Photo Credit: Molly Woodriff

Photo Credit: Molly Woodriff

Tuberculosis (TB) is a global scourge for which innovative answers are desperately needed. Nine million people caught the disease in 2013 alone; about one-and-a-half million died.

Low and middle-income countries are particularly susceptible. Over 95 percent of TB deaths take place in these regions. Consider India: it hosts one-quarter of all TB patients in the world.

Six patients in India will die by the time you finish reading this article[1]. Such astounding statistics, which occur under complex conditions, deserve attention and innovation so we can eliminate this menace once and for all.

To fully address the problem, it is imperative to understand its root causes. TB is a contagious bacterial disease. Most people know it affects the lungs but may be surprised to learn it can also attack other organs such as the brain, the spine, or the kidneys. TB spreads easily when symptomatic patients cough, sneeze, speak, or even sing. Germs remain in the air for hours, placing those who come in contact at risk.

Several conditions within India increase its citizens’ chances of contracting the disease. The country is crowded. Its high population density (1,090 people per square mile) provides an ideal platform for the TB bacteria (Mycobacterium tuberculosis) to proliferate. Urban and rural poverty creates low-quality living conditions that contribute to the higher risk of infection. Poverty has another effect: large numbers cannot afford long and complicated treatment, especially in the case of Multi-drug Resistant TB (MDR-TB). Additionally, undernutrition, tobacco smoking, HIV infection, and diabetes are important risk factors.

At the bottom of all this: most of the Indian population is dependent upon private healthcare facilities. About 86 percent of healthcare spending comes straight out of patients’ pockets because they lack timely access to quality public health facilities.  In almost 60 percent of cases, TB patients receive treatment in private clinics or hospitals. For most, private doctors are first point-of-contact. Unfortunately, many are unable to afford these high-cost private treatments due to poverty or lack of health insurance. It is noteworthy that just 25 percent of Indians have any kind of health insurance. 

Fig 1. Infographic for TB statistics in India [2]

Fig 1. Infographic for TB statistics in India [2]

To curb TB in India, major challenges ahead can be divided in three parts:

Diagnostic costs are unaffordable

There are mainly four types of TB tests performed today by Indian diagnostic labs. Two of these are much less expensive per patient than the other two. However, the cheaper tests are not approved by the World Health Organization (WHO); the more expensive tests are.

According to research conducted by the Initiative for Promoting Affordable & Quality Tests (IPAQT) and the Clinton Health Access Initiative (CHAI), a sputum smear test costs about $2.00 while the (preferred) GeneXpert tests costs about $64.00. This huge difference has created a large market for low cost, sputum smear testing labs (which make impressive profits as a result).

Unfortunately, a $64.00 test is out of reach for a patient whose monthly household income is about $85.00. This problem leads to inaccurate test results, wrong diagnostics, and missed cases.

The supply chain for MDR TB drugs is riddled with challenges

MDR TB cannot be controlled without an adequate, uninterrupted supply of second-line drugs. These drugs are expensive (about $40.00 for TB and about 50 times more for MDR TB), which means they must be used effectively.

The markets for these drugs are relatively small and uncertain, making suppliers reluctant to commit resources to their manufacture. Uncertainties in the timing of grant disbursements result in uncertain procurement planning. Suppliers and manufacturers have long lead times for obtaining the drugs, because they do not start production until final purchase orders are received. Inventory management and /or consumption tracking systems are also lacking for drug storage facilities at state and district levels.

DOTS non-adherence and poor follow-up

Many patients miss some or all of their medication doses, which adversely affects their treatment. This phenomenon, known as non-adherence, is influenced in India by several factors. One of these: travel requirements. In India, patients must report to DOTS[3] centers three times a week during morning hours to receive their medications. Traveling long distances--and losing much-needed time—often results in non-adherence, especially for poor patients who lose pay when they are away from work.  

Smoking and alcoholism are other reasons for DOTS non-adherence. Also, non-availability of drugs—for the reasons mentioned above—is positively associated with non-adherence among patients. Lack of follow-up and forgetfulness by patients and/or health workers are also prevalent.

Innovations and Solutions

Having understood the problem at large, let’s have a look at the innovations taking place in this space. There are numerous initiatives underway to control the situation. Private foundations and governments both participate, and their collaboration is making a positive difference.

For example, the Revised National Tuberculosis Control Program (RNTCP) is having more success than an earlier version of the program (NTCP) due to the active public-private partnerships.

RNTCP, an umbrella program by the Indian government, has seen considerable success in the recent past. The treatment rate is now at 88 percent, while total cost per capita has come down to $0.1. Every day, some 15,000 suspected cases are examined under this program and about 3,500 patients begin treatment. More than 600,000 health workers have been trained to administer DOTS. The tests through public labs are free and, thanks to RNTCP, 11,500 designated lab microscopy centers have been upgraded.

Given the huge burden of TB, the success of RNTCP depends on additional innovations in diagnostics, drug delivery, and adherence. Some of the prominent initiatives are:

·         eCompliance biometric-based delivery model: Innovated by the Operation Asha team, this model involves delivery of DOTS and an effective feedback system using a biometric-based monitoring tool. The program is funded by the Bill & Melinda Gates Foundation and the National TB Program

·         GxAlert: This technology is meant to notify hospitals about TB cases directly from the diagnostic lab. A USB device connects to a diagnostic device that automatically receives lab results over an online server. The data is thus delivered to those who need it in real time.

·         Nikshay mobile app: This mobile app has been launched through a government-run project known as Nikshay. Project Nikshay is a web-based solution for monitoring the effectiveness of RNTCP.

The app has been e-mailed to all general physicians, both public and private, in Mumbai. As per government mandate, TB has become a notifiable disease. The app attempts to make the notification process simpler to reach more patients and doctors.

·         99Dots: This program uses a smart pill box and 99DOTS to improve TB drug adherence. 99DOTS is a mobile communication-based adherence technique that combines blister packaging and mobile phones to monitor and improve TB medication adherence at very low cost.

There are a number of other innovations and technologies available that need better integration with the national umbrella TB control program. At the same time, innovations must be socially relevant and not just another blind imitation of technology used elsewhere. Since India ranks low in digital literacy, any digital, mHealth or ICT based innovation can become effective with novel design and effective communications. Only with these efforts can India come out of this dire situation and eradiate TB more quickly.

 

 

 

 

 

 

 

 

[1] Calculation based on considering 320,000 TB deaths in India in 2013, and an average reader takes 10 min to read this article.

[2] (Paragraph 1), http://timesofindia.indiatimes.com/india/Over-9-3-lakh-TB-patients-in-India-undetected-Report/articleshow/24600851.cms

(Paragraph 1), http://www.tbfacts.org/tb-statistics-india.html

(Paragraph 6), http://www.tbfacts.org/tb-india.html

(Paragraph 1), http://www.thehindu.com/news/national/says-who-india-has-highest-number-of-multidrugresistant-tb-in-south-east-asia/article3156259.ece

[3] Stands for Directly Observed Treatment, Short course. DOTS is a control strategy recommended by WHO for tuberculosis. http://www.who.int/tb/dots/whatisdots/en/

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