Real data

India may have a million more tuberculosis patients than we estimated

A new study indicated that there are 2.2 million tuberculosis patients being treated in the private sector alone.

India has a quarter of the world’s disease burden of tuberculosis. In 2014, the World Health Organisation estimated that there were 2.2 million cases of tuberculosis throughout the country. If that didn’t sound bad enough, a new statistical analysis suggests that there are 2.2 million tuberculosis patients seeking treatment at private healthcare facilities alone, in addition to the 1.6 million cases in government hospitals.

As an indicator of the number of cases of the disease, Nimalan Arinaminpathy, a researcher at the School of Public Health at Imperial College London, and his colleagues from various Indian institutions, analysed the sales of tuberculosis drugs in private healthcare facilities in 2014. They adjusted the data to account for possible over-prescription of drugs and other factors. What they found is that India is more likely to have had 3.8 million tuberculosis cases that year, an increase of a third from the WHO estimate.

“We've known for a while that it is critical to engage with the private sector, to control India's TB epidemic,” said Arinaminathy, the lead author of the paper that has been pubished in Lancet Infectious Diseases. “There are innovative new schemes being developed and piloted, such as efforts to engage with the private sector in Mumbai and Patna. However, our results show that the scale of the problem is even greater than has previously been recognised.”

Inadequate surveillance

Public health experts have repeatedly pointed out the gaps in reporting incidence of tuberculosis and possibility of underestimating the number of cases for the lack of a robust TB surveillance system. Previous estimates of tuberculosis cases in the private sector have relied on informed opinion, which is a reflection of the number of cases that fail to be reported to public health authorities.

In this study, Arinaminpathy and his team turned to data from the ground instead. Despite this, as Arinaminpathy cautions, the results serve to indicate that TB incidence is much higher than previously recognised but better surveillance will still be needed to pin down the true number.

"One of the things we have tried to do is try and divide them by state and we hope that will be a useful instrument for the government to target the states necessary for increase in notification," he added.

The huge gap in recording TB cases might also be due to the fact that many patients with TB symptoms do not approach doctors at the initial stages. “Patients from low-income communities especially, people from urban slums and rural areas, when they develop cough and its persistent, they seek advice from pharmacies,” said Srinath Satyanarayana, a PhD candidate at the McGill International TB Centre at Montreal.

Satyanarayana is the lead author of another study that shows how pharmacies in India contribute to delays in TB diagnosis.

Pharmacy first

Looking at previous analysis that showed that 25% of TB patients have their first contact with the healthcare system at pharmacies, Satyanarayana and his collaborators devised patient simulation study to check how the system works. They trained healthy people to enact symptoms of TB, visit the pharmacists and report the care received. A "simulated patient” would not carry a doctor’s prescription but simply would simply tell a pharmacists that he had a cough.

In some cases a pharmacist would ask about the duration of the cough and if there were other symptoms. The patient would then elaborate with symptoms typical of TB – a cough for more than two weeks, fever and weight loss.

“We found that in only about 13% of cases, [the pharmacist] asked them to go to healthcare providers without providing antibiotics and steroids,” said Satyanarayana. “The remaining 87% of the pharmacies gave them some medicine and in 40% of the cases these contained antibiotic.”

This practice of prescribing antibiotics not only delays a TB patients diagnosis and treatment, it also increases the chances of the disease spreading from the infected person. Secondly, the antibiotics given by the pharmacist will not help a person suffering from TB.

Moreover, unnecessary use of antibiotics only increases anti-microbial resistance, a immense and growing threat in India.

Plugging the gaps

The Revised National Tuberculosis Control Programme, the flagship programme in India for the control of the disease, and the Indian Pharmaceutical Association have out a policy document saying that pharmacists should be able to recognise people with TB symptoms and refer them to the nearest healthcare facility. But the new study shows that a very different reality on the ground.

The silver lining, however, is that in none of the cases did pharmacists give TB drugs without a prescription, a practice that would increase multi-drug resistance TB and make it more difficult to treat. Also, once simulated patients approached pharmacists with sputum tests that confirmed TB, the pharmacist immediately referred patients to hospitals without giving them antibiotics or steroids.

“What RNTCP should recognise is that pharmacies are an important source of healthcare for patients with TB,” said Satyanarayana. “Once they recognise that, they should have a formal mechanism in every district to identify all the pharmacies and inform them what their roles and responsibilities are, and how their practices can help TB control.”

We welcome your comments at letters@scroll.in.
Sponsored Content BY 

How sustainable farming practices can secure India's food for the future

India is home to 15% of the world’s undernourished population.

