TB Facts logo

TB in India – TB burden, NSP, private TB care

TB Burden in India

Each year 12 lakh (1,200,000) Indians are notified (that is reported to the RNTCP) as having newly diagnosed TB. In addition at least 2.7 lakh (270,000)  Indians die. Some estimates calculate the deaths as being twice as high. TB can affect any age, caste or class but cases are mainly poor people and mostly men. Slum dwellers, tribal populations, prisoners and people already sick with compromised immune systems are over-represented among the cases, compared to their numbers in the population. Children comprise 40% of the population but are currently under-diagnosed in India.

Case notification is estimated to be only 58%. Over one third of cases are not diagnosed, or they are diagnosed but not treated, or they are diagnosed and treated but not notified to the RNTCP. This could be even high, and the WHO (World Health Organisation) estimates that another 10 lakh (1,000,000) Indians with TB are not notified.

Calls for improved treatment & care for TB in India

Calls for improved treatment and care for TB in India

The economic burden of TB is extremely high. Between 2006 and 2014, TB cost the Indian economy a massive USD 340 billion.

TB treatment & care in India is provided by the government’s Revised National TB Control Programme (RNTCP) as well as through private sector health providers.

In 2013 the number of suspected TB cases examined under the RNTCP increased to 651 per 100,000 population. A total of 928,190 smear positive TB patients were diagnosed. There is more about the testing & diagnosis of TB in India.

In 2014 India achieved complete geographical coverage for diagnostic and treatment services for multi-drug resistant TB. In 2013, 248,000 cases of TB were tested for drug resistance and 35,400 were found to have either MDR or rifampicin resistant TB. However, only 20,700 received treatment. Yet these cases, about a third of the estimated number, cost over 40% of the annual RNTCP budget. There is more about drug resistant TB in India.

HIV & TB co-infection

Almost two thirds of  TB patients registered by the RNTCP received HIV screening in 2013, and 44,000 (5%) were found to be infected. More than 80% of these received anti-retroviral treatment (ART) and 95% received co-trimoxazole preventative treatment (CPT).

RNTCP Phase II (2007-2011)

Before 2010 all patients receiving treatment through the governments RNTCP program, were placed in one of three categories, Cat I, Cat II, or Cat III. This was according to whether they had received treatment before, whether they were seriously ill and whether they were sputum positive. However all categories received different combinations of up to four of the main first line anti TB drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol).

Streptomycin was added for those who had received TB treatment before and who had relapsed. Of course the addition of Streptomycin to an existing failing combination contravened one of the fundamental aspects of TB chemotherapy, which is that one single new drug shouldn’t be added to a failing regime. The fact that this was done meant that effectively no treatment was provided for those with drug resistant TB.

The provision of treatment for patients with drug resistant TB

In 2010, with the launch of the DOTS-Plus Guidelines (in future known as the Programmatic Management of Drug Resistant TB) TB treatment for drug resistant TB started to be provided. Treatment categories I & II became the treatment regimes for new and previously treated patients respectively. Category III was phased out, and two new categories were introduced. These were Category IV for patients requiring treatment for MDR TB, and category V for patients requiring treatment for XDR TB.

There is more about Drug Resistant TB in India.

National Strategic Plan (NSP) 2012 -2017

For the five year plan National Strategic Plan for 2012 – 2017, the vision of the government was for a TB free India, through achieving Universal Access by provision of quality diagnosis and treatment for all TB patients in the community. This was a major policy change. It involved extending the reach of RNTCP services to all people diagnosed with TB, including those with drug resistant TB, and those seeking treatment in the private sector. The new policy also included improving the quality of existing RNTCP services.

The aim was to achieve the following targets by the end of 2015:

  • early detection and treatment of at least 90% of estimated TB cases in the community, including HIV associated TB
  • initial screening of all previously treated (retreatment) smear-positive TB patients for drug resistant TB and the provision of treatment services for multi drug resistant TB
  • the offer of HIV counseling and testing for all TB patients, and linking HIV infected TB patients to HIV care and support
  • successful treatment of at least 90% of all new TB patients, and at least 85% of all previously treated TB patients
  • the extension of RNTCP services to patients diagnosed and treated in the private sector.

