TB treatment programme – Issues

  • RNTCP or the Revised National Tuberculosis Control Program is the state-run tuberculosis control initiative of the Government of India.

  • It incorporates the principles of directly observed treatment-shortcourse (DOTS), the global TB control strategy of the World Health Organization.
  • The program provides, free of cost, quality anti-tubercular drugs across the country through the numerous Primary Health Centres and the growing number of private-sector DOTS-providers
Issues with current TB treatment
  1. Diagnosis by smear microscopy-
  • Diagnosis is primarily done examining sputum samples of the patient under a microscope. The detection of TB bacilli in the sample confirms the diagnosis.
  • The national programme’s heavy dependence on the century-old, insensitive smear microscopy as a primary diagnostic tool has been strongly criticised.
  • The test is not very sensitive,i.e. it does not detect all cases. So false negatives are high.
  • Further the microscopy is ill-equipped to diagnose drug-resistant TB. This is particularly worrying as the number of drug-resistant cases is steadily increasing.
2. Treatment of MDR-TB
  • Current treatment regimen includes oral treatment with 4 drugs, i.e.HRZE- Isoniazid, Rifampicin, Pyrizinamide and Ethambutol- thrice weekly for 6 months.
  • Its called directly observed treatment-shortcourse (DOTS) as its done under the supervision of a treatment provider.
  • The RNTCP currently treats patients without knowing their resistance profile.
  • This along with its current regimen of thrice weekly drugs even to those with prior resistance has been associated with “failure and amplification” of resistance to rifampicin drug. It is therefore likely, under programme conditions, to be generating more MDR cases
  • The Standards for Tuberculosis Care in India (STCI),  the WHO and national TB institutes — advocates drug sensitivity testing for all presumed MDR-TB cases. However, this may not become a reality in the near future. Progress is threatened by slow uptake of the new molecular test
3. TB notification
  • The private practitioners should mandatoryily notify new TB cases to RNTCP. In spite of mandatory notification, TB patients [treated by private doctors] are not notified to the RNTCP.

How these problems need to be addressed

  • Accelerate implementation of the transition to daily dosing
  • Universalise drug susceptibility testing (National Institute for Research in Tuberculosis, the RNTCP is planning to start daily dosing using fixed dose combination in 5-6 States and then expand it to the rest of the country. RNTCP is currently procuring drugs to make this shift.)
  • Ministry should develop e-Nikshay, an advanced version to the existing Nikshay system for notifying TB patients
  • The government should eliminate taxation on TB diagnostics and drugs considering TB as a public health emergency.
  • The Ministry of Health should minimises the out-of-pocket expenditure by families by supporting the cost of TB testing and [providing] free drugs.
  • The government should establish a “state-of-art TB surveillance system for capturing all TB cases, public and privately-treated.” This is essential for the country to “capture and respond to local and focal epidemics.”
  • The national strategic plan (NSP) for TB control for 2012-17 developed by the Union Ministry of Health & Family Welfare had raised the bar for tackling the rapidly growing TB epidemic in the country. The main goals of the strategic plan are to provide universal access to early diagnosis and treatment and improve case detection.

Child-friendly TB drugs launched

  • For the first time, child-friendly TB drugs for first-line medication in a fixed-dose combination was launched by TB Alliance, UNITAID and WHO at the 46th Union World Conference on Lung Health in Cape Town, South Africa.
  • These drugs, which meet the WHO’s revised dosage guidelines of 2010, are meant for children weighing less than 25 kg.
  • The fixed-dose drugs are already available and countries can place an order, which can take 2-3 months for delivery
  • The Mumbai-based Macleods Pharmaceuticals is the only company manufacturing the child-friendly drugs.
  • According to the WHO, each year, at least 1 million children become ill with TB.
  • The medicines will cost $15.54 for the six-month course of treatment.

Advantages

  • The availability of child-friendly TB drugs of correct dosages will increase drug adherence and thereby reduce acquired drug resistance.
  • Since the fixed-dose combinations come in a dissolvable form, tablets no longer need to be crushed. Instead, the required number of paediatric tablets can be dissolved in water.
  • The tablets are flavoured, thus making it easier for children.
  • In the absence of fixed-dose combination drugs of correct dosages, children were typically treated with multiple pills intended for adults. The adult drugs had to be crushed or split to achieve an appropriate dose for a child. Crushing medicines often led to imprecise dosing. Crushing also makes the drugs bitter to taste, making it all the more difficult to administer to young children.

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