India’s fight against tuberculosis (TB) has made remarkable progress despite which formidable challenges remain. With the launch of ‘Call To Action For TB Free India’ last week amidst strong commitment from India’s Health Ministry and other partners in fight against TB, it is high time to start preparing and acting upon the promises made towards ending TB in India, and eventually, the world. “
Dr Mario Raviglione, Director of the World Health Organization (WHO)’s Global Tuberculosis Programme, moderated a panel discussion on ‘TB Free India: Challenges and Way Forward’ right after the high-profile launch of Call To Action For TB Free India, by Jagat Prakash Nadda, Union Health and Family Welfare Minister of Government of India.
Dr Raviglione summarised that India remains the number-one highest TB burden country in the world. Although 2.2 million TB patients get treated every year in India yet 1 million patients are missed by public health system. We do not know what happens to them – they may be receiving care from private sector but we do not know. But ‘missing 1 million’ patients of TB do exist as studies and surveys show. So reaching out to the unreached people who need TB services is indeed a step in the right direction.
Dr Suvanand Sahu, Deputy Executive Secretary, Stop TB Partnership, said: “In India we need to look at missing TB cases differently than elsewhere – For example, in Africa, missing cases may not be receiving any treatment but in India, perhaps it is likely that most missing cases are receiving some kind of treatment from private sector probably, which may not be getting documented. TB notification and counting of TB cases in India has worked in the past in a manner so as to make it only possible for some patients who are in some particular system to be counted and reported. This is something which is changing now which is very good.”
Dr Sahu added: “It is important to respect people’s choice in Indian context from where they choose to go first when they get sick: private, public or informal health systems. So we need to respect people’s choice and accordingly make available best quality services for TB wherever they seek care. Indian standards for TB care needs to be shared and improvement in quality needs several initiatives. First step is to make those missing cases visible – NIKSHAY (an online TB notification system of RNTCP) is a good tool to do that. Once missing patients get visible, we need to provide good quality uniform TB services wherever they opt to seek care. We also need to look at out of pocket expenses – lot of people spend out of pocket expenses in public as well as private sector.”
“Equity is very important – the ones that are not reached by public health system, should not be among the most marginalized poor people. It is very important to see how access is increased. May be disproportionately higher access to people who are under-served or people who have difficulty in accessing care might be able to reach the unreached” said Dr Sahu.
TB-HIV co-infection continues to pose challenge. Anti-TB drug resistance is another massive challenge confronting India. But there is hope as first-ever nationwide anti-TB drug resistance surveillance study is currently going on, results of which may come soon in next few months. This surveillance data will inform more accurately the current situation of anti-TB drug resistance in the country, so that programme can be adapted to respond to the challenge.
Dr Raviglione pointed out that India has made major advances in diagnosing multidrug-resistant tuberculosis (MDR-TB): 3-4 years ago India was diagnosing 3000-4000 cases every year and now it is diagnosing nearly 25000 cases every year. We need to do much more as we still miss a million cases. TB care has to be improved too as despite all efforts, even today 1000 TB-related deaths occur every day.
Do not forget the recommendations of joint monitoring mission
Dr Paul Nunn, a noted TB expert and Director of Global Infectious Disease Consulting (GIDC), shared that the recommendations of probably the world’s largest joint monitoring mission (JMM) which were handed over to the government need to be followed upon by TB and public health community.
“First recommendation was to increase the funding. We heard from the [health] secretary that funding is always an issue but they are optimistic that funding will come through and political support will be given. We need to monitor that and follow. He also emphasized that there should be no waste – and money should be effectively used. As money flows out to the periphery it may be difficult for TB community to ensure that it is being effectively spent – because of health systems constraints. So the next issue is that TB community needs to be working very closely with the health system to ensure every penny is effectively spent” said Dr Nunn.
“We heard the promise that the TB diagnostic tests such as cartridge-based nucleic acid amplification tests (CB-NAAT) will be procured rapidly – please make sure that happens” added Dr Nunn.
WHO Representative to India Dr Nata Manabde reminded the huge gap in awareness within the medical community with half the doctors not recognizing TB symptoms as per the guidelines and Indian Standards for TB Care.
Communicating effectively is key!
There is no doubt that raising awareness and public consciousness is going to be instrumental in social mobilization towards controlling TB, and eventually eliminating it. And so is effective communication! Jose Luis Castro, Executive Director, International Union Against Tuberculosis and Lung Disease (The Union) made precisely this point: “We speak about tuberculosis in very technical terms. We have to curate this message – we have to communicate powerful stories that engage and helps people relate TB with their daily lives. Voices of affected communities along with other stakeholders such as policy makers can further make these stories engaging and strong. Stories of patients being cured, TB services that are working, TB is disease that can be treated and is not a tragedy, among other key themes, need to be communicated as effectively as possible.”
Roadmap to TB-free India needs to be well resourced too!
