Expert Recommendations to Comprehensively Address India's TB problem
As the government considers taking important initiatives to transform TB control in India, we have requested various experts to put together their thoughts on critical areas which need immediate attention and action. Government action on these issues is not only likely to enhance TB control but also assist in reaching its commitment of Universal Access.
1. Public Awareness and Community Engagement:
India has been a leader in basic TB control. Yet it has failed on issues of prevention, community engagement and empowerment with regard to TB. Patients and patient communities will remain passive recipients of care unless investments are made for empowerment. Our fight to successfully combat TB must begin with engaging and empowering individuals and communities. This can be done if India:
(a). Creates a comprehensive multi-media awareness campaign that is culturally relevant and gender sensitive to ensure awareness of TB, its symptoms and the need for early diagnosis and treatment.
(b). Identifies brand ambassadors and patient advocates at the local and national level through public campaigns and initiate community engagement and empowerment programs to help create awareness and fight stigma.
(c). Creates a multi-lingual TB helpline in each state to provide all information on TB, its symptoms, treatment and availability of government health services.
(d). Strengths community and institutional infection control measures to act as a strong preventive tool.
(e). Create collaborations with all stakeholders especially patient groups and Key Affected Populations.
2. Early and Accurate Diagnosis for All:
Delayed and inaccurate diagnosis is considered one of the primary drivers of India's TB epidemic and its growing menace of drug resistance. India's National Strategic Plan emphasizes the goal of universal access to quality diagnosis. To achieve this critical goal, India must:
(a). Endorse the End TB Strategy (http://www.who.int/tb/post2015_strategy/en/), approved by the World Health Assembly in May 2014 and in line with this strategy scale-up implementation of new diagnostic tests, and offer universal drug-susceptibility testing (DST) to all TB patients by 2017, to ensure rapid detection of all forms of TB.
(b). Substitute sputum smear microscopy with WHO-endorsed, highly sensitive molecular diagnostics by 2017, while simultaneously scaling up capacity for liquid cultures and DST.
(c). Make accurate TB tests in the private sector affordable by waiving import duties on all WHO-endorsed TB diagnostic tests, accompanied by a price control mechanism.
(d). Ensure that all new diagnostics for TB undergo rigorous validation before approval by the Drug Controller General of India (DCGI). This will prevent the use or entry of sub-optimal tests. This will also generate evidence for appropriate diagnostic policy by the RNTCP.
3. Addressing DR-TB as a priority:
Multi- Drug Resistant (MDR) TB is a global epidemic, with as many as 90 countries already reporting Extensively- Drug Resistant (XDR) TB. India is believed to have close to 100,000 cases of MDR-TB. This threatens to reverse the excellent progress made by India's DOTS program over the last few decades. In many of India's urban centers like Mumbai MDR-TB is encountered in frightening numbers with some strains resistant to all available drugs as reported in 2012. A single case of MDR-TB can infect another 10-20 cases a year unless started promptly on effective treatment. Considering the infectious potential of these strains we have the makings of an uncontrollable epidemic. To address this menace, the government must:
(a). Provide all TB patients with an upfront Drug Susceptibility Test, to rapidly identify MDR and more severe forms of DR-TB. It's important that instead of giving a standardized regimen we individualize treatment regimens, choosing only drugs to which we know TB bacteria are sensitive to.
(b). Consider introducing, under controlled conditions, two new drugs Bedaqualine and Delamanid which have the potential of curing the most resistant TB strains. These have recently got FDA and EU approval.
4. Nutrition and Patient Support:
TB often afflicts the most vulnerable commonly between the ages of 15-44 leading to a loss in income and poverty. Also the outcomes of TB treatment require better nutrition. To address these issues the government should:
(a). Provide food/nutrition supplements for all TB patients with low body weight/below poverty line - this will act as an adherence enabler as well as address nutritional issues.
(b). Create economic support programs - to support TB patients and their families during treatment period, to avoid further impoverishment but also encourage family support.
(c). Provide Patient counselors to identify and address risk factors that cause poor outcomes eg. under nutrition, smoking, alcoholism and poor social support.
(d). Employ cured patients as peer counselors and DOTS providers to ensure building empowered communities and providing patient support.
5. Health information systems:
As India struggles with addressing TB, we must recognize the critical need for a robust comprehensive surveillance system for TB needs to be rapidly developed throughout the country to aid planning and action:
(a). While the government has made some progress with the launch of the TB Drug Resistance Survey, we simultaneously need to revitalize the e-system, Nikshay as a repository of confidential patient information and use it effectively to analyze disease trends and target interventions.
(b). Effectively implement mandatory notification to understand the accurate number of TB cases in the country and also effectively monitor their treatment in the private sector.
6. Engaging the Private sector:
By some estimates 70% of all of India's TB patients seek care in the private sector. Many believe that inappropriate treatment in this sector also leads to increased DR-TB. There are several key initiatives that can be taken to innovatively engage and partner with the private sector to control TB:
(a). Private sector Engagement can be done through innovative incentive based schemes such the Public Private Interface Agencies as proposed in the NSP. This should be accompanied by trainings on the Standards of TB Care in India and continuous monitoring.
(b). Through new schemes, the government must ensure that accurate diagnosis and appropriate treatment is available free to all patients in the private sector. To ensure early diagnosis and treatment, this should be done on priority for DR-TB cases nationwide.
(c). The government must widely publicize acceptable guidelines for diagnosis and treatment to ensure that there is harmony between public and private sectors.
7. Prioritize Changes in Treatment of TB:
Current treatment practices for TB in India continue to be disjointed and need several changes to ensure alignment between international practices and the public and private sectors. Some important steps in this regard include:
(a). Provide quality assured drugs for entire treatment period for each patient through accredited public and private outlets/pharmacies.
(b). In line with the expert recommendations shift from the intermittent regimen to the daily regimen under direct observation to have uniformity of care across all healthcare sectors and achieve the vision of the for universal access as also preventing further drug resistance to.
(c). Provide drug susceptibility testing guided treatment as a norm to all suspected drug resistant TB cases to ensure appropriate treatment and prevent MDR-TB cases from becoming XDR-TB.