Abstract:: Tuberculosis continues to be a daunting challenge for our healthcare system. Even after fifteen years of the much publicised Revised National Tuberculosis Control Programme that envisages directly observed short course chemotherapy (DOTS), TB continues to spread and drug resistant strains, MDR and XDR, are also increasingly reported. More than 50% of TB patients seeking private health care, but the level of awareness regarding treatment of TB among private practitioners appears to be poor. All this call for an urgent revamp of TB control strategy in India.
Key Words: Tuberculosis, RNTCP; MDR tuberculosis
The disease tuberculosis (TB) is as old as mankind. Despite being curable with proper treatment, the disease burden in terms of morbidity and mortality is still very high in India. India has the highest TB burden in the world accounting for one fifth of the global incidence of TB.(1) About 10 million people in India have pulmonary tuberculosis. Among them about 2.5 million are sputum positive.
Improper treatment of tuberculosis leads to development of drug resistance. MDR TB and XDR TB are on the rise in India. According to national TB control programme, 2011 report, about 73,000 patients in India suffer from multidrug resistance TB.(2)
In India about equal number of TB cases are treated by both private and public sector.(3) However there is no system of recording or reporting of TB cases detected and treated in the private sector. Hence the estimates by RNTCP regarding tuberculosis may not reflect the actual burden of TB in India. Besides, no nation-wide survey has been conducted in the recent years regarding the incidence of TB, drug resistance in TB and treatment compliance and outcome of cases.
The best method to control tuberculosis and to prevent the emergence of drug resistance TB is early diagnosis and proper treatment of cases to ensure a cure for all detected cases. Aiming for a cure in the majority of detected cases is not sufficient as the others who have active disease will spread the infection. A study conducted by the Global Alliance for TB drug development found that more than 35% of all the treatment in the private sector in India fall outside the national and international recommendation and constitute non recommended strengths.(4) A study by Udwadia et al in Bombay (2010) showed that only 6 doctors out of 106 respondents wrote a correct regimen for tuberculosis.(5) It is estimated that 50-80% of TB patients in India still seek treatment in private sector. The treatment in private sector in India is substandard according to many studies.(6-8)
Out of the total market of USD 94 million for the first line anti TB medicines in India, public sector purchases drugs worth USD 24 million. Private sector purchase accounts for the remaining USD 70 millions.(9) Private TB drug market in several high burden countries including India are substantial, stable and complicated.(4) Both loose drugs and fixed drug combinations are used.
In this issue of OJHAS, a study by Jyothi Khadse et al point out that there is inadequate knowledge among private practitioners in India regarding the management of TB.(10) Such studies clearly indicate that even though RNTCP in India covers the whole population, a substantial number of TB patients are still treated by the private sector, but most of the private practitioners do not follow any standard guidelines in managing TB cases. There are various schemes under RNTCP for publicprivate partnership, but the programme has failed to reach the population. Improper management of TB in private sector and failure of RNTCP to involve the private sector is a cause for concern as this may be one of the important reasons for development of drug resistance TB.
Hence there is an urgent need to streamline the management of TB in India to achieve control of the disease and to prevent the emergence of drug resistance. The health policy maker in India need to plunge into action before it is too late. How can we ensure a proper management of tuberculosis in the private sector? We propose the following:
• Make tuberculosis a notifiable disease
• Regulate the private TB market to ensure proper dosing and combination.
• Just like Indian MTP act, implement Indian TB act. Let TB be treated by only doctors with adequate knowledge and training with a special license to manage TB cases.
• Ensure all TB cases are managed as per “International standards for TB care”
• Ensure proper recording and reporting of each case
• Ensure cure for all cases of TB.
• Ban over counter sale of TB drugs
• Legal action against those who do not comply with the standards of care.
References:
1. WHO Report 2011. Global tuberculosis control. WHO. Geneva. Available at http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf
2. TB India 2011. RNTCP Status Report. Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi. March 2011. Available at http://tbcindia.nic.in/pdfs/RNTCP%20TB%20India %202011.pdf
3. Uplekar MV, Rangan S. Private doctors and tuberculosis in India. Tubercle lung dis 1993;74: 332-337.
4. Wells WA, Ge CF, Patel N, Oh T, Gardiner et al. Size and usage patterns of private TB drug markets in the high burden countries. PLOS One 2011: 6(5)e 18964. doi:10.1371/journal. Pone.0018964. Available at http://www.plosone.org/article/info%3Adoi %2F10.1371%2Fjournal.pone.0018964
5. Udwadia Z F, Pinto LM, Uplekar MW. Tuberculosis management by private practitioners in Mumbai,India: Has anything changed in two decades? PLOS One 2010;5(8): e 12023. doi:10.1371/journal.pone.0012023. Available at http://www.plosone.org/article/info:doi %2F10.1371%2Fjournal.pone.0012023
6. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private clinics in India. Int J of Tuberc Lung Dis 1998;2;324-329.
7. International institute for population science (IIPS) and Macr International 2007. National family health survey (NFHS-3), 2005-2006:India. Volume-1.
8. Kelkar-Khambete A, Kielmann K, Pawar S, Porter J, Inamdar V et al. India’s Revised National Tuberculosis Control programme: Looking beyond detection and cure. Int J Tuber Lung Dis 2008;12: 87-92.
