India accounts for a quarter of the 9.6 million cases of TB that occur worldwide. India also accounts for a third of the 'missing 3 million' TB cases that do not get diagnosed or notified. TB incidence is declining very slowly, and we are now seeing severe forms of multi-drug resistant TB (MDR-TB), especially in cities such as Mumbai. While the Indian government must get credit for making basic TB treatment freely available, the public sector alone cannot control TB. Why?
There is growing evidence that the quality of TB care in the private sector is suboptimal.
Half of all patients with TB seek care in the private sector. Private healthcare providers are often the first point of care even for patients who are eventually treated in the public Directly Observed Treatment, Short-Course (DOTS) program. TB patients in India get diagnosed after a delay of nearly two months, and are seen by at least three different practitioners before a diagnosis is made. During this long process, TB patients can infect many others in the community. Most patients initially begin seeking care in the informal private sector, including pharmacists, unqualified practitioners, and AYUSH specialists.
Problems in the private sector
There is growing evidence that the quality of TB care in the private sector is suboptimal. Private doctors tend to rely on empirical antibiotic therapies and rarely order sputum tests for TB. Even if diagnosis is made correctly, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug combinations that are not recommended by the World Health Organization or the Revised National TB Control Programme (RNTCP).
Incorrect diagnostic and treatment protocols also increase the risk of drug resistance to first-line and/or second-line drugs.
Incorrect diagnostic and treatment protocols increase the risk of drug resistance to first-line and/or second-line drugs.
Even if the correct TB treatment is started, it is important to make sure patients complete the full course. Adherence will ensure cure and prevent drug-resistance. However, private practitioners generally struggle to safeguard adherence among their TB patients. A patient might not adhere to the entire course due to several reasons which include lengthy treatment, side effects of medicines and low threat perception of the disease. These result in patients stopping treatment prematurely or switching doctors--again increasing the chances of developing drug-resistance.
The need for engagement
The engagement of the private sector is necessary to increase TB case notifications. Since 2012, it is mandatory for all TB cases in the country to be notified to the Revised National Tuberculosis Control Program (RNTCP). By notifying TB cases, we can ensure that patients receive free TB drugs and other benefits. Notification also helps us to understand the true magnitude of the TB epidemic and to raise adequate funds. In fact, under-funding of RNTCP is a major stumbling block to achieve India's National Strategic Plan for TB control. While individual private practitioners may face legitimate challenges in notifying TB cases, there is no excuse for private laboratories and hospitals--they must notify all TB cases to the district or city health authorities.
We must remember that we endeavour not just to control a disease, but to save human lives.
These providers must be educated about the importance of suspecting TB in any person with a cough for two weeks or longer. Early referral for sputum tests which detect the TB bacteria can help in reducing diagnostic delays, and reduce the spread of infection in the community. Correct TB treatment needs to be taken for at least six months depending upon the clinical response, and should involve the appropriate anti-TB drugs, given in the right dosages. If not, drug resistance can emerge, with poor outcomes for the patient and the community.
It is important for private practitioners to follow Standards for TB Care in India, and use the correct drugs and combinations. It is important that pharmacists avoid dispensing antibiotics without prescriptions, and instead refer patients with chronic cough for TB testing.
Every TB patient, along with close family members, should receive detailed counselling on the critical importance of completing treatment. Mobile phones can and should be used for tracking and supporting adherence. The TB Missed Call initiative, a helpline with a toll free number (1800-11-6666) now provides information, counselling and treatment support services for TB. All patients with risk factors for drug-resistance must be screened for MDR-TB using WHO-approved tests such as Xpert MTB/RIF (GeneXpert) and liquid cultures which are now more affordable in over 115 private labs via the IPAQT initiative. Since MDR-TB requires long-term and specialized management, patients should be referred to private chest specialists, or to specific government hospitals where free MDR-TB treatment is available.
It is important that pharmacists avoid dispensing antibiotics without prescriptions, and instead refer patients with chronic cough for TB testing.
As more than half of patients seek care in the private sector, the government needs to engage more with private practitioners and explore innovative ways to do so. They must find ways to ensure that private care providers follow proper diagnostic and treatment protocols, and notify cases to the RNTCP. Ultimately, TB patients need quality care, regardless of whether they choose to seek care in the public or the private sector. Therefore, it is also important for the private sector to work hand in hand with the RNTCP, and improve the overall quality of TB care in the country. We must remember that we endeavour not just to control a disease, but to save human lives.
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