Disease Control

Why India’s TB control is faltering: Poor diagnostics, drug supply disruptions and no counselling

A new report by international NGOs highlights how India lags in both policy and practice in preventing and treating tuberculosis.

India’s tuberculosis control programme is not fully equipped to prevent, diagnose, and treat patients. The Revised National Tuberculosis Control Program uses outdated diagnostic techniques, suffers from repeated medicine stock-outs and lacks capacity to counsel tuberculosis patients, according to the Out of Step report released by the Stop TB Partnership and Médecins Sans Frontières last week.

Tuberculosis is caused by a bacteria which mostly infects the lungs. The Stop TB Partnership is an international body with more than 1,500 partners working towards fighting tuberculosis, and Médecins Sans Frontières or MSF is an international medical charity.

The report, which was released just ahead of the G20 summit on Friday and Saturday, analyses tuberculosis control programmes of 29 countries including India, checks their performance on diagnostics and treatment as per World Health Organisation guidelines and ranks each country.

“India is not looking good on the scorecard,” said Dr Madhukar Pai, associate director at McGill International TB Centre in Montreal, Canada.

Inadequate diagnostics

India is still heavily dependent on smear microscopy, one of the oldest ways of diagnosing tuberculosis. A laboratory technician looks for the tuberculosis bacteria on the slide with the sputum sample. This technique can detect tuberculosis in only 70% of cases, and is not a very sensitive test for pediatric tuberculosis, tuberculosis in HIV patients and extrapulmonary tuberculosis.

As per WHO guidelines, all patients suspected of having tuberculosis infections should be screened using the cartridge-based nucleic acid amplification test or CB-NAAT, which can pick tuberculosis bacteria even in small samples or when there are only smaller amounts of bacteria. The machine also picks out bacteria that are resistant to the tuberculosis drug rifampicin. The results are ready in two hours time.

Last year, India acquired 628 CB-NAAT machines for use across the country. New tuberculosis testing guidelines state that the samples of children, HIV-positive people and patients with suspected extrapulmonary tuberculosis will be tested using these CB-NAAT machine. This means that all other tuberculosis cases will not be checked for whether the infections are caused by drug-resistant bacteria.

“India is still too reliant on sputum microscopy and that means many patients will never get drug susceptibility testing and we will be treating them blind, without any information on whether the drugs will work or not,” said Pai.

Many countries such as Indonesia, Brazil, Kenya and Zimbabwe, offer CB-NAAT testing as an initial test for all suspected tuberculosis cases.

Another drawback in the programme is that few patients who test positive for rifampicin resistance get drug sensitivity tests for other drugs, although the WHO recommends these tests be done. India plans to offer the tests only in a phased manner. Find Diagnostics, a global non-profit organisation that works to provide high-quality, affordable diagnostic tests, is helping the programme begin testing for resistance to second line tuberculosis drugs. Its Line Probe Assay testing method is supposed to provide better profiles of drug resistance in just two days.

“The idea is to extend this second line Line Probe Assay to all laboratories,” said Sanjay Sarin, who heads the organisation in India.

Disruption in medicine supply

Every year, some parts of India are affected by medicine shortages. Scroll.in spoke to the state TB officers of Odisha, Jharkhand and Uttar Pradesh who confirmed stock outs of different TB drugs at different points of time this year.

Dr Sunil Khaparde, the deputy director general of Central TB Division, dismissed these stock outs and said that there were minor distributor-supply issues. However, such disruptions in supply interrupt patients’ treatment and can cause drug resistance.

The government programme is supposed to ensure that TB patients all over India get their daily regimen of drugs and is phasing out the intermittent regimen, which is consists of three doses every week. The intermittent regimen, the Out of Step report said, triples the drug resistance as opposed to the daily treatment. Currently India and China are the only countries among the 29 studied which follow intermittent dosing. Since the beginning of this year, only HIV-positive patients in India have been getting their daily doses of medicine.

(Photo: Daro Sulakauri/MSF)
(Photo: Daro Sulakauri/MSF)

Moreover, two new drugs – bedaquiline and delamanid – that have been approved by the World Health Organisation for treatment especially of drug resistant tuberculosis, are not being used extensively in India. While access to bedaquiline is limited to six centres including Delhi, Mumbai, Chennai, Ahmedabad, and Guwahati, delamanid has not yet been registered as a drug in the country.

Lack of counselling

Priya Gupta (name changed), who works with a non-profit organisation that helps HIV patients, contracted multi-drug resistant tuberculosis in October last year.