Dr Jorge A Coarasa from World Bank shared that India at current pace plans to invest around INR 3000 crores over the five years (2012-2017). To scale up TB control efforts, we need to spend INR 4500 crores. India needs additional investment to meet the commitments made by its adoption of WHO’s End TB Strategy.
Dr Urban Webber, Head of High Impact Asia, Global Fund to fight AIDS, Tuberculosis and Malaria (The Global Fund) also underlined the funding issue: “We need to work towards increasing domestic funding not only from government side but also from private sector. Big money is also very shy – it runs away very easily if it senses some problems. However it also seizes opportunities. This makes it easy for successful programmes to attract funding.”
Diagnosing TB early, accurately, is possible!
Not only every presumptive case of TB needs accurate and early diagnosis, but also drug susceptibility testing (DST) needs to be done without delay. DST provides critical information about a particular patient’s resistance or sensitivity towards specific anti-TB drugs. Every patient needs a combination of effective sensitive drugs as per the Standards of TB Care and other treatment guidelines.
Dr Mario Raviglione pointed out that less than 10% patients get drug-susceptibility testing (DST) although the National Strategy Plan (NSP) of India’s RNTCP calls for universal access to DST. “We need to do DST on Day-1 of contact with a person with presumptive TB and not Day 60 or 90 – doing DST that late is a clinical malpractice.”
Dr Ranjini Ramachandran a noted medical microbiologist from WHO India, explained the dilemma confronting India regarding this issue: “It is an important dilemma confronting us – TB community feels that we should be able to do DST on day-1 in order to prevent emergence of drug resistance. On other hand there are capacity building issues. In India we almost entirely rely on smear microscopy which is not going to tell us whether the patient is drug-resistant or not. And we are testing for a miniscule of patients by molecular tests to look for rifampicin drug resistance. So first thing we have to do is to see what are the molecular tests we have and which are the groups that need to be prioritised to have this testing and then gradually scale up for everybody who needs to get this testing – this cannot happen overnight in India.”
“Eventually we do need to identify drug resistance at first point of contact of a patient with a health system (public and private both). Apart from rifampicin resistance there is a growing understanding now that there may be more fluoroquinolone resistance in India. We need to look at drug resistance surveillance survey data which will inform us better [drug resistance surveillance is currently undergoing in India]. We need to build capacity to effectively utilize these tests over the next few years too! Additionally we need to realize that molecular tests cannot serve all our DST needs so we need to build capacity to scale up and fully utilize liquid culture systems” added Dr Ramachandran.
Dr KS Sachdeva, Additional Director General, Central TB Division, Ministry of Health and Family Welfare, Government of India said to Citizen News Service (CNS) that “India is not only addressing MDR-TB but also other forms of drug resistance such as isoniazid (INH) resistance, mono or poly resistance etc. National programme envisions to move towards universal DST and DST-guided treatment by 2019. Already lot of work has been done. We have scaled up laboratories to do liquid culture, gene sequencing, etc to 62 in 2015 – we aim to have 120 laboratories by 2019. This is backed up by a good procurement plan for supplies and drugs. We are also looking at ways on how to improve patient experience of using public [health] system. We have revised our incentives to healthcare providers, we have tried to meet some of the out of pocket costs of patients when they go for TB testing or follow up (these costs get reimbursed by the programme). We are trying to provide counselling to MDR-TB patients in 28 districts and initial results are very encouraging as number of patients dropping out of the programme has come down, treatment outcomes have improved, etc. We are also looking at introduction of new regimens and new drugs.”
Utilizing synergies between different health and development programmes
Dr Nata Manabde rightly commented that “trick lies in addressing issues in interrelated manner.” Dr KS Sachdeva agreed and said “TB-HIV collaborative activities are now a decade old in India. TB-diabetes collaborative activities have been ongoing since 2-3 years and have been scaled up further. We are also looking at smoking cessation for TB patients and other synergies between different health and development programmes.”
Dr Suvanand Sahu added that “We also need to explore how can we use the delivery channels of other health programmes. There is a community outreach mechanism and it will be a missed opportunity not to integrate TB services in those opportunities.”
Dr Paul Nunn pointed out that during JMM it was found that very few HIV infected patients (who did not have active TB disease) were receive Isoniazid Preventive Therapy (IPT). “We need to ensure that IPT is procured in sufficient quantity to give to all those people living with HIV (PLHIV) who do not have active TB disease but have latent TB and to eligible paediatric population.” Dr Sachdeva informed that “Orders for IPT procurement have already been placed. In next 24 months all PLHIV and children less than six years will get IPT. IPT will be provided to PLHIV in antiretroviral therapy (ART) centres.”
The campaign for TB-free India envisions to achieve zero deaths, disease and poverty due to TB. As an intensified supplement to the existing National Strategic Plan (NSP) of RNTCP, it aims to unite existing and new stakeholders in the fight against TB.
India’s fight against TB has certainly come a long way ahead, but the journey through the proverbial ‘last miles’ are going to be defining one – as the programme confronts and hopefully overcomes formidable-looking challenges. Ending TB is possible!