TB control: Can we intensify detection to turn the tide?

At long last, tuberculosis (TB) is a notifiable disease in India. On the May 7, 2012, the ministry of health and family welfare issued a government order that requires all healthcare providers to notify every TB case to local health authorities (e.g. district or municipal health officers). Healthcare providers include clinical establishments run or managed by the government, private or NGO sectors, as well as individual practitioners.

For the purpose of case notification, the government order defines a TB case as: 1) a patient diagnosed with at least one sputum specimen positive for TB bacteria (where TB bacteria are stained and seen under a microscope), or culture positive for TB bacteria (where bacteria are grown in a lab), or rapid molecular test positive for TB (which detect DNA of TB bacteria); or 2) a patient diagnosed clinically (without microbiological proof) and given anti-TB drug treatment.

This move by the government is long overdue and critically important for controlling the TB epidemic in the country. TB control in India is the responsibility of the Revised National Tuberculosis Control Programme (RNTCP). The RNTCP is widely appreciated for having made a big contribution by expanding basic diagnostic and treatment services to cover 100 per cent of the Indian population. This has saved thousands of lives, and ensured free TB diagnostic and treatment services to large numbers of patients.

And yet India continues to have the highest TB burden in the world, with over 2 million new TB cases reported every year and nearly 1,000 deaths every day. While these statistics are staggering and worrisome by themselves, they are mostly derived from the TB database of the RNTCP, largely driven by the number of patients managed in the public sector. Nobody in India has a good handle on the exact number of TB patients managed in the private sector.

The private sector in India is estimated to manage over half of all TB patients in the country, and a majority of Indians initially seek medical care for all ailments in the private sector. So, if the private sector does not notify or report TB cases, one can never really know the true magnitude of the TB problem in the country. Without situational awareness, it is impossible to control any disease epidemic. And without accurate surveillance data, we will never know if our control programmes are effective.

This is clearly demonstrated in two infectious diseases – smallpox and polio. The smallpox eradication programme succeeded because of mass vaccination campaigns to reduce the incidence of smallpox in endemic areas, and surveillance systems which detected and reported cases early enough to permit the containment of outbreaks. The polio eradication programme in India is dependent on an extensive surveillance programme to identify and track every single case of polio in the country. That is how we know that India is no longer endemic for polio.

Mandatory notification

In addition to better tracking and monitoring of the TB epidemic, mandatory notification will also allow expansion of free TB diagnostic and treatment services to poor patients in the private sector who often pay a lot of money, out-of-pocket. More importantly, notification allows the RNTCP to engage with the private sector.

It is well known that TB management practices in the private sector vary widely, often deviating from established standards. For example, inaccurate, blood-based, antibody tests are widely used, along with irrational drug regimens. The governmental order on TB notification does not define a TB case based on antibody blood tests, and the government of India has actually decided to ban these tests which are strongly discouraged by the World Health Organisation. Rampant use of antibiotics is another big concern. Indeed, since TB drugs are easy available over-the-counter, antibiotic-resistance is a major threat for the control of TB. By getting the private sector to notify TB cases, there is now an opportunity to realign their TB care practices with international standards.

Government orders are meaningless, unless they are implemented. The RNTCP is currently planning a ‘next-generation’ information and communications technology (ICT) system that will migrate from paper-based to electronic tracking of TB in India. Along with mandatory notification, such a comprehensive e-TB system will help track each and every TB case in the country, and could revolutionise the way patients are diagnosed, treatment is delivered and monitored, and support public-private mix partnerships to incentivise and engage the private sector. India’s leadership in information technology is well-known. It has displayed the transformational power of e-governance. India needs to leverage these to create an integrated approach to innovation in delivery systems, monitoring and engagement of the private sector.

Ultimately, to control tuberculosis and prevent drug resistance, political commitment and substantially greater resources are necessary. Political commitment has already been shown by the government’s decision to make TB notifiable, and to ban inaccurate TB blood tests. The RNTCP has also shown great commitment by setting the ambitious goal of universal access to quality diagnosis and treatment for all TB patients in the country.

RNTCP’s vision recently received the much-needed financial commitment. The Planning Commission has raised allocation for the RNTCP to about Rs 710 crore for 2012-13, an 80 per cent increase over the last fiscal year’s budget. All these welcome developments suggest that TB control in India is at a critical juncture. Can India turn the tide?

(The writer is a TB researcher and professor at McGill University in Canada)