Tackling TB in India: Poor counselling, huge dropout rate hamper treatment

RNTCP data shows 2,640 patients dropped out of treatment in 2014, figure rose to 2,976 in 2015

“I am an orphan. How do I get identification documents for free treatment?” Raju asks. He was first diagnosed with TB in 2015. Living on the pavements, he opted for private care briefly before money ran out. Six months later, he was diagnosed with MDR strain. Admitted to Sewri TB Hospital now with both his lungs damaged, he says he is alone. “No one visits me. The doctor has no time, he comes once in the morning when I am usually asleep… I feel suicidal.”

The hospital has counsellors from Medecins Sans Frontieres (MSF), but no one has counselled him on the MDR drug regime and its heavy side-effects. Raju’s is a classic case of how poor counselling facilities and the huge rate of patients dropping out of treatment have handicapped the fight to control TB, leading to instead increase in MDR and XDR infection.

Since 2010, RNTCP has registered 1.99 lakh patients, of which 12,691 are MDR cases and 1,243 are extensively drug-resistant (XDR) patients, a figure escalating each year. The count of MDR and XDR patients registered in Mumbai rose by 22 per cent in 2014 from 2,707 in 2013.

Explaining the huge dropout, former TB Cell official Dr Arun Nakhawa says, “The top reason for defaulting treatment is migration. Inability to adhere to heavy drug is a second reason for why patients drop out.”

In 2014, RNTCP data showed 2,640 patients dropped out of treatment in the city. The figure rose to 2,976 in 2015. This year, until March, 885 patients have already defaulted on the treatment, which is 9 patients going off treatment each day.

For 1.99 lakh patients registered in last five years, however, there are only over 27 counsellors under the TB Cell in Mumbai. Sagar Patra, counsellor from Population Services International, says, “Counsellors are important for TB patients. We explain the disease and what effects a medicine can have. The family is counselled on how to take care of the patient. All this helps in completing full treatment.”

But he has 130 patients under him in Wadala and visiting each frequently becomes difficult. In Wadala’s slums, Patra has gone looking for labourer Lankesh Patel, shop clerk Amol Dharve and daily wager Mukund Pawar over eight times in the last four months. All three, migrants from Uttar Pradesh and Madhya Pradesh, stopped taking medicines in March this year due to drug side-effects or migration. “If they don’t continue their treatment, the bacteria will get stronger,” Patra worries.

“The bacteria acts very cleverly. Whenever the patients gets irregular with medication, it amplifies its resistance against those drugs,” explains Dr Zarir Udwadia, chest physician at Hinduja Hospital.

According to Dr Rajan Naringrekar, former superintendent at Sewri TB Hospital, a lot of patients admitted to the hospital for MDR or XDR treatment are migrants who have been irregular with their treatment either due to alcoholism or drug side-effects. The M-East ward, G-North and P-North wards comprising Govandi, Chembur, Dharavi and Malad have the highest TB burden in Mumbai. Govandi, Chembur and Dharavi are also regions with largest migrant population.

In Thakkar Bappa Colony in Chembur, migrant workers are part of a shoe making industry for six months and leave Mumbai for their villages for remaining six months. “For such patients, we prepare a ‘transfer out’ form so that they can continue treatment at other centre in their village. But we have noticed they switch off their phones and cut contact. It becomes difficult to know whether they are continuing treatment,” Patra explains.

Data from the RNTCP shows 2,829 patients migrated out of Mumbai in 2015 from 1,385 in 2014.

Source: The Indian Express