At nine deaths an hour, TB is winning in India’s largest state
Low detections, a faulty system of diagnosis and a health department in denial are contributing to an alarming death rate from the disease in India's largest state
India loses on average of 1,150 lives every day to tuberculosis (TB), according to data compiled by the World Health Organisation (WHO). In 2016 alone, over 430,000 Indians succumbed to it. Disease control policies do not appear to be helping, however. Many sufferers lack access to treatment and disappear off the medical radar, making it almost impossible to track how TB is spreading.
Adding to the challenge for public health officials, patients are becoming resistant to antibiotics. WHO estimates that in 2016 there were 600,000 new cases of resistance to Rifampicin, the most effective first-line drug against TB, in India, and that 490,000 of those cases involved Multi Drug-resistant TB (MDR-TB).
Inevitably, India’s largest and most populous state, Uttar Pradesh (UP), chalks up the highest numbers. But its strategy to combat the disease is falling apart. UP alone accounts for one-fifth of TB deaths in India – which translates to more than nine deaths every hour.
Eight-year-old Aditya attends a convent school in Lucknow, UP’s capital. In October, he began experiencing intermittent fever, coughing and loss of weight and appetite. When his health didn’t improve after two weeks, a chest x-ray and sputum culture test were advised. He was diagnosed with tuberculosis and put on a six-month TB regimen.
According to government figures, in 2014 there were 7,600 TB diagnoses in Lucknow. The figure given for 2017 is 13,600, representing almost a two-fold rise.
Neighboring Kanpur, an industrial city, is known as the state’s TB capital. More than 13,800 new cases were diagnosed there last year, compared to just 5,700 in 2014.
“The government doctors poach TB patients for their private clinics to make money through diagnostic tests and pharmacists”
The twin cities account for one in ten new TB cases in UP, although they make up a mere combined 3.5% of the state’s 200 million population. Cases include all forms of TB, from pulmonary to musculoskeletal, and types of infection, from MDR-TB to XDR-TB (Extensively Drug-resistant) and TDR (Totally Drug-resistant).
The state’s health department claims that the higher figures of recent years reflect aggressive efforts to get private doctors to report diagnoses. Rejecting the suggestion that TB is on the rise in the state’s biggest cities, State TB officer Dr Alok Ranjan insists that “densely populated cities and industrial towns like Lucknow and Kanpur always have a higher prevalence of TB. The numbers have gone up because private practitioners were encouraged and incentivized to notify the cases of late. Lucknow and Kanpur have done the best in this regard.”
This is not really true. While government data shows cases reported by private doctors in the two cities rose between 2014 to 2017, the same period also witnessed a huge bump in cases diagnosed in public hospitals. Those were up from 5,600 to 8,500 in Kanpur and from 7,400 to 10,300 in Lucknow. Clearly, the state health department needs to check its own figures.
500,000 TB patients untraced
WHO pegs the total tuberculosis figure in UP at over 780,000. The state has records of only 280,000 patients, however. That means some 500,000 patients are untraced, a situation that seriously undermines the federal government’s plans to eradicate TB by 2025.
Tracing TB patients in a state with a population of 200 million people is a major challenge. “We don’t know if those people are aware of the disease or receiving proper treatment. Each one of them can infect 10 others,” says a public health official.
Meanwhile, government and private doctors blame each other for the situation. “Private practitioners avoid [reporting] TB cases since they fear losing patients to the government hospitals. They don’t even keep track of patients’ treatment. Half-treated cases are not only responsible for large numbers of TB deaths but also pose a threat of MDR, XDR and TDR tuberculosis,” claims Dr Ranjan.
He has a point. Out of the 280,000 cases recorded, only 62,000 have come from private doctors. Officials believe that in reality private doctors encounter double the number of cases diagnosed via the public system.
However, private doctors blame government doctors for the low levels of notifications. “The government doctors poach TB patients for their private clinics to make money through diagnostic tests and pharmacists. They don’t [report these] patients for obvious reasons,” a private practice doctor told Asia Times.
The state launched a door-to-door survey for early detection, diagnosis and treatment of TB in August. The first phase was carried out in the slums of six districts – Ghaziabad, Meerut, Agra, Varanasi, Unnao and Gautam Budh Nagar.
A team looked for symptoms of TB in people who had been experiencing fever or coughing for 15 days or more, or who had been spitting blood while coughing, or had experienced loss of weight or appetite. They collected sputum in cases where TB was suspected.
The entire exercise was in vain, however, as only 400 cases were detected out of 200,000 people surveyed. The government had expected a 5% detection rate.
A faulty survey procedure was blamed for the extremely low detection figure. Instead of collecting early morning sputum, which gives better results due to higher bacterial content, the team collected afternoon samples. Dr, Ranjan admits the mistake. “Our teams were not adequately trained for the first-ever survey. We ironed out these issues in the second phase.”
Conducted in 25 districts between December 26 and January 9, the second phase saw only 2,200 cases detected from 900,000 people screened. The third phase, in March, aims to cover the remaining districts of the state.
Diabetes and HIV are also adding to the TB tally. UP has nearly 150,000 HIV patients and over 1 million diabetics. More than 5% of diabetics and more than 15% of HIV patients are said to catch TB due to lower immunity. Most are unaware that they suffer from either ailment and pose a threat to others.
“Malnutrition, poor living conditions, irregular meals and sleep decrease the T-cell count and lower the overall immunity, thus making TB vaccination ineffective,” says Dr Om Shrivastav, an infectious disease expert at Mumbai’s Kasturba, Jaslok and Lilavati hospitals. T-cells fight against infections, including TB.
Poor diagnostic tests are also a key contributor to the failure of TB control programs, experts say. X-rays, Monteux tests and sputum culture tests are known to be unreliable but are still being used by doctors across India. By contrast, the CB-NAAT (cartridge-based nucleic acid amplification test), the most sensitive serological test available for free in the government set-up, is grossly under-utilized.