unlike the public sector, private practitioners rarely implement directly observed treatment in their busy clinical practice, and have little time to track patients who drop out.
Thus, in the private sector, there is a need to create systems to support patients during therapy. Technologies such as mobile phones could play a role in reminding patients about medications, and be used to contact patients who do not return for follow-up.
Fourth, engagement of the private sector is necessary to increase rates of TB case notification.
Since 2012, it ismandatory for all TB cases in the country to be notified to the RNTCP. Sadly, even in 2014, most private practitioners and private hospitals do not notify TB cases.
By notifying TB cases to local health authorities, private practitioners can get help from the public sector to help follow up patients who drop out during therapy, or need special care for MDR-TB. Notification also helps to understand the true magnitude of the TB epidemic in India, and to raise adequate funds.
The RNTCP could make notification of TB cases more practical and simpler, by allowing the doctors, hospitals and laboratories to notify via websites and mobile phones.
Fifth and last, engagement of the private sector is critical to detect drug-resistance and ensure that all patients with MDR-TB get linked to appropriate second-line treatment. All patients with risk factors for drug-resistance must be screened for MDR-TB using WHO-approved tests such as Xpert MTB/RIF (GeneXpert) which is now more affordable in over 60 labs via the IPAQT initiative (www.ipaqt.org). Since MDR-TB requires long-term and specialized management, patients should be referred to private chest specialists, or to specific government hospitals where free MDR-TB treatment is available.
Ultimately, TB patients need a complete solution to their problem, regardless of whether they seek care in the public or the private sector. Therefore, it is important for the private sector to work hand in hand with the RNTCP, and improve the overall quality of TB care in the country. This will not only help control TB, but also save lives.
DR. VIJAI KUMAR RATNAVELU
Director, Pulmonary Medicine & Critical Care, Yashoda Super Specialty Hospital, Secunderabad, India
DR. MADHUKAR PAI
Professor, McGill International TB Centre, McGill University, Montreal, Canada