A close-up of India's tuberculosis epidemic shows, for the first time, how a million of the now 2.8 million TB patients go 'missing' or never show up in the Revised National TB Control Programme.
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Almost 28% of the patients don't have access a government TB centre and around half a million patients either never complete their long diagnostic process or medical treatment, found a joint study by Indian and US scientists published in PLOS Medicine on Tuesday.
The 'missing' patients are important because each patient with active TB can infect 10-15 other people within a year.
Experts from the Indian Council of Medical Research and Harvard University, among others, found that only 39% of all TB patients in India managed a one-year recurrence-free survival.
Using the 'cascade of care' statistical model that helped health economists around the world fine-tune the HIV care programme,
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"We estimated that of about 2.7 million prevalent TB patients in India in 2013, only 72% managed to reach government TB health facilities,'' said the study's main author Dr Ramnath Subbaraman from Harvard Medical School told TOI. At every progressive step, the number of patients kept shrinking. At the stage of seeking successful diagnosis, the 72% had reduced to 60%. Finally, only 53% of the 2.7 million started TB treatment at these centres. Worse, only 45% of WHO's estimated number of patients completed treatment.
A part of the problem is due to inadequate diagnostic facilities. "Each patient has to be diagnosed with two sputum smears and is put on a course of antibiotics. Thereafter the patient undergoes a chest X-ray as well as further treatment before being identified as a TB patient. Many patients living in rural areas don't complete this rigourous process,'' said Dr Subbaraman.
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The study found that the two biggest gaps where patients slipped out of the system were in the diagnosis stage and then during the treatment phase. "Half a million who make it to the government sector are lost in these two stages,'' he added. Worse, barely 14% of the drug-resistant TB patient completed treatment at government centres.
Another of the study's author, Dr Madhukar Pai, from McGill International TB Centre in Canada, said, "For the first time, this study provides us with an end-to-end view of what is happening to TB patients in India, as they try to navigate the health system. It is clear that there are many gaps, and RNTCP needs substantially greater funds to modernize its TB services and track each individual patient, to make sure all patients make it to the finish line.''
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ICMR director-general Dr Soumya Swaminathan, who is also an author of the study, said the government would now concentrate on "active case finding'' in vulnerable populations as well as in spreading awareness among urban slums and tribal areas.
"The cascade study shows that even after diagnosis, people don't start treatment or drop out later. There clearly is a need for counseling services like the ones provided at anti-retroviral treatment centres for HIV,'' she said.
"The need of the hour is to reach all TB patients and avoid delays in diagnosis. We need to now more about how and where patients seek care,'' Dr Swaminathan added