The team analysed drug sales data to show that the actual number of tuberculosis cases in India may be vastly under-reported, primarily because many people opt for treatment from private healthcare providers, who usually fail to report tuberculosis cases to public health officials.
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The WHO’s Global TB Report 2015, estimated that only 12 per cent of all case notifications came from the private sector. This is the main reason for the difficulty to accurately estimate the exact number of TB cases in India. Using data of drug sales collected by IMS Health, he found that India’s TB burden in 2014 was 3.8 million instead of 2.2 million.
Increasing effortsDr Sunil Khaparde, manager of India’s Revised National TB Control Program (RNTCP) and one of the authors says, “While India’s RNTCP has achieved tremendous success over the years, the country continues to have a large number of TB cases”.
Evidence before this study showed that not all cases of TB are reported to public health authorities. Also, the use of antibiotics and steroids (which can be harmful to individuals who actually have TB), as well as the total number of medicines given, decreased sharply when the pharmacy staff made a decision to refer the patient to a doctor, which was far more commonly done when the patient presented with a laboratory test confirming TB. Less than 3,000 cases were reported in 2012 and just under 39,000 cases were reported in 2013.
According to a study based on the commercial sale of anti-TB drugs in India, the country’s TB burden is higher than the government’s estimates.
“Our work points to the urgent need for further strengthening of tuberculosis surveillance in the private sector. There is no doubt that private hospitals need to report the TB cases they treat”, he said. Researchers estimated the treatment volume, or the total patient-months of treatment for TB in the private sector, taking into account the proportion of prescriptions for a given drug that were for TB, as well as the proportion of total drug sales.Overall, on a national level, there was roughly twice as much TB treatment in the private sector as in the public sector.
Excess usage of antibiotics has led to significant antimicrobial resistance that threatens the effective prevention and treatment of TB, as resistant microorganisms (including bacteria, fungi, viruses and parasites) are able to withstand attack by the antimicrobial drugs. In 2014, 6.3 million TB cases were reported worldwide, with India accounting for over 25% of them – the highest for any country.However, the new findings illustrate that India’s private sector is treating an appreciably higher number of patients for TB, than has been previously recognised.
“Our study clearly showed that not a single pharmacy gave away first line anti-TB drugs (isoniazid, rifampicin, ethambutol, pyrazinamide and streptomycin) without prescriptions”, said Madhukar Pai, Canada Research Chair at McGill University, in Quebec, Canada. However, the good news is that none of the pharmacies dispensed first-line TB drugs.
In the Lancet study, healthy individuals were trained to pose as TB patients and interacted with pharmacists – to understand how the pharmacies in these cities treated patients presenting themselves with TB symptoms.
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“The midpoint of these ranges yields an estimate of 2.2 million cases, two to three times higher than now assumed”, the study said.
