Tuberculosis is a major public health problem in India. Early diagnosis and complete
treatment of TB is the corner-stone of TB prevention and control strategy.1
Notification is one of the earliest measures in public health practice.
It is especially employed for communicable and other acute diseases where public health action may be triggered
by an individual case, or where an individual case may be the indication that a disease outbreak is occurring.2
Notification, if implemented effectively, informs policy makers and programme managers about the burden of disease in the
community which helps in planning, implementing and evaluating health promotion and disease intervention programmes. However,
notification is also criticized as it affects the privacy and confidentiality of patients, and disregards their autonomy and
human rights.3
Our country has a huge private sector and it is growing at enormous pace.
Private sector predominates in health care and TB treatment. Extremely large quantities of anti-TB drugs
are sold in the private sector. Non standardized prescribing practices among some of the private providers
with inappropriate and inadequate regimens and unsupervised treatment continues without supporting patient
for ensuring treatment adherence and completion with unrestricted access to first and second line TB drugs
including without prescription. This frequently leads to treatment interruptions and subsequent drug resistance.1
Recently researchers at the Hinduja Hospital in Mumbai documented the presence of
Totally Drug Resistant strain of TB (TDR-TB) in India for the first time in the December 21, 2011. Though the
Union ministry of health has denied the presence of TDR-TB reported in Mumbai, there is nothing extra-ordinary
that these cases have come up.
India has become the third country in the world to identify patients with TDR-TB.
Earlier, TDR-TB cases were first identified in 15 patients in Iran in 2006 and then in Iraq in 2007.The authors
write, Only 5 of 106 private practitioners practising in a crowded area called Dharavi could prescribe a correct
prescription for a hypothetical patient with MDR tuberculosis. The majority of prescriptions were inappropriate and
would only have served to further amplify resistance, converting MDR tuberculosis to XDR tuberculosis and TDR tuberculosis.
In order to ensure proper TB diagnosis and case management, reduce TB transmission and
address the problems of emergence of spread of Drug Resistant-TB, it is essential to have complete information of all
TB cases. Therefore, Govt. of India declared Tuberculosis a notifiable disease on 7th May 2012. All public and private
health providers shall notify TB cases diagnosed and/or treated by them to the nodal officers for TB notification.4
Issues regarding Notification
Making TB a notifiable disease, will, perhaps, yield some positive outcomes for instance,
all private doctors or healthcare providers, laboratories and other caregivers will have to report every single case
of TB to the government which will surely give a more real situation analysis of the burden of TB, where TB patients
are getting treated and who is treating them (public or private healthcare centres), and other data that might have a
positive outcome on public health. However, this may also boomerang especially for those populations who are currently
unreached and might be forced to go underground for a range of reasons and refrain from accessing public or private
healthcare system. Will making TB a notifiable disease really help us reach these unreached populations is a big
question to which we see no clear answer.
We also apprehend confidentiality related issues and ethical issues regarding HIV notification.
There is another brewing human rights question. With close to 100,000 people estimated to
contract multidrug-resistant TB (MDR-TB) in India annually, the RNTCP has provided standard treatment to only 3610
patients since the inception of DOTS-Plus programme (source: RNTCP Report, December 2011). Turning down, or not
reaching out, or not being able to reach out, to the remaining cases is, honestly, unacceptable in terms of
public health as well as social justice and a looming human rights emergency.
When there will be no treatment provided by the RNTCP for every person who needs
MDR-TB treatment, care and support, making every TB case notifiable, might have very far-reaching serious consequences
for the patient, her family and TB control in general. Has the government considered the impact of a positive diagnosis
of drug-resistant TB on the patient, her family and community, when the treatment may not be available for her?
Presently MDR-TB treatment is available to less than 3% and 97% of those-in-need are denied treatment, care and
support for MDR-TB. In communities that are identified to be at higher risk of TB such as injecting drug users,
illegal migrants, people living with HIV (PLHIV), among others, making TB a notifiable disease might not bear
positive public health results.5
Challenges to implementation
Declaring a condition or disease notifiable is only the first step; more important
is effective implementation of the notification. There is enough evidence of ineffective implementation of existing
regulations in India.6 If a few private providers (both practitioners and laboratories) comply with
notification and others do not, patients may opt for a facility which does not notify as they may fear the dangers of
notification i.e. breach of privacy with consequent stigma and discrimination. This might shunt patients from a facility
that notifies to a facility that does not notify; the latter is not likely to meet any adequate standards of care. The
possibility of notification leading to such an adverse outcome cannot be ruled out. To summarize making TB a notifiable
disease alone will not help unless accompanied by a very sensitive approach that ensures that no negative public health
or social justice outcome is allowed to negate the gains made by TB control in the past years. There is a need to work
on rational use of anti-TB drugs as well as involvement and regulation of the private sector. Such measures could then,
create some benefits in terms of protection of the health of patients and their contacts. Notification would be justified
if such a multi-pronged approach could save some lives.
References:
- Central TB Division, MOH&FW. Guidance for TB notification in India 2012. Available at
http://tbcindia.nic.in/pdfs/Guidance%20tool%20for%20TB%20notification%20in%20India%20-%20FINAL.pdf.
Accessed March 29th, 2013.
- Birkhead GS, Maylahn CM. State and local public health surveillance. In Teutsch S, Churchill R, editors.
Principles and practice of public health surveillance. New York: Oxford University Press; 2000. pp 264-246.
- Gawde N. Do we need notification of tuberculosis? A public health perspective. Indian Journal of Medical Ethics.
2013 Jan-Mar;X(1):56-58.
- Matharu S. Totally drug resistant TB surfaces in Mumbai, govt. in denial: One World South Asia. Available at
http://www.downtoearth.org.in/content/totally-drug-resistant-tb-government-denial-mode. Accessed March 29th, 2013.
- Shukla S, Ramakant B. CNS. Available at http://www.citizen-news.org/2012/05/what-does-making-tb-notifiable-disease.html. Accessed April 2nd, 2013.
- Duggal R. The notifiable disease syndrome: Health administrator [Internet]. 2008;21(1-2):79-80. Available at http://data.unaids.org/Publications/IRC-pub01/jc338-namebased_en.pdf. Accessed April 8th, 2013.
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