Introduction
India has far more cases of tuberculosis than any other country in the world. There are about 2 million new cases each year and India accounts for nearly one third of prevalent cases globally.
Tuberculosis is an infectious disease that commonly affects the lungs, but can affect any part of the body. It develops slowly and can lead to prolonged ill health. Tuberculosis is caused by a bacterium called Mycobacterium tuberculosis. This bacterium usually attacks the lungs but may also lodge in the lymph glands. From here the disease may spread to any part of the body including brain, intestines, kidneys or bones. As reported by researchers in the October 31st issue of the New England Journal of Medicine, by September 2001, about 3.4 million patients had been evaluated for tuberculosis, and nearly 8,00,000 had received treatment, with a success rate greater than 80 percent. More than half of all those treated in the past 8 years were treated in the past 12 months. According to the study, tuberculosis kills nearly 500,000 people in India each year. Until recently, less than half of patients with tuberculosis received an accurate diagnosis, and less than half of those received effective treatment.
TB in India:
- India has one third of all TB patients in the world
- 40% of the Indian population is infected with TB bacillus
- Each day, 20,000 get infected and 5,000 develop the disease
- Each year 18 lakh people develop TB, of whom 8 Lakh are infectious
- More women die of TB than all causes of maternal mortality put together
National Tuberculosis Control Programme The Indian tuberculosis control programme is now one of the largest public health programs in the world. The programme has been remarkably successful, although it still faces many challenges. Direct health benefits to date include the treatment of 1.4 million patients, and prevention of more than 2,00,000 deaths. The programme has prevented more than 2 million tuberculosis infections and, therefore, more than 200,000 secondary cases. In rural areas, India has an established health infrastructure, with a large health centre for each 1,00,000 people, a smaller clinic for each 30,000 people, and a health post staffed by paramedical staff for every 5000 people.
The Revised National Tuberculosis Control Programme began in October 2, 1993. Diagnosis is primarily by sputum microscopy, treatment is directly observed, and standardised regimens and methods of recording and reporting are used. For diagnosis, physicians are trained to ask all patients attending health care facilities if they have had a cough for three weeks or more. Those with a cough undergo three sputum-smear examinations over a two-day period. If two or three of the smears are positive for acid-fast bacilli, anti-tuberculosis treatment is initiated. If all three smears are negative, one to two weeks of broad-spectrum antibiotics (e.g., trimethoprim–sulfamethoxazole) are prescribed. If only one of the three smears is positive or if symptoms persist after the administration of broad-spectrum antibiotics, a chest X-ray is obtained, usually at a larger health centre, and the patient is evaluated.
Policy direction and supervision, drugs, and microscopes are provided by the Central Government. State governments hire the general health staff as well as the specialised staff of the district tuberculosis centres, clinics, and hospitals. On the basis of their clinical features, patients are given one of three categories of treatment. All treatment is given three times weekly.
The Outcome Eight years later, delivery of service had begun in 211 districts of 19 states covering 436 million people (43 percent of the entire population). Nearly 2,00,000 health staff had been trained. More than 3000 laboratories had been provided with electricity and water connections, new binocular microscopes, and reagents.
There had been more than 250,000 supervisory visits, half to patients homes and half to health care facilities. Patient outcomes were reported one year after the start of treatment. Eighty-three percent of 6,66,037 patients due for evaluation were successfully treated. Approximately 20 percent of districts had treatment success rates of less than 80 percent, but only 5 percent had treatment success rates of less than 70 percent. For previously treated patients, the rate of treatment success was 71 percent. For patients in whom treatment had previously failed, the risk of failure of the re-treatment regimen was higher than for patients who had previously had a relapse, those who had discontinued treatment prematurely, or other patients undergoing re-treatment.
The Challenges India has faced several challenges in implementing this programme:
- The general health service often does not function optimally. This suggests that patients with tuberculosis can be identified and treated even in a relatively dysfunctional health care system.
- A large and mostly unregulated private sector provides a substantial proportion of outpatient care, and this care is of inconsistent quality.
- The level of socio-economic development can have a major effect on programme performance.
- The role and effectiveness of the government system also pose a challenge.
- Ensuring the quality of drugs is difficult.
- Establishing patient-friendly services so that no patient should have to pay for transportation or lose wages to participate.
Conclusion Sustaining this programme in India will require continued financial support, particularly for drugs and contractual supervisors, as well as continued and intensified supervision and monitoring. The creation and equipping of small laboratories and the initial training of large numbers of health workers should have long term benefits. The rate of decline in the incidence of tuberculosis will be affected by the proportion of cases resulting from recent transmission, as well as by other factors. It will be at least several years before the Indian programme can be expected to have a discernible effect on disease incidence.
Further expansion to cover the entire country is under way, with plans to cover 80 percent of the country by 2004. Coverage of the entire country will require training of 20,000 more doctors and more than 1,00,000 allied health staff, improvements in more than 6000 laboratories, and the medications to treat more than 1 million patients per year. Given the success of the programme to date, expansion on this scale appears to be possible, but it is far from assured. Continued high-level commitment and technical rigour from the central and state governments of India and assistance from international organisations will be essential.