HEALTH MATTERS: Tuberculosis – An Ongoing Health Challenge

File photo-PTI

File photo-PTI

Tuberculosis continues to be one of the leading causes of death in India. According to a survey health department’s data, TB infects about two to three million people, while more than three lakh people succumb to the disease every year. Even though several measures have been taken to control and prevent TB to a certain extent, this life threatening disease continues to take several lives.

According to official records, every three minutes, two deaths occur due to tuberculosis. The disease impacts not just those living in urban centers but a significant number of TB cases have also been found in rural areas, where a large number of people struggle to cope with TB.

In the state of Jharkhand, communities who reside near mining cities and those who work as labourers in bauxite, coal, iron ore and uranium mines, are exposed to TB. A large number of deaths have been reported, the main reasons being no early diagnosis was done because primary health care services are extremely poor, due to which many people are unable to access proper care and treatment. Those who do manage to get some drugs from local chemists are often not able to continue with their treatment since they cannot afford to buy medications. Since they are unable to continue with their treatment regime, it leads to drug resistance.

It has also been found that irrational use of TB drugs also leads to drug resistance, which poses a threat for the patient and others as well since the person can infect them with his drug-resistant organisms.

The emergence of drug resistance in TB patients is linked to deficient or deteriorating TB control programs especially in rural areas. Since there is inadequate administration of effective treatment, especially in unreached areas, substandard drugs are routinely provided to patients along with inadequate or irregular drug supply. Also, ignorance of health care workers in the treatment and control of TB is a major barrier in treatment and controlling tuberculosis. Besides, interruption of chemotherapy due to side effects cannot be prevented as well.

Overall, it is clear that multidrug resistant tuberculosis (MDR TB) strains and emerging as a threat for the public.

However, currently there is limited data on drug resistance in these areas and the patients are therefore not able to get appropriate treatment. To prevent use of poor quality drugs and irrational prescribing practices urgent steps need to be taken at all levels, especially in rural areas.

The Government should ensure rational use of anti-TB drugs. Also, treatment pattern and drugs usage should be monitored and regulated at all levels to prevent deaths and morbidity. Besides, reliable information on drug resistance at the national level is also urgently needed so that continuous survey of drug resistance across all regions of the country, with emphasis on quality control, could be possible.

Based on this data it will also ensure appropriate treatment regimens and also help create suitable policies.

There is also a need to pay special attention to impoverished families who are unable to continue with their medications due to lack of funds by providing them with monetary support. However, according to the Heath Ministry, in 2015, a significant progress has been made by India to control TB in the country through the Revised National Tuberculosis Control Programme (RNTCP), covering a comprehensive spectrum of interventions from enhanced access to TB care services, phased introduction of rapid molecular diagnostics and nation-wide expansion of services for drug resistant TB.

For patients who are co-infected by both TB and HIV, the government has taken policy decisions like ban on sero-diagnostics, making TB notifiable diseases in India, and optimization of available tools including ICT interventions for delivering high quality health services. As part of a new strategy, India is committed to adopting newer strategies and tools to ensure universal access to quality TB care, combating drug resistance and thereby, saving lives.

As per the newer initiatives, 500 CBNAAT machines have been introduced in addition to existing 121 machines to offer rapid quality diagnostics at the earliest. This is big leap in fight against TB, especially DR-TB

Besides, new anti-TB drug, Bedaquiline, has also been introduced under Conditional Access Programme (CAP) to improve outcomes of drug resistant TB treatment. Technical and operational guidelines for RNTCP has also been revised which will enable higher efficiency of diagnostic algorithm and offers best treatment at first instance to improve outcomes

healthMost importantly, healthcare workers surveillance handbook has been developed to ensure their safety and protection against TB, thereby reducing their vulnerability. Guidelines for prevention and management of Adverse Drug Reactions (ADRs) to reduce iatrogenic suffering of TB patients has also been done. Diagnostic and treatment services for TB have also been decentralized. However, unless these are monitored, the quality of services will not be clear.

According to World Health Organisation (WHO), TB prevalence has reduced from 211 per lakh population to 195 per lakh population, while mortality has further reduced from 19 per lakh population to 17 per lakh population. Incidence of tuberculosis has further reduced from 171 per lakh population to 167 per lakh population.

However, the Joint Monitoring Mission (JMM) in 2015 observed that the implementation of National Strategic Plan (NSP) during the period of 2012 to 2017 was not on track.

The projected increases in case detection by the RNTCP have not occurred, while vital procurements are delayed and many planned activities have not been implemented. Similarly, the JMM observed that of the recommendations of it came out in 2012, about two thirds have not been fully implemented. For the most part, CTD has completed the policy work requested. Work is held up for lack of timely decisions, especially at central level.

Clearly, despite the growing number of tuberculosis cases across the country and several gaps in health care and treatment services as well as poor monitoring of drug resistance, the current health landscape does not appear to be taking steps to prevent and control tuberculosis. Allocation of funds for TB has been reduced significantly. Such fund cuts therefore has had a severe impact on several projects earmarked to study tuberculosis across all states, because without finances, the task force assigned to identify the status of TB in India cannot undertake research or carry out surveys to understand the disease burden.

Previously, the task force following tuberculosis per centre were provided a sum of 1.5 crores for their research for a period of three to five years. The other sum provided to ad hoc projects was seventy lakhs for a period of 3 years. However, due to fund cuts, these projects cannot be carried out.

Unless, each task force and organizations are provided with adequate funds to assess the prevalence of all forms of tuberculosis across all states in both rural and urban settings, in order to put together strategies to control and prevent Tuberculosis in the country, many lives will continue to be lost and India will continue to remain the TB capital globally.

(Mohuya Chaudhuri is a journalist and researcher)