9. Global alliance for TB drug development. Pathway to patients: charting the dynamics of global TB drug market. TB alliance, New York. 2007
10. Khadse J, Bhardwaj SD, Ruikar M. Assessment of Knowledge and Practices of Referring Private Practitioners Regarding Revised National Tuberculosis Control Programme in Nagpur City- A Cross Sectional Study. Online J Health Allied Scs. 2011;10(4):2. Available at http://www.ojhas.org/issue40/2011-4-2.htm
Key Words: Tuberculosis, RNTCP; MDR tuberculosis
The disease tuberculosis (TB) is as old as mankind. Despite being curable with proper treatment, the disease burden in terms of morbidity and mortality is still very high in India. India has the highest TB burden in the world accounting for one fifth of the global incidence of TB.(1) About 10 million people in India have pulmonary tuberculosis. Among them about 2.5 million are sputum positive.
Improper treatment of tuberculosis leads to development of drug resistance. MDR TB and XDR TB are on the rise in India. According to national TB control programme, 2011 report, about 73,000 patients in India suffer from multidrug resistance TB.(2)
In India about equal number of TB cases are treated by both private and public sector.(3) However there is no system of recording or reporting of TB cases detected and treated in the private sector. Hence the estimates by RNTCP regarding tuberculosis may not reflect the actual burden of TB in India. Besides, no nation-wide survey has been conducted in the recent years regarding the incidence of TB, drug resistance in TB and treatment compliance and outcome of cases.
The best method to control tuberculosis and to prevent the emergence of drug resistance TB is early diagnosis and proper treatment of cases to ensure a cure for all detected cases. Aiming for a cure in the majority of detected cases is not sufficient as the others who have active disease will spread the infection. A study conducted by the Global Alliance for TB drug development found that more than 35% of all the treatment in the private sector in India fall outside the national and international recommendation and constitute non recommended strengths.(4) A study by Udwadia et al in Bombay (2010) showed that only 6 doctors out of 106 respondents wrote a correct regimen for tuberculosis.(5) It is estimated that 50-80% of TB patients in India still seek treatment in private sector. The treatment in private sector in India is substandard according to many studies.(6-8)
Out of the total market of USD 94 million for the first line anti TB medicines in India, public sector purchases drugs worth USD 24 million. Private sector purchase accounts for the remaining USD 70 millions.(9) Private TB drug market in several high burden countries including India are substantial, stable and complicated.(4) Both loose drugs and fixed drug combinations are used.
In this issue of OJHAS, a study by Jyothi Khadse et al point out that there is inadequate knowledge among private practitioners in India regarding the management of TB.(10) Such studies clearly indicate that even though RNTCP in India covers the whole population, a substantial number of TB patients are still treated by the private sector, but most of the private practitioners do not follow any standard guidelines in managing TB cases. There are various schemes under RNTCP for publicprivate partnership, but the programme has failed to reach the population. Improper management of TB in private sector and failure of RNTCP to involve the private sector is a cause for concern as this may be one of the important reasons for development of drug resistance TB.
Hence there is an urgent need to streamline the management of TB in India to achieve control of the disease and to prevent the emergence of drug resistance. The health policy maker in India need to plunge into action before it is too late. How can we ensure a proper management of tuberculosis in the private sector? We propose the following:
• Make tuberculosis a notifiable disease
• Regulate the private TB market to ensure proper dosing and combination.
• Just like Indian MTP act, implement Indian TB act. Let TB be treated by only doctors with adequate knowledge and training with a special license to manage TB cases.
• Ensure all TB cases are managed as per “International standards for TB care”
• Ensure proper recording and reporting of each case
• Ensure cure for all cases of TB.
• Ban over counter sale of TB drugs
• Legal action against those who do not comply with the standards of care.
References:
1. WHO Report 2011. Global tuberculosis control. WHO. Geneva. Available at http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf
2. TB India 2011. RNTCP Status Report. Central TB Division, Directorate General of Health Services, Ministry of Health & Family Welfare, Nirman Bhavan, New Delhi. March 2011. Available at http://tbcindia.nic.in/pdfs/RNTCP%20TB%20India %202011.pdf
3. Uplekar MV, Rangan S. Private doctors and tuberculosis in India. Tubercle lung dis 1993;74: 332-337.
4. Wells WA, Ge CF, Patel N, Oh T, Gardiner et al. Size and usage patterns of private TB drug markets in the high burden countries. PLOS One 2011: 6(5)e 18964. doi:10.1371/journal. Pone.0018964. Available at http://www.plosone.org/article/info%3Adoi %2F10.1371%2Fjournal.pone.0018964
5. Udwadia Z F, Pinto LM, Uplekar MW. Tuberculosis management by private practitioners in Mumbai,India: Has anything changed in two decades? PLOS One 2010;5(8): e 12023. doi:10.1371/journal.pone.0012023. Available at http://www.plosone.org/article/info:doi %2F10.1371%2Fjournal.pone.0012023
6. Uplekar M, Juvekar S, Morankar S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private clinics in India. Int J of Tuberc Lung Dis 1998;2;324-329.
7. International institute for population science (IIPS) and Macr International 2007. National family health survey (NFHS-3), 2005-2006:India. Volume-1.
8. Kelkar-Khambete A, Kielmann K, Pawar S, Porter J, Inamdar V et al. India’s Revised National Tuberculosis Control programme: Looking beyond detection and cure. Int J Tuber Lung Dis 2008;12: 87-92.
9. Global alliance for TB drug development. Pathway to patients: charting the dynamics of global TB drug market. TB alliance, New York. 2007
10. Khadse J, Bhardwaj SD, Ruikar M. Assessment of Knowledge and Practices of Referring Private Practitioners Regarding Revised National Tuberculosis Control Programme in Nagpur City- A Cross Sectional Study. Online J Health Allied Scs. 2011;10(4):2. Available at http://www.ojhas.org/issue40/2011-4-2.htm