Food security is a pressing problem in India and in the world. According to the Food and Agriculture Organization of the UN (FAO), it is estimated that over 190 million people go hungry every day in the country.

Evidence for India’s food challenge can be found in the fact that the yield per hectare of rice, one of India’s principal crops, is 2177 kgs per hectare, lagging behind countries such as China and Brazil that have yield rates of 4263 kgs/hectare and 3265 kgs/hectare respectively. The cereal yield per hectare in the country is also 2,981 kgs per hectare, lagging far behind countries such as China, Japan and the US.

The slow growth of agricultural production in India can be attributed to an inefficient rural transport system, lack of awareness about the treatment of crops, limited access to modern farming technology and the shrinking agricultural land due to urbanization. Add to that, an irregular monsoon and the fact that 63% of agricultural land is dependent on rainfall further increase the difficulties we face.

Despite these odds, there is huge potential for India to increase its agricultural productivity to meet the food requirements of its growing population.

The good news is that experience in India and other countries shows that the adoption of sustainable farming practices can increase both productivity and reduce ecological harm.

Sustainable agriculture techniques enable higher resource efficiency – they help produce greater agricultural output while using lesser land, water and energy, ensuring profitability for the farmer. These essentially include methods that, among other things, protect and enhance the crops and the soil, improve water absorption and use efficient seed treatments. While Indian farmers have traditionally followed these principles, new technology now makes them more effective.

For example, for soil enhancement, certified biodegradable mulch films are now available. A mulch film is a layer of protective material applied to soil to conserve moisture and fertility. Most mulch films used in agriculture today are made of polyethylene (PE), which has the unwanted overhead of disposal. It is a labour intensive and time-consuming process to remove the PE mulch film after usage. If not done, it affects soil quality and hence, crop yield. An independently certified biodegradable mulch film, on the other hand, is directly absorbed by the microorganisms in the soil. It conserves the soil properties, eliminates soil contamination, and saves the labor cost that comes with PE mulch films.

The other perpetual challenge for India’s farms is the availability of water. Many food crops like rice and sugarcane have a high-water requirement. In a country like India, where majority of the agricultural land is rain-fed, low rainfall years can wreak havoc for crops and cause a slew of other problems - a surge in crop prices and a reduction in access to essential food items. Again, Indian farmers have long experience in water conservation that can now be enhanced through technology.

Seeds can now be treated with enhancements that help them improve their root systems. This leads to more efficient water absorption.

In addition to soil and water management, the third big factor, better seed treatment, can also significantly improve crop health and boost productivity. These solutions include application of fungicides and insecticides that protect the seed from unwanted fungi and parasites that can damage crops or hinder growth, and increase productivity.

While sustainable agriculture through soil, water and seed management can increase crop yields, an efficient warehousing and distribution system is also necessary to ensure that the output reaches the consumers. According to a study by CIPHET, Indian government’s harvest-research body, up to 67 million tons of food get wasted every year — a quantity equivalent to that consumed by the entire state of Bihar in a year. Perishables, such as fruits and vegetables, end up rotting in store houses or during transportation due to pests, erratic weather and the lack of modern storage facilities. In fact, simply bringing down food wastage and increasing the efficiency in distribution alone can significantly help improve food security. Innovations such as special tarpaulins, that keep perishables cool during transit, and more efficient insulation solutions can reduce rotting and reduce energy usage in cold storage.

Thus, all three aspects — production, storage, and distribution — need to be optimized if India is to feed its ever-growing population.

One company working to drive increased sustainability down the entire agriculture value chain is BASF. For example, the company offers cutting edge seed treatments that protect crops from disease and provide plant health benefits such as enhanced vitality and better tolerance for stress and cold. In addition, BASF has developed a biodegradable mulch film from its ecovio® bioplastic that is certified compostable – meaning farmers can reap the benefits of better soil without risk of contamination or increased labor costs. These and more of the company’s innovations are helping farmers in India achieve higher and more sustainable yields.

Of course, products are only one part of the solution. The company also recognizes the importance of training farmers in sustainable farming practices and in the safe use of its products. To this end, BASF engaged in a widespread farmer outreach program called Samruddhi from 2007 to 2014. Their ‘Suraksha Hamesha’ (safety always) program reached over 23,000 farmers and 4,000 spray men across India in 2016 alone. In addition to training, the company also offers a ‘Sanrakshan® Kit’ to farmers that includes personal protection tools and equipment. All these efforts serve to spread awareness about the sustainable and responsible use of crop protection products – ensuring that farmers stay safe while producing good quality food.

Interested in learning more about BASF’s work in sustainable agriculture? See here.

This article was produced by the Scroll marketing team on behalf of BASF and not by the Scroll editorial team.