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OJHAS Vol. 10, Issue 4:
(Oct-Dec 2011) |
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| Management of Tuberculosis- The
Need to Enforce Proper Treatment Guidelines among Private
Practitioners in India. |
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Vishnu Sharma M, Professor and Head, Dept of pulmonary Medicine, AJ Institute of Medical
Sciences, Mangalore, Karnataka, India,
Anupama N, Associate Professor, Dept. of Physiology, Kasturba
Medical College, Mangalore, Karnataka, India. |
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Address for Correspondence |
Associate Professor,
Dept. of Physiology,
Kasturba
Medical College,
Mangalore, Karnataka, India.
E-mail:
anupamavsharma@yahoo.com |
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Sharma VM, Anupama N. Management of Tuberculosis- The
Need to Enforce Proper Treatment Guidelines among Private
Practitioners in India. Online J Health Allied Scs.
2011;10(4):1 |
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Submitted: Jan 13,
2012; Revised: Jan 14, 2012; Accepted: Jan 14, 2012; Published: Jan
15, 2012 |
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| Abstract: |
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Tuberculosis
continues to be a daunting challenge for our healthcare system. Even after
fifteen years of the much publicised Revised National Tuberculosis Control
Programme that envisages directly observed short course chemotherapy (DOTS), TB
continues to spread and drug resistant strains, MDR and XDR, are also
increasingly reported. More than 50% of TB patients seeking private health care,
but the level of awareness regarding treatment of TB among private practitioners
appears to be poor. All this call for an urgent revamp of TB control strategy in
India.
Key Words:
Tuberculosis, RNTCP; MDR tuberculosis
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The
disease tuberculosis (TB) is as old as mankind. Despite being curable
with proper treatment, the disease burden in terms of morbidity and
mortality is still very high in India. India has the highest TB burden
in the world accounting for one fifth of the global incidence of
TB.(1) About 10 million people in India have pulmonary tuberculosis.
Among them about 2.5 million are sputum positive.
Improper treatment of tuberculosis leads to development of drug resistance. MDR TB and XDR TB are on the rise in India.
According to national TB control programme, 2011 report, about 73,000 patients in
India suffer from multidrug resistance
TB.(2)
In India about equal number of TB cases are treated by both private
and public sector.(3) However there is no system of recording or reporting
of TB cases detected and treated in the private sector. Hence the estimates
by RNTCP regarding tuberculosis may not reflect the actual burden of TB in
India. Besides, no nation-wide survey has been conducted in the recent years
regarding the incidence of TB, drug resistance in TB and treatment compliance
and outcome of cases.
The best method
to control tuberculosis and to prevent the emergence of drug resistance TB is
early diagnosis and proper treatment of cases to ensure a cure for all detected
cases. Aiming for a cure in the majority of detected cases is not sufficient as
the others who have active disease will spread the infection.
A study conducted by the Global Alliance for TB drug development found
that more than 35% of all the treatment in the private sector in India
fall outside the national and international recommendation and constitute
non recommended strengths.(4) A study by Udwadia et al in Bombay (2010)
showed that only 6 doctors out of 106 respondents wrote a correct regimen for
tuberculosis.(5) It is estimated that
50-80% of TB patients in India still seek treatment in private sector. The
treatment in private sector in India is substandard according to many
studies.(6-8)
Out of the total market of USD 94 million for the first line anti TB
medicines in India, public sector purchases drugs worth USD 24 million.
Private sector purchase accounts for the remaining USD 70 millions.(9)
Private TB drug market in several high burden countries including India
are substantial, stable and complicated.(4) Both loose drugs
and fixed drug combinations are used.
In this issue
of OJHAS, a study by Jyothi Khadse et al point out that there is inadequate knowledge
among private practitioners in India regarding the management of TB.(10) Such studies clearly indicate
that even though RNTCP in India covers the whole population, a substantial
number of TB patients are still treated by the private sector, but most of the
private practitioners do not follow any standard guidelines in managing
TB cases. There are various schemes under RNTCP for public-private partnership,
but the programme has failed to reach the population. Improper management of TB in private sector and failure of RNTCP to
involve the private sector is a cause for concern as this may be one
of the important reasons for development of drug resistance TB.
Hence there is
an urgent need to streamline the management of TB in India to achieve control of
the disease and to prevent the emergence of drug resistance. The health policy
maker in India need to plunge into action before it is too late. How can we ensure a proper management
of tuberculosis in the private sector? We propose the following:
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Make tuberculosis a notifiable
disease
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Regulate the private TB
market to ensure proper dosing and combination.
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Just like Indian MTP act,
implement Indian TB act. Let TB be treated by only doctors with adequate
knowledge and training with a special license to manage TB cases.
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Ensure all TB cases are
managed as per “International standards for TB care”
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Ensure proper recording
and reporting of each case
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Ensure cure for all cases
of TB.
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Ban over counter sale of
TB drugs
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Legal action against those
who do not comply with the standards of care.
-
WHO Report 2011. Global
tuberculosis control. WHO. Geneva. Available at
http://www.who.int/tb/publications/global_report/2011/gtbr11_full.pdf
- TB India 2011. RNTCP
Status Report. Central TB Division, Directorate General of Health Services, Ministry of Health & Family
Welfare, Nirman Bhavan, New Delhi. March 2011. Available at
http://tbcindia.nic.in/pdfs/RNTCP%20TB%20India%202011.pdf
- Uplekar MV, Rangan
S. Private doctors and tuberculosis in India. Tubercle lung dis 1993;74:
332-337.
- Wells WA, Ge CF, Patel
N, Oh T, Gardiner et al. Size and usage patterns of private TB drug
markets in the high burden countries. PLOS One 2011: 6(5)e 18964. doi:10.1371/journal.
Pone.0018964. Available at
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0018964
- Udwadia Z F, Pinto LM, Uplekar
MW. Tuberculosis management by private practitioners in Mumbai,India:
Has anything changed in two decades? PLOS One 2010;5(8):
e 12023. doi:10.1371/journal.pone.0012023. Available at
http://www.plosone.org/article/info:doi%2F10.1371%2Fjournal.pone.0012023
- Uplekar M, Juvekar S, Morankar
S, Rangan S, Nunn P. Tuberculosis patients and practitioners in private
clinics in India. Int J of Tuberc Lung Dis 1998;2;324-329.
- International institute
for population science (IIPS) and Macr International 2007. National
family health survey (NFHS-3), 2005-2006:India. Volume-1.
- Kelkar-Khambete A, Kielmann
K, Pawar S, Porter J, Inamdar V et al. India’s Revised National Tuberculosis
Control programme: Looking beyond detection and cure. Int J Tuber Lung
Dis 2008;12: 87-92.
- Global alliance for TB drug
development. Pathway to patients: charting the dynamics of global
TB drug market. TB alliance, New York. 2007
- Khadse J, Bhardwaj SD, Ruikar M. Assessment of Knowledge and
Practices of Referring Private Practitioners Regarding Revised National
Tuberculosis Control Programme in Nagpur City- A Cross Sectional Study. Online
J Health Allied Scs. 2011;10(4):2.
Available at http://www.ojhas.org/issue40/2011-4-2.htm
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