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[BANGALORE] India’s tuberculosis burden may be more than twice the 1.56 million patients recorded in its official surveillance system, according to studies released on 25 August. 
India’s private healthcare sector may have treated around 2.2 million TB patients in 2014, a number that was not captured in the surveillance system, according to one of two studies in Lancet Infectious Diseases.
A second study, published simultaneously, finds that pharmacists frequently delay the treatment of TB patients by dispensing wrong drugs and also fail to refer them to qualified doctors. On the other hand, the study suggests, pharmacists can play a major role in the management of TB and help prevent the development of drug resistance.

Both studies highlight the urgent need for India’s TB programme to co-opt the private healthcare sector. “To control India's TB epidemic, there needs to be better engagement with the private sector so that patients can receive coordinated, high-quality care that meets international standards,” said Nimalan Arinaminpathy, epidemiologist at the Imperial College London and an author of the first study.

India has the largest number of TB cases in the world, with drug-resistant TB fast emerging as a major threat. Currently, the most effective treatment offered by the government through its Directly Observed Treatment, Short Course (DOTS) programme, under which patients are given free drugs under the observation of government healthcare workers. The quality of healthcare in the private sector, on the other hand, is variable, with patients often not receiving the full course of treatment, or being prescribed irrational combinations of anti-TB drugs. Both are risk factors for drug-resistance.

This makes the high number of 2.2 million patients being treated in the private sector a concern. It also means that the Indian government’s efforts to increase notification —compulsory since 2012 — are falling short. In 2014 only 106,414 private-sector patients were notified, in addition to the 1.42 million cases recorded in the public sector. “Government efforts (to increase notifications from private sector) need to continue, and to be further amplified,” said Arinaminpathy.

Arinaminpathy’s team estimated the number of TB patients treated privately from the sales of 189 tuberculosis drugs in India. By assuming that treatment lasted 2—6 months, they calculated the number of patients treated in 2014 at around 2.2 million — far above a WHO estimate of 800,000 patients in the private sector.

In the second study, the authors trained volunteers to approach 622 pharmacies in Delhi, Mumbai and Patna cities and presented symptoms of tuberculosis. These “simulated patients” either told pharmacists that they had experienced 2—3 weeks of cough and fever, or gave them laboratory reports confirming tuberculosis.

The researchers found that 87 per cent of the pharmacists dispensed unnecessary steroids and antibiotics to patients with coughs and fevers and did not refer them to doctors or give anti-TB drugs. Those volunteers who showed reports positive for TB were referred to doctors more often, but were also given unnecessary medication.

The fact that pharmacists refrained from giving the patients anti-TB drugs meant that they were not contributing to drug-resistant TB. However, by delaying proper treatment, they were allowing patients to infect others. 

Jishnu Das, an economist at the World Bank and a co-author of the second study, says it was uncertain diagnosis, rather than profit motive, that leads to antibiotic abuse by pharmacists. This is why the use of all antibiotics decreased sharply when pharmacists were shown a confirmed laboratory diagnosis, suggesting that pharmacies can be engaged in TB control and ‘antimicrobial stewardship’.

“I am convinced that pharmacists are a potential avenue to reach the missing million TB patients in India,” said Madhukar Pai, an epidemiologist at McGill University and a co-author. “Pharmacies are everywhere and they see thousands of patients with cough. By getting them to ask a few simple questions, we might be able to identify those with presumed TB and get them referred for TB testing.”

This piece was produced by SciDev.Net’s South Asia desk.

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