WITH THE Bihar prohibition law also banning methylated spirit and ethanol, laboratories in the state are fast running out of essential ingredients to conduct tuberculosis tests. Laboratories, which have been sourcing supplies from the open market under the cover of buying reagents, were told in February to use Injecta, a type of methylated spirit, till an alternative arrangement was made. But officials admit that Injecta has a falsification rate of over 40 per cent. Sources said Chief Minister Nitish Kumar has now taken note of the matter.
The Bihar Prohibition and Excise Act, passed in October 2016, bans the use of all types of alcohol, including methylated spirit and ethanol used for medical purposes and in labs. The state has 732 designated microscopy labs and 60 fluoroscent microscopy labs, besides the Intermediate Reference Library at Patna to test TB. Together, these labs need approximately 2,000 litres of methylated spirit and ethanol to test TB in a year.
Officials say the labs had stocks of spirit and ethanol to last only four-six months when the ban came into force, most of which were exhausted by September-October 2016. While there has been no fall yet in the number of tests conducted, with officials procuring the required ingredients somehow, almost all Communicable Disease Officers (CDOs) in the state have rung alarm bells.
The use of Injecta too remains stuck in technical complications, allowed only as a stop-gap arrangement on special order. Last August, the State Programme Officer (SPO), TB Programme, Dr K N Sahay, had raised the issue with the Central TB Division under the Union Ministry of Health and Family Welfare. A few days later, the Director General, Health Services, Union Ministry of Health and Family Welfare, Dr Jagdish Chandra Prasad, wrote to the Bihar Principal Secretary saying that nothing had been done to address the issue.
Says Dr Sahay, “We have taken up the matter afresh with the Excise Commissioner. They have agreed to arrange methylated spirit and ethanol for us, but we will have to take an NoC (no objection certificate) for every stock.” The Excise Department order specifies that a vehicle with GPS and equipped with a digital lock would be used by the state Health Department to carry the needed methylated spirit while the department would itself directly provide the ethanol. “We will distribute it to all districts from here and ensure we have enough stock,” Dr Sahay says.
In 2016, 64,178 cases of TB were detected in Bihar, against 64,937 in 2015 and 68,145 in 2014. The districts with the most cases were Muzaffarpur, Gaya, Patna, Darbhanga and Saran. Over 800 government labs tested 4,55,533 slides, compared to 4,49,017 in 2015 and 4,69,849 in 2014. Government hospitals are estimated to get only 35 per cent of the TB cases, while the private sector doesn’t notify more than 10 per cent of the cases it gets. Mycobacterium tuberculosis (TB) is of two types — pulmonary (of lungs) and extra pulmonary. Tests for TB include X-ray, sputum microscopy, Gene Xpert, Line Probe Assay, culture (liquid and solid), and drug susceptibility test. The X-ray test, however, is only suggestive and hence other tests are conducted to confirm TB. The most common one, sputum microscopy, requires large amounts of alcohol. Ethanol is required to disinfect surfaces, including for heating and while preparing slides.
In Gaya, district TB officer Dr Vijay Kumar says they conducted 3,503 sputum microscopy tests in 2016. Its lab at Gaya needs at least 10 litres methylated spirit and alcohol a month, and the stocks ended on July 31. Even if he could procure ethanol illegally from the open market, he can’t show vouchers for the purchase, Kumar points out. Three months ago, a senior doctor in the Gaya Tuberculosis Development was issued a showcause notice to explain illegal purchase of spirit.
In Darbhanga, CDO Dr A K Singh gets one of his assistants to explain the problem. The assistant, speaking on condition of anonymity, says that for conducting Fluoroscent Microscopy to check for TB, they were forced to buy paint used on wood to light a lamp to heat slides, in place of ethanol. However, the paint leaves a dark stain that can be misleading. Darbhanga conducted 3,191 TB tests in 2016, the same as the year before. The district labs need at least 10 litres of ethanol a month to do sputum microscopy and other tests. “We borrowed methylated spirit from a health NGO to conduct tests,” says the assistant.
A Darbhanga Tuberculosis Demonstration and Training Centre (TBDC) employee says, “Just as liquor is available despite prohibition, so is ethanol. We buy it from the open market and show it as reagent. The ban has forced us to use whatever means wherever to get spirit.” It has also forced labs to shift to tests where lesser quantities of spirit and ethanol are required, for example the Line Probe Assay test rather than sputum microscopy. In case of sputum microscopy, sputum has to remain diluted with ethanol for 42 days to rule out any bacteria formation.
However, except for three labs in Bihar — Intermediate Reference Laboratory, Patna, the nodal lab for TB in the state; TBDC, Bhagalpur; and TBDC, Darbhanga, which can do all kinds of TB tests — the rest can do only sputum microscopy. Which means cases from the other labs are also being referred to the three. For making culture and for drug susceptibility test, ethanol is required. While a suggestion has been made to carry out confirmatory tests through the Gene Xpert method — an advanced procedure that detects DNA sequences for TB and indicates resistance or no resistance to known anti-TB drug Rifampicin, and requires less alcohol — this has its limitations. Besides, it still requires some alcohol to be used as disinfectant.