Increase in TB cases, a major concern

The WHO has put the TB cases in India to 2.8 million in 2015, compared with 2.2 million in 2014

Finally coming to terms with the enormity of its tuberculosis problem, India is preparing a radical overhaul and expansion of its national treatment programme to fight an affliction that kills more adults worldwide than any other infectious disease.

The severity of the matter was underscored last Thursday when the World Health Organisation substantially increased its estimate of the number of new patients with TB in India, to 2.8 million in 2015, compared with 2.2 million in 2014 — more than in any other country in the world and more than a quarter of the world total.

The organisation’s estimate of new global TB patients rose to 10.4 million, from 9.6 million a year earlier, in large part because of the revised numbers in India. But increases were noted in Indonesia and several other countries. The revision in India follows a study published in August in the journal Lancet Infectious Diseases that estimated the number of Indians afflicted with TB at 3.6 million, about 50% higher than previous Indian government and WHO figures for 2014. The increase confirms numerous Indian district and state studies from recent years.

Tuberculosis, an ancient and deadly bacterial disease that most commonly affects the lungs, has been curable for decades using a cocktail of antibiotics taken for six months. India brought this cure to the masses in the 1990s, and had early success in reducing the number of cases. But that faded, in part because it failed to reach patients in the private sector, where the vast majority of Indians get medical care.

The disease killed 4,80,000 people in India last year, accounting for about a quarter of the 1.8 million deaths worldwide, the WHO report said. When not treated properly, tuberculosis not only spreads but also mutates into more drug-resistant forms, which are far more difficult to treat. Multidrug-resistant TB, in which the two most powerful drugs are ineffective, is contagious and curable only about 60% of the time. A Mumbai pulmonologist, Dr Zarir Udwadia, warned in a paper in 2011 that he had found four TB patients who were totally drug resistant.

Experts say the severe underestimation of TB patients in the country was the result of undercounting of patients in the private sector. The government and international experts simply tallied the patients in government programmes and added to those a guess at the number being treated privately. It turns out the world “had little idea of the true scale of the problem in India — the worst affected country,” said Dr Nimalan Arinaminpathy, the lead author of the Lancet paper and a senior lecturer at Imperial College London.

The Lancet authors calculated the amount of TB medicine sold in the private sector and then worked backward to estimate how many people were taking the drugs. Dr Sunil Khaparde, the manager of India’s TB programme and a co-author of the study, agreed in an interview that it had given India a better estimate of its TB problem. But he added that the country plans to conduct a prevalence study during the next three years to determine with more certainty the actual number of cases.

To reach more patients, Khaparde said the government planned to provide free TB drugs and diagnostic tools to patients being cared for by private medical practitioners, as it does now for patients in government programmes. To do so, Khaparde said the government would expand several pilot programmes that have proved successful in involving private medical practitioners. The goal is to ensure that their patients are adequately treated and monitored so that they finish the six-month regimen to be cured of regular TB, or a longer course of nine months to two years to have the best chance of overcoming drug-resistant disease.

The WHO Representative to India, Dr Henk Bekedam, credited the administration of Prime Minister Narendra Modi for not only acknowledging the evidence of greater prevalence of the disease but also being ready to carry out significant changes to the government’s long-standing TB programme. India plans to increase spending to $300 million from $96 million, Khaparde said.

Five-year plan

Modi personally led a 1 1/2-hour review of the country’s TB programmes with top health officials and state officials earlier this year, demanding improvements. “Its good he’s interested and wants to see things changed,” Bekedam said, adding that the main question now was how quickly and effectively the country could put the changes in place. A new five-year plan scheduled to take effect in 2017 is still being drafted.

Udwadia, in an interview, called the revised estimates of turberculosis in India “long overdue,” but expressed scepticism that the government would successfully expand the pilot programmes. “I don’t see them rolling out on a countrywide basis,” he said. “They will remain small pockets in isolation.”  To succeed, the programme will have to persuade private practitioners and their patients to use the free diagnostics and medicines provided by the government, said Dr Sreenivas A Nair, the WHO’s tuberculosis officer in India. In the past, the government failed to persuade private practitioners to send their patients to the government programmes.

The new programme does not try to persuade private practitioners to give up their patients, but instead allows them to continue treating the patients while they register for the government’s free diagnostics and drugs. Once registered, the patients are monitored by the government, which offers home visits, counselling and screening of household members. The greatest dangers are an interruption in treatment or a cocktail of medicines too weak to kill the bacteria, which can help breed drug-resistant forms of the disease.

To improve the monitoring, the government plans to instruct patients to call after taking their daily doses. If no call is made, reminders will be sent to patients, their family members and, finally, health workers. “For TB, what’s required is proper surveillance,” Sreenivas said. “Why we eradicated polio is we know where the cases are and take action.”

India already derives more than half of its funding for fighting TB from international aid groups. Sreenivas said India would need more assistance to expand its programmes. The Global Fund to Fight AIDS, Tuberculosis and Malaria, which expects to spend $119 million on tuberculosis programmes in India in 2016, “will definitely consider any proposal that supports a major expansion of India’s programs on TB,” said Seth Faison, a spokesman.