Activities to achieve these targets

The RNTCP planed to achieve these targets by:

  • using rapid diagnostics for the diagnosis of TB and drug resistant TB
  • expanding services for the management of multi drug resistant TB
  • strengthening urban TB control
  • strengthening public-private mix initiatives
  • improving the quality of basic DOTS services
  • aligning with National Rural Health Mission supervisory structures.

Development of the Standards for TB Care in India (STCI)

The Standards for TB Care in India has been produced in order that there should be a widely accepted standard for the provision of TB treatment and care in India. Based on other international guidelines and standards, it was developed by a large number of organisations and individuals, both within and outside of the Government of India (GOI). It was first published by the World Health Organisation in 2014. The Standards describe what should be done, and the TB treatment and care that should be provided throughout India. This is in contrast to the national guidelines from the Central TB Division of the GOI which describe how actions are to be accomplished.

There is more about the treatment that is provided for TB in India including the treatment for drug resistant TB in India and also more about the testing & diagnosis of TB in India, as set out in the Standards for TB care in India. There is also more about the RNTCP.

Private sector health care

The private sector in India, unfortunately, has been a source of mismanagement of TB and hence of drug resistance. This includes the use of incorrect diagnostics (e.g. blood tests), incorrect regimes and a lack of supervision to ensure all TB patients complete their TB treatment. So every effort is being made to engage the private sector in India and improve the quality of care provided by private practioners.1Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/

There is also a lack of regulation for over the counter drugs for TB and this contributes to the problems of drug resistant TB. There have been calls for the Indian government to do more to educate patients about the appropriate tests and the right treatment for TB.2Udwadia, Z “This should not exist”, Hindustan Times, November 27, 2012 www.hindustantimes.com/

The RNTCP has tried to involve non public health providers in promoting TB care, but it is believed that many patients continue to seek treatment elsewhere and currently go unreported. A number of studies and surveys of TB prevalence including self reporting of TB prevalence, have suggested that up to 46% of patients may not be currently reported.3Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONE www.plosone.org/article/info:doi/10.1371/journal.pone.0024160

There are are many reasons why people in India seek care from the private sector. These include:

  • poor knowledge about TB
  • poor knowledge about services available through the national programme
  • the convenience of services
  • a desire for confidentiality
  • a desire for personalized care.

“Many people are unaware that all the medicines needed to treat TB patients are available free of cost at Indian government hospitals. Most people tend to spend huge amounts in private hospitals.”4Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/

Free TB treatment for patients in private sector

In 2014 the Ministry of Health and Family Welfare started a pilot project in Mumbai to provide patients in the private sector with free treatment. Since the scheme started in August 2014 some 10,675 new patients have registered under the scheme of whom 656 are patients with multi drug resistant TB.

Under this scheme, called the Private Practitioner Agency (PPIA), if a patient goes to a doctor who is registered with the PPIA and they are diagnosed with TB, then:

the doctor issues them vouchers for x-ray and medicines. The chemists and labs provide free medication or diagnostic tests when the patient produces the voucher

The government then reimburses the chemists and labs. Under the program a patient only has to pay the private doctor’s consultation fee.

One drawback of the scheme however, is that it only caters for first line TB treatment. Multi drug resistant TB patients still have to register with the RNTCP in order to get free treatment. As TB treatment takes a long time it has been realised that free medicines are necessary if people are not going to abandon their treatment.

