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Report card grades India's tuberculosis control efforts

A report card grading each Indian state on its effectiveness in controlling tuberculosis was issued on the occasion of World Tuberculosis Day on March 24. As the report indicates, India's success in tackling the disease has been mixed

A report card grading each Indian state on its effectiveness in controlling tuberculosis was issued on the occasion of World Tuberculosis Day on March 24. Issued by a coalition of health advocates, the report card was presented in conjunction with World TB Day events around India.

Four states -- Delhi, Himachal Pradesh, Manipur and Rajasthan - received the highest marks for achieving the TB control targets set by the World Health Organization. These states are detecting and curing at least 6 of 10 people estimated to have infectious TB using high quality DOTS (Directly Observed Treatment, Short Course) treatment services. Gujarat, Kerala, Maharashtra, Tamil Nadu and West Bengal were also commended for making good progress toward reaching this goal.

The progress in other parts of the country was not so encouraging. While DOTS services have been started in most states in the country, the program has not been able to reach substantial numbers of patients with infectious TB. Andhra Pradesh, Assam, Bihar, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Orissa, Punjab and Uttar Pradesh, which together account for 56% of the national population, currently enroll and cure less than 3 of 10 people with infectious TB.

The Revised National TB Control Program (RNTCP) is committed to making DOTS available in all parts of the country, enrolling 7 out of 10 infectious cases and curing 6 out of the 7 enrolled. Since its launch in 1997, the RNTCP has rapidly extended DOTS treatment services to cure 26% of people with infectious TB nationwide.

The report card has been produced by the Massive Effort Campaign against AIDS, TB and Malaria in India, in a collaborative effort with the National Center for Advocacy Studies, Pune, Saahasee, Delhi and Results International.

Facts about Tuberculosis in India

India is comprised of 35 states and union territories. Within India, the primary responsibility for TB treatment falls onto the state governments, with heavy support from the Revised National TB Control Programme (RNTCP). RNTCP began in 1997. DOTS is the central element in the revised programme which also scaled up TB services and infrastructure for treatment.

Through the RNTCP, India has begun one of the largest rollouts of the DOTS treatment strategy over the last 6 years. At present, the government figures put the DOTS coverage at about 550 million people, and the Government is expecting to scale this up to 950 million people in the next 18 months. However, it is important to note that "coverage" - having DOTS services in a district, does not necessarily translate into "detection" - ensuring that all those who have symptoms of the diseases are being diagnosed and treated by DOTS services.

The Global Fund to fight AIDS, TB, and Malaria (GFATM) approved an application in their first round of giving to expand DOTS coverage to 3 new states (56 million people) beginning in 2003. A second round GFATM grant will increase that number 110 million.

The magnitude of the TB problem in India

  • India is home to the largest number of TB cases in the world. More than 30 percent of the global burden of TB is borne by India.
  • Each day in India, more than 20,000 people in India get infected with the tuberculosis bacillus, 5000 people develop TB, and more than a 1000 die - that is nearly one person per minute. The annual number of TB deaths in India is 421,000.
  • India needs to put at least 3500 (70%) of these new TB patients on DOTS (Directly Observed Treatment, Short Course) each day, and cure 2975 out of those (85%) in order to reduce the death rate by half by the year 2010.
  • TB kills more people in India than HIV/AIDS, STD's, malaria and other communicable diseases combined.

DOTS and India

DOTS is the only strategy which has proven effective in controlling TB on a mass basis. To date, 148 countries are implementing the DOTS strategy. India has adapted and tested DOTS in various parts of the country since 1993, with excellent results, and the RNTCP now covers more than 498 million in 23 States.

