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India
is home to one-in-three of the world's tuberculosis (TB) cases
and the country is expanding coverage of its TB programme at
record-breaking speed. In its shadow, drug resistance is also
upping the pace. Is there something fundamentally awry with the
response to TB in
India
? Some Indian experts think more of the same is sufficient –
but has the time come to re-think the way TB is tackled?
Amid
recent concerns about the possible emergence of drug resistant
TB in
India
, a member of the government's committee on TB control outlined
the national strategy for addressing the problem:
"Unfortunately research scientists are yet to come up with
medicine for XDR-TB. Therefore it is time to focus on DOTS and
restrict the new form of TB," said Dr Rajendra Prasad.
DOTS
(or directly-observed treatment short-course) is the
internationally-recommended TB control strategy that includes
standardized case detection, treatment and patient support. It
requires consistent drug supply and effective monitoring
systems.
India
has adopted and implemented DOTS in various parts of the country
since 1993. Full national DOTS coverage was reportedly achieved
at the end of March 2006, with an estimated treatment success
rate of 86%.
But
is it really "time to focus on DOTS" more intensively?
According to the World Health Organization (WHO), drug resistant
TB is a symptom of poor programme performance. If we hope to
change the outcome, and decrease the proportion of drug
resistant TB, doesn't the DOTS model need to be adapted or its
implementation improved? More of the same might only compound
the TB drug resistance threat.
Despite
recent DOTS coverage gains, many communities in the country
remain underserved by TB services. Rural settings, poor
communities and mobile populations, for example, are subject to
social and economic factors that often lead to incomplete or
inappropriate treatment. In addition, TB diagnosis is difficult
among people living with HIV – a growing proportion of people
with TB in
India
.
The
country does indeed need more and better TB drugs and
diagnostics in the public sector. But better strategies to make
TB control programmes work more effectively for the most
vulnerable and hard to reach communities are also essential to
improving treatment adherence and, as a consequence, reducing
drug resistance.
The
2006 annual Indian TB Report said: "Drug-resistant TB has
frequently been encountered in
India
and its presence has been known virtually from the time anti-TB
drugs were introduced for the treatment of TB". Over the
next five years (2006-2010), Drug Resistant Surveillance is
being carried out in 10 states of
India
to gauge the extent of problem.
From
March 2007,
India
will also launch a 'DOTS-Plus' programme. DOTS-Plus, conceived
by the WHO and its partners, is a strategy for the management of
multi-drug resistant TB (MDR-TB). It uses second-line anti-TB
drugs to cure MDR-TB. DOTS-Plus pilot projects are only
recommended in settings where the DOTS strategy is fully in
place to protect against the creation of further drug
resistance.
Potential
ways to improve DOTS programme performance are well known and
documented. One is to move beyond approaches that place
health centres at the centre of TB services, to community-based
versions of DOTS.
The
need to attend to problems faced by frontline workers is also
important. For example, provision of transport and other
logistical support to increase work performance, geographic
coverage and patient compliance.
Another
key area is improving patient-health worker communication, which
in turn works to reduce TB-related stigma, raise local awareness
and improve treatment literacy.
The
India
'DOTS Plus' programme will make second-line drugs available in
the country for people with MDR-TB. Just as the widespread use,
or misuse, of first-line anti-TB drugs can lead to loss of drug
sensitivity, the arrival of less effective, more toxic and
costlier second-line TB drugs may give rise to various new forms
of drug resistant TB.
The
emergence of extensively drug resistant TB (XDR-TB) in
India
therefore cannot be ruled out – especially if we do not attend
to the factors that are known impediments to effective TB
responses and treatment in the country already.
More
DOTS without better implementation might be just what is not
needed.
(Bobby Ramakant is a
public health and development Journalist, a part of The Key
Correspondent Team coordinated by Health
and Development Networks. Website: www.TheCorrespondent.org
email: bobby@hdnet.org)
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