The scheme has been so successful in Mumbai that it has already been started in Nagpur and it is going to be started in a number of other cities as well.5Barnagarwala, T “Free TB treatment plan a hit in Mumbai, ministry to replicate project in other cities, Indian Express 2015, Mumbai-free-tb-treatment-plan-a-hit

Making TB a notifiable disease in India

With the aim of improving the collection of patient care information, in May 2012 India declared TB to be a notifiable disease. This meant that in future all private doctors, caregivers and clinics treating a TB patient had to report every case of TB to the government.6Sinha, K “Finally, tuberculosis declared a notifiable disease”, The Times of India, May 9, 2012 //articles.timesofindia.indiatimes.com/2012-05-09/india/31640562_1_mdr-tb-tb-cases-tb-diagnosis

Comments made in response to this move included concerns about enforcement of notification by private practioners;

“This is definitely a positive step forward. But, I am skeptical about the practical possibility in implementing the policy. Most private practioners consider themselves unaccountable to the government. .. The government should be clear about the action that will be taken in case of non compliance of the private practioners.”

There was also concern about whether when people are referred to the RNTCP from the private sector there would be a good enough service, and whether in practice treatment would be available.

A year later it appeared that the concern about whether all patients would be notified was justified, as it was said that:7“Two suspected cases of resistant TB strain in Bhopal”, The Hindu, May 28, 2013www.thehindu.com/health/medicine-and-research/guidelines-for-tuberculosis-notification-sent-out/

“A year after TB patient reporting to the government has been made mandatory for private practioners and hospitals, most cases are going unreported.”

Dr Kl Sahu, State TB officer, Madhya Pradesh

According to Indian government data of the estimated 90,000 TB cases handled by private doctors, only 5,000 were reported in Madhya Pradesh. However, in other parts of India although there was a slow start to reporting there were beginning to be improvements. In Pune there have been 727 new TB cases reported by private hospitals and clinics between May 2012 and July 2013.8“Private hospitals report 700 TB cases”, The Times of India, August 19, 2013http://articles.timesofindia.indiatimes.com/2013-08-19/pune/

“Initially the response was poor but now, with constant follow-up, private doctors and hospitals have started notifying us of the TB cases”

S T Pardeshi, Medical officer of health, Pune Municipal Corporation

Major Sources for TB in India

Draft 2015 report on Indian Revised National TB Control Programme from Joint Monitoring Mission www.tbonline.info/media/uploads/documents/jmmdraft2015.pdf

Revised National Tuberculosis Control Programme Guidelines on Programmatic Management of Drug Resistant TB (PMDT) in India www.tbcindia.nic.in

Revised National Tuberculosis Control Programme National Strategic Plan 2012-2017

Standards for TB Care in India www.tbcindia.nic.in

TB India 2015 Revised National TB Control Programme Annual Status Report, New Delhi, 2015 www.tbcindia.nic.in

References

   [ + ]

1. Pai, M “Formidable killer: drug-resistant tuberculosis”, The Tribune, India, August 6, 2013www.tribuneindia.com/2013/
2. Udwadia, Z “This should not exist”, Hindustan Times, November 27, 2012 www.hindustantimes.com/
3. Satyanarayana, S “From where are Tuberculosis patients accessing treatment in India? Results from a cross-sectional community based survey of 30 districts”, PLoS ONE www.plosone.org/article/info:doi/10.1371/journal.pone.0024160
4. Bhalchandra Chorghade “To fight MDR-TB, act on time”, http://dnasyndication.com/dna/MUMBAI/
5. Barnagarwala, T “Free TB treatment plan a hit in Mumbai, ministry to replicate project in other cities, Indian Express 2015, Mumbai-free-tb-treatment-plan-a-hit
6. Sinha, K “Finally, tuberculosis declared a notifiable disease”, The Times of India, May 9, 2012 //articles.timesofindia.indiatimes.com/2012-05-09/india/31640562_1_mdr-tb-tb-cases-tb-diagnosis
7. “Two suspected cases of resistant TB strain in Bhopal”, The Hindu, May 28, 2013www.thehindu.com/health/medicine-and-research/guidelines-for-tuberculosis-notification-sent-out/
8. “Private hospitals report 700 TB cases”, The Times of India, August 19, 2013http://articles.timesofindia.indiatimes.com/2013-08-19/pune/