Monday, October 22, 2012

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.

No comments:

Post a Comment