India: Study finds doctors also adding to burden of drug-resistant TB cases

A cross-sectional survey of private practitioners in Pune city has revealed that 38% of the surveyed doctors reported use of one or more second-line anti-TB drugs in newly diagnosed patients when they should only be treated with first-line drugs.

Inappropriate use of second-line, anti-TB drugs for treatment of drug-sensitive TB may lead to more complicated forms of drug-resistant TB.

Training by Revised National TB Control Programme (RNTCP) did not significantly impact reported prescription practices of private practitioners in Pune city.

The survey report, tuberculosis management practices of private practitioners in Pune Municipal Corporation, was recently published in the international journal Plos One in June 2014.

This study was carried out by city tuberculosis officer Narendra Thakur and his team comprising health staff from the RNTCP. "The findings of the survey are very crucial. We have found that high proportion of private practitioners in Pune report TB management practices not in accordance with international guidelines," Thakur said.

In Pune city, training has been offered and promoted by RNTCP since 2003. "However, the impact of its efforts to influence the quality of TB care in the private sector in Pune had remained largely unknown. We sought to assess the influence of the training on private practitioners in Pune by comparing reported clinical practices," he added.

According to the third National Family Health Survey in India, conducted in 2006, the private sector remains a primary source for healthcare for patients of all socio-economic levels.

He said, "As private practitioners play a significant role in the diagnosis and treatment of TB, approaches to engage them are critical. Training and education should focus on raising the minimum standard of care provided to patients diagnosed and treated in the private sector, and reducing the inappropriate use of second-line drugs that could lead to more cases of drug resistant TB."

A large portion of patients with tuberculosis (TB) in countries with high TB prevalence first consult a private practitioner.

In India, it is estimated that 46% of patients with TB seek treatment from the private sector. "However, TB diagnosis and treatment practices among private practitioners in India vary widely and are not formally regulated," Thakur added.

Manohar Pawar, joint director (tuberculosis) of Directorate Health Services (DHS) said, "Early diagnosis, appropriate and complete treatment of TB is the cornerstone of TB prevention and control strategy. Inappropriate diagnosis and irregular/incomplete treatment with anti-TB drugs may contribute to complications, disease spread and emergence of drug-resistant TB."

The World Health Organisation (WHO) says that 2.1% of all new cases in India are multi-drug resistant (MDR)-TB while as many as 15% of re-treatment cases are developing MDR-TB.

Senior family physician Prakash Mahajan, former president of General Practitioners' Association (GPA), Pune branch, during whose tenure the survey was carried out, said, "The association must conduct continued medical education programme more frequently so that doctors are constantly made aware about the seriousness of emerging epidemic of multi-drug resistant tuberculosis and how prescribing correct treatment regimen is of crucial importance. Besides, the government's training programme should also have provision for conducting post-training evaluation to find out whether the training imparted to the private doctors is really put to use in a correct manner or not. Imparting training to doctors is not sufficient, we need to assess them periodically."

The survey

The cross-sectional survey of private practitioners was carried out in Pune city in 2012-13

The survey report - Tuberculosis Management Practices of Private Practitioners in Pune Municipal Corporation, India - recently published in the international journal Plos One in June 2014.

Private practitioners of allopathic medicine and those having a degree in any system of medicine like allopathy, homeopathy, Ayurveda or Unani were considered eligible for participation in the study. Specialists who generally do not treat TB cases (for example psychiatrists) were excluded.

Study participants were interviewed in person using a pre-tested semi-structured questionnaire by one of seven trained interviewers. The questionnaire contained sample clinical case scenarios and responders were asked to describe their approach to diagnosis and treatment for each scenario. A combination of open-ended and multiple-choice questions was used

A total 249 private doctors were interviewed. Of them, a total of 136/249 (55%) had been exposed to RNTCP training and 142/249 (57%) were involved with RNTCP. More than 90% of private practitioners either work as referring centre or Directly Observed Treatment (DOT) centre

For treatment of new cases of pulmonary TB, 48/136 (35%) of private practitioners exposed to RNTCP training adhered to treatment standards compared to 36/113 (32%) of private practitioners without exposure to RNTCP training

Overall, 34% (84/249) of private practitioners reported use of only four first line drugs for treatment of new pulmonary TB

About 38% (94/249) indicated that in addition to four first line drugs they would use one or more second line anti-TB drugs. This is concerning because inappropriate use of second-line anti-TB drugs for treatment of drug-sensitive TB may promote the emergence of more complicated forms of drug-resistant TB.

Overall, 26% (65/249) of private practitioners reported use of second line TB drugs fluoroquinolones for new TB patient when the drug should only be used in patients with multi drug resistant tuberculosis.

Use of second line drugs to treat new pulmonary TB was greater for private practitioners who had been exposed to RNTCP training compared to those not exposed, though this association did not reach statistical significance.

Efforts invested

In 2002 India's Revised National Tuberculosis Control Programme (RNTCP) introduced guidelines for involvement of private practitioners (PP) through an initiative called ?Public Private Mix' which encompasses training activities and formal collaboration with the RNTCP.

RNTCP provides training and encourages private practitioners to adhere to the International Standards of TB Care (ISTC). Private practitioners may also collaborate formally with the RNTCP by serving as a referral facility, diagnostic centre, or treatment centre after entering into a formal memorandum of understanding with the RNTCP.

Source: The Times of India