India needs to address gaps in the TB care cascade
A recent study in PLoS Medicine provides an end-to-end view of what happens to TB patients in India as they try to navigate the Indian government’s TB program.
In 2015, WHO estimated that there were 10.4 million new TB cases worldwide. Six countries accounted for 60 per cent of the total burden, with India accounting for 27 per cent of the global cases. The WHO highlighted that about 4.3 million TB patients globally are “missed” by health systems annually and remain either untreated or unreported to national governments, which may undermine global efforts to combat TB. India alone has more than one million of these missing TB patients every year.
A study I contributed to, published in the journal PLOS Medicine last week, provides insight into gaps in care where TB patients in India’s government program go “missing.” The research team, led by Ramnath Subbaraman at Harvard Medical School, used an analysis called the “cascade of care,” which estimates the number of patients who successfully reach each step in diagnosis and treatment required to achieve the ideal patient outcome, which is one-year recurrence-free survival in the case of TB.
Over the last decade, the HIV community has very effectively used the cascade of care analysis to identify and plug gaps so that more patients receive effective treatment. UNAIDS recently endorsed an ambitious “90-90-90” global target based on the cascade. The TB community has lagged behind in using the cascade analysis for monitoring programs and setting public health targets. To our knowledge, this study is the first published national TB care cascade.
The study finds that, out of about 1.9 million TB patients who reached government TB diagnostic facilities in India in 2013, only about 1.6 million were successfully diagnosed with TB. Most of the approximately 300,000 undiagnosed TB patients had either sputum smear-negative or multidrug-resistant TB—two forms of TB disease that cannot be diagnosed using sputum microscopy, the most common TB test currently used in the government program.
In addition, the study estimates that, out of the 1.6 million diagnosed TB patients, about 1.4 million got started on TB treatment in the government program. About 212,000 patients were successfully diagnosed but did not get started on TB treatment. Previous studies suggest that the government TB program is unable to find some of these diagnosed patients because of poor record keeping.
Taken together, these two gaps suggest that about half a million TB patients in India reach government TB diagnostic facilities but are either not successfully diagnosed, or not started on treatment. The study also highlights gaps that occur at the end of the cascade. India’s government TB program currently only reports statistics on the number of patients who complete TB treatment; however, the study points out that a considerable percent of these patients will suffer from relapse of TB disease within the first year after completing TB treatment.
For the first time, this cascade of care study provides an end-to-end view of what happens to TB patients in India as they try to navigate the Indian government’s TB program. The government urgently needs to commit considerably greater funds to modernize TB services in India and to track each TB patient, to ensure that all patients make it to the finish line.