"What we have achieved in the past decade in TB control, we weren't able to achieve in the preceding 30-40 years of national TB programme" said Dr KS Sachdeva, Chief Medical Officer (CMO), Central TB Division, Government of India.
RNTCP, is run by Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, has achieved a new sputum positive TB case detection rate of more than 73% in 2010 and a treatment success rate of more than 87% against global benchmark of 70% and 85% respectively (these benchmarks were used by WHO Stop TB Strategy only till 2005). The WHO recommended treatment for TB called Directly Observed Treatment Short-course (DOTS) is now being offered to more than 1,25,000 patients each month in India, which is largest in the world in terms of patients initiated on treatment in a country.
"As we all know, TB is an infectious disease and it is very important for us to detect TB early and provide complete treatment. It is seen that most patients do not feel the need to continue the treatment as they feel better of the programme emphasizing for adherence to the treatment and keeping default rate to the minimum with the help of community DOTS provider, majority of the patients enrolled under the programme complete their treatment" said Dr Sachdeva. One wonders if RNTCP programme performance is optimal, then how come India is home to one of the highest burdens of drug-resistant TB?
UNIVERSAL ACCESS TO QUALITY TB CARE FOR ALL TB PATIENTS FROM WHICHEVER HEALTHCARE PROVIDER THEY CHOOSE TO SEEK CARE
Dr Sachdeva further informs that having achieved the global objectives of case detection and treatment success rate for last three consecutive years (these ‘global objectives’ of detecting 70% new TB cases and treating 85% of them, were in use by global WHO Stop TB Strategy till 2005), the programme has set for itself an ambitious target of Universal Access to Quality TB Care for all TB patients from whichever healthcare provider they choose to seek care. This calls for reaching out the unreached and fostering an active involvement of private healthcare providers, non-governmental organisations and empowering community to demand for quality anti-TB services. This probably refers to implementing the Patients' Charter for TB Care – a rights and responsibilities based framework that is an integral component of WHO Stop TB Strategy – but hasn't been rolled out satisfactorily - in letter and spirit.
Newer challenges like multi-drug resistant TB and TB-HIV co-infection have the potential to reverse the gains made by the programme in the last decade. Conscious of these challenges, the programme started addressing TB-HIV co-infection. "The intensified TB-HIV package were rolled out by the programme in the year 2000 and the entire country is now implementing TB-HIV collaborative services" said Dr Sachdeva.
The programme recognizes treatment of multidrug-resistant TB (MDR-TB) as a 'standard of care.' With close to 100,000 MDR-TB patients every year in India, it is indeed a matter of hope that India recognizes MDR-TB treatment as a standard of care. However, the number of patients of MDR-TB currently on treatment is abysmally low - and India's RNTCP aims to treat 30,000 MDR-TB patients annually by 2013. Despite of recognizing seemingly-insurmountable challenges, how can one ignore that only a small minority (30,000 every year) of MDR-TB patients in India are, thankfully, likely, to receive standard care by 2013, and many times more number of MDR-TB patients in India will not be able to access the standard care. What are the options for them, one wonders?
Dr Sachdeva said the best way to prevent emergence of MDR-TB is by implementing quality DOTS services. According to the World Health Organization (WHO), drug-resistant TB is the outcome of poor DOTS programme performance. So how will more of the same be a solution, one wonders.
However for patients who do develop MDR-TB, DOTS Plus services for management of MDR-TB were rolled out in thr year 2007 and by December 2010, 12 states are implementing the DOTS Plus and the entire country wil be covered by 2011 in phase wise manner. Covering the entire country, doesn't imply providing standard care for MDR-TB to all - rather as said above, RNTCP aims to at least provide proper care to 30,000 patients annually by end of 2013.
While we should see the challenge MDR-TB poses to TB programmes globally, and in India as well, the country "has one of the most ambitious plans to scale up treatment of MDR-TB compared to any other country in the world" said Dr Sachdeva (because by 2013, the RNTCP intends to place at least 30,000 patients of MDR-TB on treatment annually). Thanks to India for envisioning one of the most ambitious plans to respond to MDR-TB, but honestly it is clearly not enough - and unacceptable - to turn an alarming number of MDR-TB patients on the blind spot.
The treatment duration for MDR-TB is long - two years - and expensive - it costs about Rupees one lakh (INR 100,000) per patient for the drugs alone.
One of the challenges in scaling up treatment is laboratory capacity. The diagnosis of MDR-TB is a laboratory-based diagnosis and needs to be done from a RNTCP accredited TB Culture and Drug Susceptibility Testing (C and DST) Laboratory. Strengthening laboratory capacity of India and other high burden MDR-TB countries is clearly warranted before treatment of MDR-TB patients can be effectively and successfully rolled out. RNTCP currently aims to establish a network of 43 C and DST laboratories to diagnose MDR-TB by end of 2013, said Dr Sachdeva. A value-added service at each of these 43 C and DST laboratories is that it will be equipped with the newer molecular based diagnostic tests (line probe assay - LPA) which can diagnose MDR-TB within 48 hours as compared to 6-12 weeks with conventional tests currently available. This is indeed commendable to reduce the diagnosis time for MDR-TB so drastically and enable the patients to be put on appropriate standard treatment as soon as possible.
"The programme further intends to leverage on newer diagnostic platforms which are being made available by validating and demonstrating their effectiveness in programme settings. The Indian government is committed to support the programme till it ceases to be a public health problem" said Dr Sachdeva.
India and many other countries have made unprecedented progress in TB control programmes over the past decade but a lot more needs to be done by all means to effectively control TB. Only coming years will testify how well India could succeed in achieving universal access to quality TB care for all TB patients from whichever healthcare provider they choose to seek care.
Bobby Ramakant - CNS
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