“They did not inform me of any side-effects,” said Gupta. “My joints stiffened and I could not even lift my hand. They would not tell me about it for a long time. Later one doctor told me it could be a side-effect of the medicine Pyrazinamide.”

Counselling is an important part of the WHO’s tuberculosis control strategy and, on paper, India’s tuberculosis programme provides for counsellors for MDR-TB patients at district level. However, many of these positions lie vacant, say health activists.

While India’s HIV control programme has Integrated Counselling and Testing Centres where counsellors explain the disease, how drugs should be taken and how the spread of the disease can be prevented, there is very little infrastructure for a similar service in the tuberculosis programme. The National Strategic Plan had aimed to appoint treatment counsellors at every health facility by 2017.

Apart from these specific problems of poor diagnostics, drug supply disruptions and lack of counselling, the tuberculosis programme also suffers from an overall lack of funding. Although Finance Minister Arun Jaitley announced in February this year that India plans to eliminate tuberculosis by 2025, the budget for control of communicable diseases including tuberculosis has been slashed by Rs 13 crore in 2017-’18 compared to the previous year.

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

Virat Kohli and Ola come together to improve Delhi's air quality

The onus of curbing air-pollution is on citizens as well

A recent study by The Lancet Journal revealed that outdoor pollution was responsible for 6% of the total disease burden in India in 2016. As a thick smog hangs low over Delhi, leaving its residents gasping for air, the pressure is on the government to implement SOS measures to curb the issue as well as introduce long-term measures to improve the air quality of the state. Other major cities like Mumbai, Pune and Kolkata should also acknowledge the gravitas of the situation.

The urgency of the air-pollution crisis in the country’s capital is being reflected on social media as well. A recent tweet by Virat Kohli, Captain of the Indian Cricket Team, urged his fans to do their bit in helping the city fight pollution. Along with the tweet, Kohli shared a video in which he emphasized that curbing pollution is everyone’s responsibility. Apart from advocating collective effort, Virat Kohli’s tweet also urged people to use buses, metros and Ola share to help reduce the number of vehicles on the road.

In the spirit of sharing the responsibility, ride sharing app Ola responded with the following tweet.

To demonstrate its commitment to fight the problem of vehicular pollution and congestion, Ola is launching #ShareWednesdays : For every ​new user who switches to #OlaShare in Delhi, their ride will be free. The offer by Ola that encourages people to share resources serves as an example of mobility solutions that can reduce the damage done by vehicular pollution. This is the fourth leg of Ola’s year-long campaign, #FarakPadtaHai, to raise awareness for congestion and pollution issues and encourage the uptake of shared mobility.

In 2016, WHO disclosed 10 Indian cities that made it on the list of worlds’ most polluted. The situation necessitates us to draw from experiences and best practices around the world to keep a check on air-pollution. For instance, a system of congestion fees which drivers have to pay when entering central urban areas was introduced in Singapore, Oslo and London and has been effective in reducing vehicular-pollution. The concept of “high occupancy vehicle” or car-pool lane, implemented extensively across the US, functions on the principle of moving more people in fewer cars, thereby reducing congestion. The use of public transport to reduce air-pollution is another widely accepted solution resulting in fewer vehicles on the road. Many communities across the world are embracing a culture of sustainable transportation by investing in bike lanes and maintenance of public transport. Even large corporations are doing their bit to reduce vehicular pollution. For instance, as a participant of the Voluntary Traffic Demand Management project in Beijing, Lenovo encourages its employees to adopt green commuting like biking, carpooling or even working from home. 18 companies in Sao Paulo executed a pilot program aimed at reducing congestion by helping people explore options such as staggering their hours, telecommuting or carpooling. After the pilot, drive-alone rates dropped from 45-51% to 27-35%.

It’s the government’s responsibility to ensure that the growth of a country doesn’t compromise the natural environment that sustains it, however, a substantial amount of responsibility also lies on each citizen to lead an environment-friendly lifestyle. Simple lifestyle changes such as being cautious about usage of electricity, using public transport, or choosing locally sourced food can help reduce your carbon footprint, the collective impact of which is great for the environment.

Ola is committed to reducing the impact of vehicular pollution on the environment by enabling and encouraging shared rides and greener mobility. They have also created flat fare zones across Delhi-NCR on Ola Share to make more environment friendly shared rides also more pocket-friendly. To ensure a larger impact, the company also took up initiatives with City Traffic Police departments, colleges, corporate parks and metro rail stations.

Join the fight against air-pollution by using the hashtag #FarakPadtaHai and download Ola to share your next ride.

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