“TB is the leading infectious killer, yet countries still follow old and dangerous [TB diagnostic and treatment] polices,” MSF Access Campaign tweeted. In another tweet, MSF International said: “Outdated tuberculosis policies are risking further spread of drug-resistant TB.”
These tweets came soon after the “Out of Step 2015” report on TB policies in 24 countries, including India, was presented recently at the 46th Union World Conference on Lung Health in Cape Town, South Africa. The report was jointly prepared by Stop TB Partnership and MSF Access Campaign.
“The results of the survey show that many countries need to take bold steps to bring their policies up to date with the latest international standards,” the report noted. India’s TB policies have been found wanting on several counts.
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For instance, unlike South Africa, Brazil and the Russian Federation which have recommended rapid molecular testing (Gene Xpert) instead of sputum smear microscopy as the initial diagnostic test for all presumptive TB cases, India has recommended its use only for people at risk of multidrug-resistant TB (MDR-TB) or HIV-associated TB, paediatric TB and extra-pulmonary TB cases. Even after limiting its usage, the roll-out has been “progressing slowly,” despite having in place “ambitious scale-up plans.”
Despite recording 71,000 MDR-TB cases (both new and retreatment) in 2014, the Indian TB policy continues to recommend the use of Category II treatment regimens containing streptomycin. It uses the drug “despite recommendations for drug susceptibility test for those at risk of MDR-TB,” the report noted.
Dr. K.S. Sachdeva, Additional Deputy Director-General, Central TB Division, Ministry of Health and Family Welfare, counters this. According to him, patients are first tested for MDR-TB and streptomycin is used only in those who do not have MDR-TB.
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In spite of evidence showing that there is a higher rate of people lost to follow up from treatment and associated risk of drug resistance generation, India continues to recommend intermittent drug regimen. However, the Revised National Tuberculosis Control Programme (RNTCP) intends to switch over to daily regimen in March-April 2016. “Procurement of drugs is at an advanced stage,” he said. “Daily regimen will be introduced in a phased manner. The switch will happen in 104 districts in five States — Kerala, Himachal Pradesh, Bihar, Sikkim and Maharashtra.”
The report states that though the use of fixed-dose combination (FDC) drugs for treating drug-sensitive TB cases improves drug adherence and make the administration easy, RNTCP does not recommend FDC formulation. According to Dr. Sachdeva, FDCs will be introduced in the 104 districts that switch over to daily regimen.
Finally, the report noted that routine hospitalisation of MDR-TB patients is a policy in India. “The policy on hospitalisation is flexible. Home-based treatment is available in places like Kerala where there is a link-up with local hospitals for admission if the need arises,” he said.
The RNTCP policy meets the international standards in a few instances. It has promptly updated the dosing guidelines for first-line drugs used for children. The WHO revised the paediatric dosages in 2010. India allows the use of the new TB drug bedaquiline for treating MDR-TB on case-by-case basis. While India has issued only interim guidance for its use, 11 of the 24 countries surveyed already have national guidelines for its use. Finally, first-line drug susceptibility testing (including at least rifampicin and isoniazid) is recommended for all rifampicin-resistant TB cases and for patients considered at risk of drug-resistant TB, the study found.