Mumbai: Pharmacies trained in tuberculosis (TB) screening and doctor referrals can significantly improve the detection and diagnosis of the disease in India, according to a recent study.

TB screening and doctor referrals increased eight times, microbiological confirmations for TB rose almost seven times and TB registrations were 62 times higher when those with symptoms visited pharmacies with trained staff compared to those without, said the study commissioned by BMJ Global Health, a repository of journals specialising in non-communicable diseases.

With 18% of the global population, India currently reports the highest incidence of TB in the world--23% or nearly a quarter of all cases.

The study was based on an intervention conducted in Patna, capital of the eastern state of Bihar, where 105 trained pharmacies successfully diagnosed 255 TB cases, three times the number of patients (83) identified with TB symptoms by 699 untrained pharmacies in the control group.

Retail pharmacies—around 750,000 nationwide—often provide the first point of medical contact for potential patients. Given that the treatment for TB, a curable disease, reaches only about 59% of patients, as IndiaSpend reported in March 2017, pharmacies could play an integral role in India’s fight against TB.

“Pharmacies as ‘gatekeepers’ have a role to play in helping potential patients,” said Amrita Daftary, one of the authors of the study. “They are usually the first point of contact for many people. People go to them when they develop any medical condition.”

Patients who were referred by trained pharmacists visited doctors 42% more often than they otherwise would have, the study found, and TB registrations, mandatory for private medical service providers after a 2012 government directive, were 62 times higher among those referred by the intervention group.

Completion rates for chest-radiograph (chest X-ray), sputum smear and GeneXpert test—three important steps in TB diagnosis—were higher for those who received referrals from trained pharmacists by margins of 37%, 13% and 23%, respectively.

Why private sector participation

TB is among India’s most deadly infectious diseases, with an estimated 2.8 million confirmed cases in 2015, according to a World Health Organization (WHO) report. Caused by the Mycobacterium tuberculosis bacteria, its transmission is airborne and occurs when an infected person coughs or sneezes.

India’s TB burden is the highest in the world, as we mentioned earlier, followed by Indonesia (10%) and China (10%).

The National Strategic Plan for Tuberculosis Elimination launched in March 2017 gave particular importance to the role of the private sector in the eradication of TB in India. The screening and referral intervention involving private retail pharmacies is meant to be a critical part of this plan.

Public-health facilities that specialise in TB in India are already overstressed, with little political will to change the situation, said a 2011 study by the National Center for Biotechnology Information.

Rural areas have poor medical infrastructure to treat the disease and private healthcare units remain unregulated, said the 2011 study, which added that “irrational” use of first-line and second-line anti-TB drugs was the other problem with TB care in India.

Patna’s TB rate exceeds Sub-Saharan Africa’s

Along with lower-than-average rates of health, income and literacy, Patna reports a TB incidence rate of 326 per 100,000 population. This is well over the incidence rate of Sub-Saharan Africa (237) and higher than the Indian average of 204. This made the city an ideal location for the project.

The intervention was carried out within an ongoing “public-private mix programme” in Patna. “Piggybacking on the PPM provided access to a vast majority of the private pharmacy providers in Patna,” Daftary said.

Of 804 private pharmacies enrolled in the programme, a random sample of 105 participated in the pilot event. They were recruited in phases: The first set of 30 pharmacists was trained in December 2015, the second in February 2016, and the last set of 45 pharmacists in May 2016.

Their training comprised five components: (i) identifying TB through tell-tale symptoms, screening and diagnostic testing, and stewardship of antibiotics, (ii) referring potential TB patients for doctor consultations and chest X-rays, (iii) offering a financial incentive of Rs 50 for every completed doctor referral and chest test, (iv) added incentive of Rs 200 for positively diagnosed cases, and (v) field support with SMS reminders to reinforce the pharmacists’ training and screening process.

In parallel, 699 of 804 pharmacies, which did not receive the training, were observed for referral rates.

Trained group spotted 725% more cases

During the 18-month pilot period, 81% or 84 pharmacies in the intervention group referred at least one customer for a TB screening, followed by one of two pathways: chest X-ray and a medical consultation, or a direct doctor consultation.

Overall, the trained group identified 1,674 potential TB patients based on their symptoms, while untrained pharmacists could only find 203 (fewer by 725%), according to the study. Of those identified, 255 cases referred by the intervention group and 83 cases from the control group respectively, were registered as confirmed TB notifications.

A TB notification is created when the doctor or diagnostician registers a person with symptoms on to the National TB Surveillance System, and then on to WHO.

The final stage of diagnosing TB involves the microbiological tests (MB) -- the intervention group reported 24% MB positive cases (61), while the control group reported 11% MB positive cases (9).

Why the intervention worked

Periodic group discussions and private interviews helped improve the intervention programme for pharmacists, the study found. The newly acquired ability to ‘dispense’ a screening test gave trained pharmacists a greater sense of professional responsibility towards TB patients.

“I feel good that I am able to serve my society,” said one unnamed pharmacist quoted in the study. “People are benefitting. We are able to provide care and people are getting better.”

Providers catering to customers in relatively poorer sections of the city reported a growing relationship with patients, often by way of repeated visits.

Successful doctor referrals were attributed to a sense of trust among customers for trained pharmacists. The free TB screening drove up chest X-ray referrals, and positive results from these, in turn, drove up doctor referrals.

These initiatives were seen as major facilitators for achieving a 81% referral rate among pharmacists, especially in comparison to similar studies in 2003, 2014, 2016 and 2018 which saw rather dismal referral rates of around 30-40%.

“This was a practical procedure nested into an ongoing PPM programme, providing access to their inventory of doctors and test labs,” Daftary explained. “Financial incentives were important to tap the private pharmacy sector. Individualised feedback systems for pharmacists with updates on successful doctor referrals and diagnosis also helped.”

What needs to change in the programme

Pharmacists in the study group sometimes delayed referrals to patients who demanded short-term antibiotic courses instead of sustained treatment. A solution to this could be the “creation of general public awareness about antimicrobial stewardship and the threat of drug resistance”, Daftary said.

Another roadblock was the documentation process. It was the standard practice in many pharmacies to verbally refer patients for doctor consultations. These cases did not find their way into the programme tally.

Some customers were also deterred by the distance they would have to travel to visit the contracted doctor or laboratory. “If I send [them] from here to [far], patients will say they may save money on test but transportation will cost them more (sic),” said a pharmacist quoted in the study. “So they feel better to get tested at a nearby lab.”

Some of the other barriers identified include increased workload for pharmacies, the absence of identifiable symptoms, doctor consultation fees and customer discomfort with the unknown doctor or lab they may be referred to, the study showed.

“The government should capitalise on the trust people place on pharmacies and chemists,” said Daftary. “There should be greater investment in pharmacy training to enable them to screen and refer potential TB patients.”

This story was first published here on HealthCheck.

(Saha, an MSc student at the Symbiosis School of Economics, Pune, is an intern with IndiaSpend.)

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Arunabh Saha