Dr Madhukar Pai speaking at Lady Hardinge Medical College, Delhi, India
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(CNS): It may sound rhetorical but some of the 'absolute must' steps for progressing towards ending tuberculosis (TB) are to early and accurately diagnose TB and treat with the standard combination of drugs that are sensitive and work for a particular patient. Although sounds simplistic yet these are 'easier said than done' steps! Agrees globally-noted expert on TB diagnosis: "Early diagnosis is a huge problem in India. Not only it is critical to diagnose TB early but also drug-resistant forms of TB, otherwise it is going to be a phenomenal problem! This is what is happening in places like Mumbai where delayed TB diagnosis and even-further delayed drug susceptibility testing (DST) have proved catastrophic" said Dr Madhukar Pai, Director, McGill Global Health Programs, who was speaking at the centenary celebrations of Lady Hardinge Medical College in New Delhi on 24th April 2015.
Average delay in TB diagnosis is 2 months!
Dr Pai shared: "In a study we published last year we found that an average TB patient has to wait for almost two months before a TB diagnosis is made and they have to see at least three different doctors before a doctor tests the person for TB, and then starts the anti-TB therapy. We really do not know what this two months of delay in TB diagnosis can mean in terms of actual numbers of transmission events [of TB] as it can only be modelled in a study but our guesstimate is that it is an important driver of the TB epidemic in the country."
India accounts for 25% TB burden in the world, and despite enormous efforts of India's national TB programme (formally called Revised National TB Control Programme - RNTCP) there is no indication that TB incidence is significantly declining in India. "Transmission is continuing, people are getting infected" said Dr Pai.
Only half of doctors aware when to screen a patient for TB!
"A scientific paper published earlier in April 2015 by us showed what is the quality of TB care in India -- what an average TB patient gets in terms of diagnosis and treatment in India. Anyone living in countries like India with 2-3 weeks of cough with fever, weight loss and other symptoms must be screened for TB ideally with sputum test - this is the baseline knowledge we expect our doctors to have! This is also what International Standards of TB Care and Indian Standards of TB Care say too! We found in the study review that only half of doctors in India were actually aware when they should be screening someone for TB (if she or he has 2-3 weeks of cough with other symptoms). In the same study we also looked at how many doctors were actually aware of correct management of TB: only one third of doctors were aware of the correct management of TB."
Dr Pai rightly stressed that "This means that even if people with classic TB symptoms go to a doctor there is no guarantee they will get tested for TB, and even if they do get tested for TB and get confirmed and early diagnosis, there is no guarantee they will get correct treatment as per guidelines and standards of care. This is what is happening in cities like Mumbai otherwise we would not have so much of multidrug-resistant TB (MDR-TB), extensively drug-resistant TB (XDR-TB) and other severe forms of drug-resistant TB. So TB is consistently being missed and mismanaged in Indian settings. Early TB diagnosis is not the norm usually, it is an exception!"
Most people do not go to public system when get sick
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