Unless the national programme for TB is made strong, we may end up well short of the desired impact
India ushered in World Tuberculosis day in 2022 on March 24 with mixed feelings. As the Covid-19 pandemic (hopefully) wanes, how are we seeing the other major infection that has silently and surely continued to wreak havoc in the lives of millions of Indians, year after year? TB is our silent pandemic; away from the headlines, it rages on.
The early months of the pandemic saw much discussion around Covid, leading to a drop in identification of new tuberculosis (TB) infection, and growing malnutrition, both of which are associated with a risk of increasing the burden of TB. It is estimated that this decline in access to services and an increase in malnutrition will lead to almost 0.1 million additional deaths due to TB in the coming years.
TB is identified as one of India's major public health problems. Around 1.8 million people developed TB in India, according to the union Health Ministry’s India TB Report 2021. And over 0.4 million died due to TB in India in 2020, according to the World Health Organization. Globally, India accounted for 26 percent of the new cases and over 34 percent of the deaths due to TB.
For patients suffering from TB in large parts of rural India, the Primary Health Centres are by far the most accessible health facilities. Yet the PHCs take care of only a small proportion of the overall burden of TB. Many are understaffed, and many lack essential diagnostic capabilities. Despite these shortcomings, the PHCs can play a larger role if they are geared to build trust.
This requires a greater attention to the patients, thorough examination, respectful behaviour and kind words. Alongside, strengthening primary health centers in general, and equipping them to diagnose and manage patients with tuberculosis in particular will go a long way in promoting access and helping patients navigate what today are largely unresponsive health systems.
Guidelines from the Indian government call for evaluation of all those with coughs for two weeks or more for TB. This guidance has emerged from decades of careful attention and its importance cannot be overstated. We have seen many healthy-looking patients diagnosed with TB, only because as per the recommendations, the sputum test was performed. On the ground, we often see patients being denied these tests, for reasons that the patient “does not look tubercular” or “looks healthy”. Many such patients subsequently go back home, to return after a few weeks or months with severe disease.
It is thus essential to adhere to the guidance for testing for TB, however healthy or well the patient may appear. Major constraints in diagnosing TB are the availability of chest radiography, sputum testing and cartridge-based nucleic acid amplification test (CBNAAT), close and easily enough. Patients with suspected TB continue to make several trips to different places and spend enormous amounts of money and time to be able to get themselves tested.
In the absence of easy availability, many private practitioners start treatment without the necessary tests and many public providers delay the management of the disease. The patients suffer, and also transmit the infection to others during this time. There is a need to urgently expand the diagnostic capabilities, specifically x-ray machines, sputum microscopic testing and CBNAAT machines. We would need to ensure that x-ray machines are available close enough and affordable. For much of rural India, this would mean that we need to have x-ray diagnostic facilities at PHCs.
Progress in testing
While the last decade has seen many advances in the tests for TB making it easier to detect TB as well as identify drug resistance, the process for collecting the sputum sample has remained unchanged. The onus for sample collection still rests with the patient, who may have to travel a few kilometers (such as when visiting a PHC), or even 50 km or more (to CHC or district hospital, for tests such as the CBNAAT).
Sometimes, even after making this arduous journey, the test is denied -- as the sample collection for the day may be complete or the technician is away or the cartridges are finished or the machine is out of order. With a lot of resources diverted towards Covid and the laboratory technicians busy with Covid testing, such denials are now seen even more often. No wonder then that several patients drop out after this contact.
A simple solution to this problem is to transport the sample itself: the patients can deposit their sputum sample at the PHC, from where the PHC staff can transport it to the diagnostic facility. There is strong evidence that such transport of sputum samples helps significantly in improving the detection with much convenience. We need to expand the active transport of sputum urgently.
TB is an infectious as well as a social disease. Its close relationship with determinants including livelihoods, nutrition, gender and culture, influence who will develop the disease as well as the severity thereof. The relationship between TB, informal work and labour-migration is a case in point. South Rajasthan, where we work as physicians, is a rain scarce and food scarce region – malnutrition levels among children and adults are high, and many young men migrate to cities for employment.
Poor nutrition levels, exposure to hazardous work, such as stone carving and mining; and living in overcrowded conditions while in cities lead to high levels of tuberculosis among the migrant workers. Once infected, the disease also transmits to the family members. The deadly combination affects young men the most, leading to reduced work capacity, loss of work, worsening disease and finally death. Many also contract silicosis.
Treatment and recovery from TB will be incomplete if the determinants are also not addressed. The Poshan scheme of the TB programme provides cash transfers towards nutrition and is a welcome move. However, the amount is inadequate for a nutritious diet and the scheme is also fraught with delays and omissions. Ensuring a nutritious diet will require cash transfers, nutritious food through the PDS and measures such as promoting farming and poultry, especially in high-migration areas. Efforts will also be needed to influence deep-rooted practices and customs related to nutrition such as not consuming eggs and animal products (especially among women), and stopping all sour foods and ghee/oil once the treatment has begun. It is imperative to make the workspaces safer, and reduce or ameliorate the risk of lung damage and development of irreversible conditions such as silicosis.
These steps have the potential to influence the disease and outcomes at the different steps in the lifecycle of the disease: by increasing linkages with public health systems, higher case detections and improving treatment outcomes among those diagnosed with TB.
The last decade has seen several new initiatives introduced in the national programme for TB: an addition of new tests, a cash transfer towards nutrition and a promise of newer drugs with the potential to reduce the treatment duration significantly. However, unless the foundation of the programme is made strong, the newer measures may offer little advantage and we may end up well short of the desired impact. We must remember that even today, 1,200 persons die of TB in India each day.
(The writers are doctors and co-founders of Basic Healthcare Services, a Rajasthan-based non-profit that runs primary healthcare centres. Views are personal. By special arrangement with The Billion Press)