Madhukar Pai: New insights into the tuberculosis problem in India’s private sector

Madhukar Pai

As a result of the overuse or misuse of antibiotics, antimicrobial resistant superbugs represent an extraordinary threat to global health. This threat is particularly great in India, the world’s largest consumer of antibiotics and the country facing the highest burden of tuberculosis (TB) in the world. Two studies, published simultaneously in The Lancet Infectious Diseases this week, provide several new insights into the problem of tuberculosis in India’s vast, mostly unregulated private sector.

The first study, lead by Nimalan Arinaminpathy from Imperial College, London, calculated nationwide sales of anti-TB drugs across the private sector in India. The research team then used this figure to calculate the number of TB cases. The results suggested there were 2.2 million TB cases in the private sector in 2014—two to three times higher than current estimates. Clearly, India’s private sector is treating an enormous number of patients for TB, appreciably higher than has been previously recognised. So, there is an urgent need to address this burden and to strengthen surveillance. TB burden estimates in India and worldwide might require revision.

The second study, led by Srinath Satyanarayana at McGill University, Montreal, used standardized patients (also called “simulated or mystery patients”) to understand how pharmacies in three Indian cities treated patients presenting with TB symptoms or diagnoses and to determine whether these pharmacies were contributing to the inappropriate use of antibiotics. The authors showed that pharmacies frequently dispensed antibiotics to simulated patients who presented with typical TB symptoms, and they rarely referred people with classic TB symptoms to doctors which can delay the diagnosis of TB. However, none of the pharmacies dispensed first-line anti-tuberculosis drugs, which is good news. The use of all 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 decided to refer the patient to a doctor, which was far more commonly done when the patient presented with a lab test confirming TB, thus making the diagnosis apparent to the pharmacist. These findings can inform interventions to engage pharmacies in TB control and initiatives to improve protect antibiotics from misuse.

Taken together, both studies highlight the critical importance of engaging India’s massive private sector for improving TB care and control in India. A staggering number of TB patients in India are seeking care in the private sector, and we need to do a better job of engaging private providers, and work with them to improve the quality of TB care. For example, pharmacists can be engaged to identify people with classic TB symptoms and get them appropriate to care.

As more than half of patients seek care in the private sector, the government needs to engage more with private practitioners and explore innovative ways to do so. They must find ways to ensure that private care providers follow proper diagnostic and treatment protocols, and notify cases to the Revised National TB Control Programme (RNTCP). TB patients need quality care, regardless of whether they choose to seek care in the public or the private sector. Therefore, it is also important for the private sector to work hand in hand with the RNTCP, and improve the overall quality of TB care in the country.

Lastly, it is really time for India to invest more in TB control and take the lead in ending the TB epidemic. Global TB elimination is an impossible goal without significant progress in India. With its strong research expertise in TB, and technological and pharmaceutical capacity, India has the potential to make great progress against this disease. What is urgently needed is a strong financial and political commitment from Prime Minister Modi, and engagement of both public and private sectors.

Madhukar Pai is director, Global Health Programs, McGill University, Montreal, Canada. Twitter: @paimadhu

Competing interests: None declared.