Saturday, 26 November 2016

The Missing Three Million

In Agra’s slums, community volunteers are visiting the houses one-by-one and asking the occupants a simple question: “Have you been coughing for more than two weeks?”

Of the ten million new cases of TB every year, one-third remain invisible to the public health authorities. India currently holds the dubious title of World’s TB Capital and accounts for one million of those missing patients. Many of those whose TB goes either undiagnosed or unreported are lost somewhere among the muddy streets and flapping fabrics of the poorest urban communities.

Much of India’s TB problem is socioeconomic—poor housing, poor sanitation, overcrowding, and unhealthy populations both at higher risk of developing active TB and with limited access to adequate healthcare. Active case finding among these marginalised and vulnerable populations is part of the solution to ensuring that people receive treatment and do not continue to transmit their infection to others.

A short paper published last week describes the lessons learnt from a pilot project looking for active TB cases among the half-a-million inhabitants of ‘Agra city’. Community volunteers were offered incentives to visit house-to-house and educate the inhabitants on TB, collect demographic details, and ask if anyone had been coughing.

Where the answer was ‘Yes’, potential TB patients were referred to a local health facility for further testing. What surprised me about the results of the study was that only 40% of those referred actually went of their own fruition. The other 60% had to be accompanied by the community volunteers, who returned to the homes of those not self-presenting within one week.

The study also revealed that levels of TB knowledge among the 3,940 households surveyed were actually very high. Ninety-percent of respondents had heard of TB; most of these people knew that coughing was a symptom. Yet the volunteers still managed to find 382 potential TB patients who hadn't sought out a diagnosis.

When questioned, most of the families said they relied on private healthcare providers for medical care. India’s private sector is highly variable, encompassing world-renown TB doctors all the way down to unqualified charlatans. The combination of patients not seeking out medical care and, when they do, turning to someone who won’t necessarily provide them with a correct diagnosis begins to explain why so many cases of TB go undetected.

It was beyond the paper’s scope to discuss why patients don’t seek out a TB diagnosis but, for me, this is one of the most important questions. What are the barriers that stop people living in Agra city—or in any other part of the world, for that matter—from approaching the health services with symptoms of TB?

Because new drugs, vaccines and diagnostics aren’t going to eradicate TB alone; not when millions still don’t receive the existing treatments and people continue to die from what is a curable disease.

Prasad et al. (2016) Lessons learnt from active tuberculosis case finding in an urban slum setting of Agra city, India. Indian J Tuberc. 63(3):119-202

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