“Diagnosis is not the end, but the beginning of practice,” said Martin H Fischer, German-American physician and author. Indeed, correct diagnosis is the first step to complete the cycle of treatment and cure for any disease, including tuberculosis.
As we mark another World Tuberculosis Day this year, we must look back at how far we have come in delivering TB care and services. When India revised the TB programme in 1997, only a fraction of TB patients (30 per cent) were being diagnosed and treated. While access to proper, basic TB care services and coverage has improved significantly over the last two decades, new challenges continue to emerge. TB continues to be India’s number one infectious disease with two patients dying every three minutes.
Delayed diagnosisDelays in diagnosis and subsequently in the initiation of appropriate treatment play major roles in increasing the spread of TB. This is especially critical for vulnerable populations, such as those living in crowded, unhealthy conditions, who cannot afford loss of income due to illness. Further, if they develop drug-resistant forms of the disease, the resultant costs of healthcare shoot up further. Accurate diagnosis and prompt treatment are paramount to stop TB from ruining millions of lives every year.
Studies have shown gaps not only in the provision of proper care by doctors, but also lack of awareness amongst communities about the disease and the gravity of its consequences. Common symptoms are often ignored by patients for an average of three weeks. When the patient finally visits the doctor (most likely in private practice), at least five weeks can pass before she/he is diagnosed.
Further, as we struggle with the threat of resistance of bacteria such as Mycobacterium tuberculosis to existing drugs, rapidly detecting the sensitivity of TB to prescribed drugs is now as important as detecting the disease itself. In our setting, sputum microscopy (the commonly used diagnostic tool) is not very sensitive in detecting the TB bacillus and certainly does not identify resistance. The sputum culture test needs to be performed and traditional methods take far too long — up to three months — before they show whether or not the TB bacillus is susceptible to the drug at all.
Available testsNew and rapid WHO approved diagnostic tests to detect TB and its drug resistant forms have been in use for over six years now. In India they have been around for the past four years, fast-tracking detection, and increasing the likelihood of patients receiving timely and correct treatment.
In an encouraging move, the Government procured more than 600 such specialised machines last year. While this shows its commitment toward intensifying TB control, with roughly 70 per cent of people seeking care in the private sector, we wanted to make sure these tests were more accessible.
In 2013, some of the largest diagnostic labs around the country together created a network called Improving Access to Affordable and Quality TB Tests (IPAQT), setting a ceiling price for the expensive but essential rapid GeneXpert test. A TB test in one of the 113 IPAQT labs costs ₹2,000 whereas other labs charge anywhere between ₹3,500 and ₹5,000. Still, these tests are inaccessible for a large section of India’s population.
One of the major reasons for such high costs is the 29 per cent import duty and 1 per cent clearing charge levied on diagnostic equipment. The Government has previously waived such duties, and is urged to do the same for TB diagnostics.
It is vital that we work with the Government to ensure that all WHO-approved TB diagnostic tests are exempt from duty fees. This will substantially reduce the costs of these tests. Today, with 28 lakh new patients in 2015 alone, if we in India are serious about eliminating TB by 2025, we can no longer afford delays.
Singh is president of the Global Coalition Against Tuberculosis;
Lal is CMD of Dr Lal Pathlabs