DOTS is a systematic strategy which has five components:

  1. Political and administrative commitment. TB is the leading infectious cause of death among adults. It kills more women than all causes associated with childbirth combined and leaves more orphans than any other infectious disease. And, since TB can be cured and the epidemic reversed, it warrants the topmost priority, which it has been accorded by the Government of India. This priority must be continued and expanded at the state, district and local levels.
  2. Good quality diagnosis. Top quality microscopy allows health workers to see the tubercle bacilli and is essential to identify the patients who need treatment the most.
  3. Good quality drugs. An uninterrupted supply of good quality anti-TB drugs must be available. In the RNTCP, a box of medications for the entire treatment is earmarked for every patient registered, ensuring the availability of the full course of treatment to the patient the moment he is registered for treatment. Hence in DOTS, the treatment will never fail for lack of medicine.
  4. The right treatment, given in the right way. The RNTCP uses the best anti-TB medications available. But unless treatment is made convenient for patients, it will fail. This is why the heart of the DOTS programme is "directly observed treatment" in which a health worker, or another trained person who is not a family member, watches as the patient swallows the anti-TB medicines in their presence.
  5. Systematic monitoring and accountability. The programme is accountable for the outcome of every patient treated. The cure rate and other key indicators are monitored at every level of the health system, and if any area is not meeting expectations, supervision is intensified. The RNTCP shifts the responsibility for cure from the patient to the health system.

Progress Indicators for India

WHO and RNTCP collect and analyze large amounts of data related to TB and DOTS treatment in India. Much of this data is useful in measuring the progress of TB control in India and identifying where improvements need to be made.

  • Treatment success in 2000 cohort: 84%
  • DOTS detection rate 2001: 23%
  • DOTS is available to approx. 55% or population, or 550,000,000 people (at end of 2002)
  • DOTS treatment success rate 84% of new smear-positive cases
  • Default rate (or those dropping out of DOTS treatment): 9%
  • Proportion RNTCP budget available: 100% (i.e. no funding gap for 2003)
  • Government contribution to available RNTCP funding, including loans: 90%
  • Government contribution to total TB control costs, including loans: 97%
  • Proportion gov't health expenditures used for TB: 1.9%

Social and economic toll on India from TB epidemic

  • In dollar terms, TB costs India more than 3.3 billion USD each year.
  • More than 80% of the patients are in the economically productive age group of 15 to 54.
  • It causes the loss of at least 100 million work days per year due to illness alone.
  • More than 300,000 children leave school each year on account of parental TB.
  • More than 100,000 women are rejected by their families on account of having TB.

What major challenges remain?

Funding Uncertainties

Currently, the Government of India spends about 35.6 million USD annually for RNTCP, of which 30.4 million USD comes from external sources such as the World Bank and bilateral aid. Much of the current funding expires in September 2004 and renewal is uncertain. This is a matter of concern as a funding gap of 27 million USD would remain if this void goes unfilled.

Multi Drug Resistance

Also, a matter of serious concern for the TB scenario in India is the problem of Multi Drug resistant TB. MDRTB refers to strains of the bacterium which are proven in a laboratory to be resistant to the two most active anti-TB drugs, isoniazid and rifampicin. Treatment of MDRTB is extremely expensive, toxic, arduous, and often unsuccessful.

DOTS has been proven to prevent the emergence of MDRTB, and also to reverse MDRTB where it has emerged. MDRTB is a tragedy for individual patients and a symptom of poor programme performance. The only way to confront this challenge is to improve the treatment programme and implement DOTS as rapidly as possible. A poorly performing programme will create drug-resistant cases at a faster rate than these cases can be cured, even if unlimited resources are available.

TB and HIV/AIDS

People who are infected with TB and who are also infected with HIV are at a much greater risk of becoming sick with TB as a result of deteriorated immune systems. Without HIV, the lifetime risk of becoming sick with TB in TB-infected people is about 10%, compared with at least 50% in people infected with both HIV and TB. TB "piggy-backs" on the HIV virus and therefore the current HIV pandemic could vastly increase the incidence of TB. HIV/AIDS also makes it much more difficult to identify new cases of TB through a sputum culture.

Massive DOTS expansion, using the private sector

Thus far, the RNTCP has impressively expanded DOTS treatment in India. However, much remains to be done. Just over half of the Indian population lives in a DOTS coverage area and the massive expansion planned for the next 18 months could run into difficulty. Care needs to be taken to ensure that as the services and treatment are scaled up, the quality which ensures successful treatment is not lost.

One method of expanding DOTS services is through engaging the private sector. The idea is to get DOTS delivered through private practitioners, who currently do not provide this service. Obstacles are communications with this sector, raising awareness within this community, adequate training of this sector. This provides an excellent opportunity to scale up DOTS services and engage a the business community more intensively.