Tuberculosis patients in India who seek care in the private sector face a delay of as long as two months before they are diagnosed correctly — if at all — according to systematic reviews of Indian studies. This becomes alarming as private sector accounts for almost half of the TB care delivered in India. A larger group begins their pathway to care in the private and informal sector as they are often the first point of care for patients before TB patients eventually get treated in the public sector.
But despite the huge challenges posed by the private sector in TB diagnosis and treatment, only anecdotal evidence is available to explain the delay. Two studies published recently by Andrew McDowell, a medical anthropologist, and Madhukar Pai, a TB expert, from the McGill International TB Centre, McGill University, Canada, provide the much-needed insights into the cause of delay.
Besides interviewing private practitioners holding MBBS degrees and those practising alternative medicine such as Ayurveda, Unani and homeopathy, Dr. McDowell also conducted observations in the clinics of some of the doctors who were earlier interviewed, to understand the nuances of doctor-patient interactions including diagnostic or referral recommendations, prescriptions, and final diagnosis.
Experimenting with antibiotics
One study of 175 practitioners of Indian medicine published in the Transactions of the Royal Society of Tropical Medicine and Hygiene in March 2016 involved 400 interviews and 208 hours of observation, and 2,000 observed patient interactions in 10 clinics in Mumbai. One of the highlights of this study was that none of the 175 practitioners exclusively practiced their system of training. While allopathic medicines, including antibiotics, were prescribed for acute conditions, the physicians generally prescribed their system of medicine for chronic conditions.
Though all the physicians reported seeing at least one patient with typical TB symptoms for more than two weeks in the preceding year, the patient had to visit a doctor several times before he or she was suspected of having TB. The patients were treated with broad-spectrum antibiotics and other symptomatic drugs during the first few visits. Different antibiotics were prescribed during each visit. This process of experimentation using antibiotics usually lasted for 10-14 days.
A few doctors used at least one second-line TB drug when treating drug-susceptible TB.Though fever is common and not very specific to TB, and more than two weeks of cough is one of the main symptoms of TB, no physician ever asked for laboratory investigation on the first visit. Instead the focus was in managing symptoms using non-specific therapies.
Though an X-ray should be used as a screening tool and sputum smear or GeneXpert as confirmatory tests, only 31 practitioners asked for sputum smear and only after conducting blood tests (i.e. blood cell counts and ESR) and a chest X-ray.
The good news is that 164 of the 175 AYUSH practitioners preferred to refer the TB patients to the public sector or to a chest physician and not treat the patients themselves. “Not treating TB patients could be due to a number of factors including uncertainty about treatment protocol, fear of MDR-TB, stronger messaging by RNTCP, fear of being exposed to TB themselves, and a desire to protect other patients in the waiting room from TB exposure,” Dr. McDowell says in an email to me.
However, some AYUSH practitioners did treat the TB patients who left the public sector. What is alarming is that about five per cent (nine AYUSH practitioners) used at least one second-line TB drug when treating drug-susceptible TB. “The key problem is that testing for resistance is very low. It would be unfair, however, to say that this issue is limited to AYUSH practitioners,” Dr. McDowell says. Adds Dr. Pai: “AYUSH doctors should not be treating any form of TB, and definitely not be using second-line anti-TB drugs.”
Chest X-ray and other lab tests were asked for only after months of fever.Lack of diagnostic tests
The second study was published in April 2016 in the International Journal of Tuberculosis and Lung Disease. It found private doctors using fever as a diagnostic criterion for TB due to “ubiquity of cough and paucity of sputum production by patients”. This study of 110 private doctors (MBBS and AYUSH) in Mumbai and Patna involving 143 interviews and 150 clinical observations in seven clinics found doctors from all systems of medicine treating patients symptomatically based on patient history and clinical observation without asking for diagnostic tests.
Patients were, however, asked for a chest X-ray and other lab tests when some doctors suspected TB, but “often after months of fever”. Even when patients had a history of cough, none of the practitioners of alternative medicine suspected TB on the first visit. “I will not think TB unless the problem persists for some time despite treatment,” one practitioner told the authors.
This empirical approach not only leads to delay in diagnosis and increase in the spread of TB but also exposes the patients to a broad-spectrum of needless antibiotics. Using drugs, particularly quinolones and amoxicillin-clavulanate, as diagnostic tools adds to the delay in diagnosing TB as these drugs tend to temporarily mask symptoms such as cough, fever, or sputum production. As the patients are poor and need immediate relief, the only way to reduce the experimentation with antibiotics is to work to reduce the cost of TB diagnostic tests.
The study reveals that the uptake of sputum smear testing is low in the private sector because it only confirms what the X-ray already suggests. Moreover, an X-ray presents a broader set of information about what is happening in the patients’ lungs.
The study found three reasons why doctors choose the ‘treat with antibiotics and wait’ approach while dealing with TB patients. First, there is a compulsion to provide rapid symptom relief; there is a risk of losing patients, especially when diagnostic tests are asked for during the first visit; there is the factor of financial capability of patients; and there is an easy availability of antibiotics. Second, there is a lack of clear and unique TB symptoms besides TB’s slow onset and progression. Finally, doctors perceive that many TB patients come without a cough or do not produce sputum.
These studies suggest the urgent need for the Indian TB programme to engage with private providers (allopathic and AYUSH) and change their traditional, empirical approach to dealing with TB. Ordering a chest X-ray early, a greater use of sputum TB tests (especially GeneXpert), and greater linkages and referrals to the public sector would be key issues for behaviour change management.
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