Are We Losing The Battle Against Tuberculosis?

With growing drug resistant forms, rising treatment costs and unreliable tests that can only do harm, the disease continues to remain a challenge

Even in the 21st century, tuberculosis has remained a major health challenge trailing behind only HIV as world’s leading cause of death from infectious diseases. It continues to kill two Indians every 3 minutes and nearly 1,000 every day. Yet, the task of accurately diagnosing the disease gets low priority. In fact, it has not been possible to develop an easy and effective way to diagnose the disease so far. Also, emergence of drug resistant strains has made things worse. Of late, new lethal forms of tuberculosis have emerged which undermine the efforts undertaken to prevent and control the spread of the disease. Unfortunately, what is a preventable and easily treatable disease, is now getting out of control despite all efforts from health agencies to manage and control it.

Tuberculosis is one of India’s most critical public health issues, but TB prevention and control efforts face several challenges. It continues to be a major public health problem accounting for substantial morbidity and mortality in the country. It is an infectious disease caused by a bacterium called “micobacterium tuberculosis”. It commonly affects the lungs but can also affect any part of the body. The bacterium usually attacks the lungs but may also lodge in the lymph glands from where it may spread to brain, intestines, kidneys or bones. Early diagnosis and complete treatment is the cornerstone of TB prevention and control strategy. Inappropriate diagnosis and treatment by fits and starts may contribute to complications, disease spread and emergence of drug reisistant strains. According to a study, TB kills nearly 500,000 people in India every year. Until recently, less than half of the patients with TB received an accurate diagnosis and less than half of those received effective treatment.

India has far more cases of tuberculosis than any other country in the world. It has one-third of all TB patients in the world. Over 2 million new cases each year keep India at the top of list of countries with the highest TB burden. Clearly, we are not succeeding in this battle.

It is within this context that a novel method of intervention making it mandatory to notify all TB cases, has been hailed as a timely and laudable step. The notification implies that any institute or hospital, government or private, which detects a new TB patient will have to inform the government about the case and the kind of treatment given. The decision is significant considering the number of people with drug resistantas TB increases every passing day. This will help patients get better access to quality diagnosis and treatment. It is indeed a giant step towards furthering TB care and control besides facilitating prevention of complications, drug resistance and reduced deaths due to the disease. A positive step for India’s TB management programme, it will also help the healthcare providers to offer better linkages for quality diagnostic and treatment services to the TB patients. Most importantly it hopes to facilitate the Revised National Tuberculosis Control Programme (RNTCP) to realistically estimate TB disease burden, plan resources and control majors commensurate with the actual burden of disease.

The WHO estimates that more than 60 thousand people develop serious multi-drug resistance in the country every year, and the primary reason is poor diagnosis and mismanagement of TB. The emergence of drug resistant TB has become a significant health problem in a number of countries and an obstacle to effective TB control. Though specific measures are being taken within the RNTCP to address the MDR-TB problem through appropriate management of patients and strategies to prevent the propagation and dissemination of MDR-TB, yet it is inadequate. It has to be stressed that drug resistant TB is a man-made problem caused by exposure to wrong treatment, the wrong regimen and the wrong treatment duration. Drug mismanagement can result if a patient does not follow full course of treatment or if correct drugs are not available or if patients with undiagnosed resistant TB recieve inappropriate therapies. This poses a higher risk for patients to be subjected to inadequate and poorly administered treatment, another key factor leading to the creation of drug resistant strains of TB. The tuberculosis management programmes should create treatment protocols that can be easily adhered to besides being supported by treatment counselling. Also, diagnostic delays are all too common. A lot needs to be done in this area so that each patient is diagnosed quickly and treated appropriately.

Part of the problem also relates to TB testing. It has not been possible to develop an accurate serological test for tuberculosis so far. It is a known fact that in disease endemic countries like India where most of the population has been exposed to TB these serological tests are completely ineffective. In fact, an easy and reliable way to diagnose the disease has remained a challenge. Several scientific studies have clearly shown that these tests for TB are of no value but only make the problem more complex. The WHO has already advised all TB controlled programmes against the use of these tests. And yet a whooping 1.5 million TB serological tests are done in India every year. This may end up doing more harm as some of the people may be wrongly diagnosed with TB and end up undergoing TB therapy without any need for it or suffer from incorrect treatment. This will serve as the source of new infection in the community. This crisis of mismanagement has led to an extremely drug resistant TB (XXDR-TB) reported recently in India, raising further concerns over increasing drug resistance to the disease.

The fifth Joint Monitoring Mission of India (JMM) and the World Health Organisation on the RNTCP has endorsed the National Strategic Plan (NSP) for TB control for 2012-2017. The NSP has set the goal of universal access to early diagnosis and effective treatment of the cases, irrespective of care in public or private sectors. Endorsing the NSP, the JMM has also concurred with the government view that if implemented properly, the NSP can save 750,000 lives over the next 5 years and transform TB control in the country.

India’s RNTCP is widely appreciated for having made a big contribution for expanding it’s basic diagnostic and treatment services. Yet the country has faced several challenges in implementing this programme. The RNTCP has been consistently underfunded despite the fact that TB control is a very cost effective strategy. India’s healthcare spending also remains one of the lowest in the world. Though the planning commision has raised a location for the RNTCP to about Rs 710 crore in the last fiscal year. An 80 per cent increase from the previous budget, there is no doubt that substantially greater resources are necessary to control TB. The only way forward for tackling the disease is to make every medical practitioner accountable and treat every patient correctly. Educating doctors about correct drug regimens and testing protocols should be done simultaneously. Measures should also be taken to prevent resistance to existing drugs. There is a dire need to educate people about the merits of good sanitation. Awareness programmes should focus on prevention of the spread of the disease by simply covering the mouth when coughing and making sure not to spit out the phlegam in the open. This simple measure will diminish drastically the spread of the disease. There is hope and every reason to believe that with the combined efforts of public and the health providers, half the battle will be won.

By Sunita Vakil