Public and private efforts must converge to battle it.
With two decades of high economic growth, India should have been on its way to controlling tuberculosis. Yet it remains an urgent public health problem. With 1,000 Indians dying every day of TB, and with the highest number of TB patients in the world, India is undoubtedly the crucial battleground for TB control. The enhanced detection of drug-resistant TB has increased the complexity of managing the disease, as it requires additional resources, manpower, laboratory facilities and infrastructure. The bacteria are able to evade drugs through various mechanisms and we now have forms of TB that are very difficult to treat.
In India, both the public and private sectors have contributed to the continuing TB epidemic and must take responsibility for corrective action. For example, although the public sector offers free TB care services, its primary tool of diagnosis all these years, sputum microscopy, missed half of all TB cases. Delayed detection impacts treatment outcomes, and contributes to continuing disease transmission (as TB is an airborne disease). Further, patient experiences in the public sector are often marred by impersonal care, hidden costs and disempowerment.
The private sector often uses inaccurate and expensive TB diagnostic tests. While inaccurate diagnosis can lead to increased infection and patient suffering, escalating costs have a debilitating effect on families, pushing them into a vicious cycle of poverty. There also exist well-documented cases where private practitioners prescribe inappropriate drug regimens. These practices can lead to incomplete or interrupted treatment, contributing to the manmade problem of drug-resistant TB.
So, how do we reduce TB in India and ultimately eliminate it? TB control requires a comprehensive and multi-level approach. We can begin by prioritising public awareness and addressing diagnosis and treatment in both public and private sectors. Simultaneously, we need to create an effective and workable relationship between the public and private sectors. A platform that combines many of these are the government of India’s recently issued Standards of TB Care in India (STCI). The STCI has been developed by the Central TB Division and dovetails with World Health Organisation and International Standards for TB Care endorsed recommendations. With more than 50 per cent of India’s TB patients seeking care in the private sector, its engagement is vital for effective TB control. It has the potential to bridge the gap between the government and private sector, by converging them to a single algorithm for diagnosis and treatment.
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Access to new and accurate diagnostics for TB should be rapidly expanded and provided for patients at reasonable prices (or free), while the use of poorly performing tests should be disallowed. There are several WHO recommended diagnostic techniques, such as GeneXpert and other indigenously manufactured kits, that provide quick and accurate TB diagnosis and detect drug-resistance. Early diagnosis is key to successful treatment and disease control. Improving patient outcomes involves rationalising treatment regimens in the private sector and providing support for needy patients to help them complete the full course. Shorter regimens currently being evaluated in research studies have the potential to lower default rates, which will help prevent drug-resistant TB. Perhaps the most critical aspect is a strong public information campaign that will increase awareness, empower patients, reduce stigma and help combat TB effectively.
Other key issues which require attention are infection control and nutrition. Since TB is an air borne disease it spreads quickly in close, densely knit spaces. In the absence of ventilated housing, providing patient, families and communities with sufficient information on preventive strategies can help contain the infection. Also, the government needs to introduce a provision for nutritional supplements to all TB patients. There is a well-established relationship between better nutrition and improved treatment outcomes. Since the majority of TB patients belong to vulnerable sections of society, a nutritional supplement or financial incentive (similar to Janani Suraksha Yojana) during the treatment would go a long way in reducing drop-outs and ensuring completion of therapy.
While we deal with the problem in the present, it is critical to plan for the future. The development of effective TB vaccines is vital. Although the Bacillus Calmette-Guerin vaccine is administered to all newborns, it is only effective for the first few years. There is an urgent need to invest in research and development and focus on indigenous TB vaccines. Public-private partnerships in research can go a long way in converting leads from academic laboratories into useful products. India is considered a pioneer in TB prevention and control. But substantial reductions can only be achieved if appropriate policies are followed, effective clinical and public health management is ensured and strong political commitment guides the effort.
The writer is director at the National Institute of Research in Tuberculosis in Chennai and leads the research programme on TB/HIV