Tuberculosis . . . Are we losing the war?

The Global Tuberculosis Report 2012 is out. From an initial glance it is evident that India is not doing too well in Tuberculosis Control.

A fast glimpse at the statistics -

1. 16 new cases of pulmonary tuberculosis every minute in the world.

2. 26% of the burden is in India, which means every minute we have 4 new cases of tuberculosis in the country.

3. Every 2 minutes, 5 people die of tuberculosis somewhere in the world of which one person is from India. However, it is much better than the earlier statistics which taught us that 2 tuberculosis deaths occured in India alone every 3 minutes. Recalculating, it's now 2 tuberculosis deaths every 4 minutes, or to make it more easier, one death every 2 minutes.

4. There is approximately 300,000 MDRTB patients in the world of whom only 20% patients (60,000) have been identified.

I tried to reput some of the graphs comparing few of the countries with India.

Incidence Rates . . .

	Bangladesh	Bhutan	Cambodia	China	India	Indonesia	Nepal
1990	225	784	580	153	216	206	163
1995	225	561	578	129	216	205	163
2000	225	402	577	109	216	204	163
2005	225	287	510	92	209	199	163
2009	225	220	451	80	190	191	163
2010	225	206	437	78	185	189	163
2011	225	192	424	75	181	187	163

Mortality Rates . . .

	Bangladesh	Bhutan	Cambodia	China	India	Indonesia	Nepal
1990	61	219	155	19	38	53	41
1995	60	131	135	13	38	61	30
2000	57	78	128	8.7	39	56	23
2005	51	55	93	5.7	36	37	22
2009	46	31	70	4.1	29	29	23
2010	45	24	66	3.8	27	28	23
2011	45	17	63	3.5	24	27	23

Case Detection . . .

	Bangladesh	Bhutan	Cambodia	China	India	Indonesia	Nepal
1990	21	26	12	21	80	20	33
1995	21	45	23	33	58	8.7	56
2000	26	50	26	33	49	19	74
2005	39	53	52	74	49	56	75
2009	49	72	62	90	59	65	73
2010	46	88	65	87	59	66	72
2011	45	87	64	89	59	70	71

Now, you can find out that India does not look to have made much progress comparing to countries such as China. We've already have quite a few news articles on the 2012 Report.

As you can well see, our Achilles heel is the Case Detection Rate. For many reasons, we have not been able to make any sort of improvement over the last 15 odd years. 

We at NJH also find it quite difficult to improve the Case Detection Rate and as far as I understand we are one of most under performing Tuberculosis Unit in this area. I tried to put down on what I think are the major reasons. 

A. Leave alone the public health care providers, the primary care provider for a patient with cough is not even a proper doctor. When we see the patient with more than 2 weeks cough at NJH, in 95% of the cases they would have already taken some form of anti-tuberculosis treatment. And most of the time it would be the some INH-RIF combination given in sub-therapeutic dosages. Therefore, even our sputum positivity rates suffer as the drugs would have cleaned up the sputum. Most of the patients who reach us are already in a advanced state and it is with great difficulty that we get to cure them. 

B. Many a time, anti-tuberculosis drugs from outside RNTCP is started without the patient being informed. Now, this is terrible as patients take the medicines for 1-2 months and stop as they feel much better. It is only when they bring old prescriptions that we realise that the patient has been given Anti-Tuberculosis treatment.

C. The quinolone group of antibiotics (ciprofloxacin, levofloxacin etc) are commonly used to treat Respiratory Tract Infections in Indian settings. I propose that this is very detrimental in tuberculosis treatment as almost this group of antibiotics have anti-tuberculosis properties and they are in fact used in MDRTB management. To put it short, the rampant use of antibiotics could end up fueling MDRTB as well as delaying the diagnosis of tuberculosis. 

D. Of late, I've seen quite a number of patients who have been told elsewhere (many of them senior consultants of Respiratory Medicine and Internal Medicine) that the Government Medicines are not good. We have quite a few patients who have insisted that they buy branded medicines for tuberculosis from the drug store than take free RNTCP drugs. We make such patients write a consent before we allow them to do it.

Well, I can go on and on . . .  We need to think of solutions faster. Otherwise, within a span of a decade, we could be facing the onslaught of Multidrug Resistant Tuberculosis. The emergence of XDR-TB makes things worse.

Complicating matters is the complex nature of the disease. Any clinician can easily tell you that it is not too easy a diagnosis many a time. Socio-economic factors also play a major part. The fact that there is strong association between tuberculosis and malnutrition and use of tobacco almost spells the death knell for South Asians.

Recently, when I was discussing the issue of Tuberculosis Control in India, one of my friends commented on whether the program was blemishless. Considering into fact that our country and it's leaders has become a byword for corruption, it is my sincere hope that there is not even an iota of corruption in this programme.

I hope that I would be able to discuss possible solutions and loopholes which would need to be plugged under the present RNTCP of the Indian Government in the next few articles.