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 The Revised National Tuberculosis Control Program uses outdated diagnostic techniques, suffers from repeated medicine stock-outs and lacks capacity to counsel tuberculosis patients, according to the Out of Step report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 

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.