August 25, 2016 4:31:01 am
An assessment of nationwide sales of anti-tuberculosis drugs across the private sector suggests there were 2.2 million TB cases in India in 2014 — two to three times higher than current estimates.
These findings, from a study by researchers at the Imperial College of London that will be published in the Lancet Infectious Diseases Journal on Thursday, could prompt a revision of TB estimates in the country and even worldwide.
The scientists warned that under-reporting of cases could be fuelling drug resistance — and have implications for patients across the globe. TB is a bacterial infection spread through inhaling tiny droplets from cough or sneeze of an infected person.
In 2014, 6.3 million cases of TB were reported to the World Health Organization (WHO) worldwide — a quarter of these cases from India, the highest in any country.
The new research suggests that the actual number of cases in India is under-reported. In 2014, an approximate 1.42 million patients were treated in the public sector. This is because many people opt for private healthcare, yet private providers often fail to report TB cases to public health officials. As a result, the true burden of the disease in India is difficult to estimate.
“TB is the top infectious disease killer worldwide, yet we have had little idea of the true scale of the problem in India — the country most affected. This is because many patients in India use the private medical system… However, this vast private system consists of a huge number of providers and is largely unregulated — meaning that most cases of TB seen in the private healthcare system are not reported to public health officials,” said Dr Nimalan Arinaminpathy, lead author of the research and senior lecturer, mathematical epidemiology, department of infectious disease epidemiology, School of Public Health at Imperial.
Evidence before this study showed that not all cases of TB are reported to public health authorities. WHO assesses overall TB incidence in India by estimating the proportion of cases that are notified (the case detection rate or CDR), and dividing published TB notifications by this fraction. In 2014, this approach suggested that over 800,000 TB cases in India escaped diagnosis by the public healthcare system. Most of these cases are assumed to have been treated in the private sector.
To try and reach an estimate of the number of cases of TB in India’s private healthcare system, Dr Arinaminpathy and her colleagues from a number of institutions in India calculated nationwide sales of tuberculosis drugs across the private sector. The team then used this figure to calculate the number of cases. This suggested there were 2.2 million TB cases in the private sector in 2014 — two to three times higher than current estimates.
This also has worrying implications for the emergence of drug-resistant strains of TB, explained Dr Arinaminpathy, who works closely with the Indian National Tuberculosis Programme. “Multi drug-resistant TB is a global worry, and the large number of cases of TB estimated in our study further fuels concerns about how we can control drug resistance. In the private sector, evidence suggests patients are sent off with medication without advice or support. TB treatments must be taken for six to nine months — yet patients feel better within a couple of weeks. This means they often stop taking the medication. But completing the course is key to effective treatment. For example, Mumbai currently has a worrying epidemic of drug-resistant TB and many would argue the private sector has a role in this. Delhi has the highest number of patients being treated in the private sector,” Dr Arinaminpathy said.
Researchers collaborated with IMS Health Inc, Central TB Division, government of India and the WHO for the study, which was funded by the Bill & Melinda Gates Foundation.
Study sheds light on antibiotic use
Between April 1, 2014, and November 29, 2015, researchers sampled 622 pharmacies in Delhi, Mumbai and Patna. An encouraging fact was that first line anti-TB drugs were not dispensed at any pharmacy, says lead researcher from McGill University Srinath Satyanarayana and Dr Madhukar Pai, Canada Research Chair in Epidemiology and Global Health at McGill University and the paper’s joint senior author. Dr Pai said they wanted to understand how pharmacies in the three cities treated patients with TB symptoms or diagnoses, and to determine whether these pharmacies were contributing to the inappropriate use of antibiotics. The good news is that none of these 622 pharmacies dispensed first line anti-TB drugs. However, the pharmacies frequently dispensed antibiotics to simulated patients who had typical TB symptoms and they rarely referred persons with classic TB symptoms to doctors (this can delay the diagnosis of TB). The use of antibiotics and steroids decreased sharply when the pharmacy staff decided to refer the patient to a doctor. These findings show that there is a need to engage pharmacies in TB control and initiatives to prevent misuse of antibiotics.
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