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• W2556272417 abstract "Nimalan Arinaminpathy and colleagues1Arinaminpathy N Batra D Khaparde S et al.The number of privately treated tuberculosis cases in India: an estimation from drug sales data.Lancet Infect Dis. 2016; 16: 1255-1260Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar attempted to provide a mathematical approach to estimate the burden of tuberculosis cases in India from drug sales data as an alternative to WHO's conventional approach. The authors already list several limitations of their approach in estimating the disease burden. On the basis of several years of first-hand operational research experience on tuberculosis in India, I wish to provide insights into further limitations of this approach. The first paragraph of the Article gives the impression that the entire problem of tuberculosis in the country is due to the unregulated private health-care sector. Although the private sector is a problem, as evinced in earlier studies,2Udwadia Z Pinto L Uplekar M Tuberculosis management by private practitioners in Mumbai, India: has anything changed in two decades?.PLoS One. 2010; 5: e12023Crossref PubMed Scopus (162) Google Scholar, 3Uplekar M Pathania V Raviglione M Private practitioners and public health: weak links in tuberculosis control.Lancet. 2001; 358: 912-916Summary Full Text Full Text PDF PubMed Scopus (221) Google Scholar the fact that this sector manages more than 50% of tuberculosis cases cannot be completely ignored, especially in view of the inability of India's public sector to cater to the country's huge population. Several other factors influence tuberculosis diagnosis and treatment. These include patient behaviour—eg, shopping around, and treatment interruption resulting from either early or no symptomatic relief, side-effects of medicines, social stigma, financial factors, or migration. While making the estimates, the authors assumed that the average duration of tuberculosis treatment in the private sector would range from 2 to 6 months. Considering the extent of medical pluralism in India, this assumption could be strongly biased. Many patients continue tuberculosis treatment when they are sick and when they can afford to, and might discontinue treatment as a result of the reasons mentioned above. Treatment can range from a few days to months or even years. Moreover, it is usual practice for patients to obtain treatment from several places; however, there is no documented evidence of the extent of such practices. In many areas, patients can get antituberculosis drugs without prescription. The regulatory enforcement for pharmacists remains weak, and many are unaware of rules. In the absence of an electronic database, it is hard to know the exact number of patients on treatment, and what quantities of different antituberculosis medicines they consume and from which places, especially in a country like India with the complex scenarios described here. India's Government took a bold step of launching mandatory tuberculosis notification for all sector providers; however, enforcement of this policy is weak.4Uplekar M Atre S Wells W et al.Mandatory tuberculosis case notification in high tuberculosis-incidence countries: policy and practice.Euro Resp J. 2016; (published online Oct 20.)https://doi.org/10.1183/13993003.00956-2016Crossref PubMed Scopus (25) Google Scholar In my opinion, investing in a well designed electronic recording and reporting system that includes patient data, laboratory records, and drug sale data would be worthwhile, because it will help not only to assess the exact burden of tuberculosis in the country with a regulatory control, but also to plan resources for the future. This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on Dec 14, 2016 This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on Dec 14, 2016 I declare no competing interests. The number of privately treated tuberculosis cases in India: an estimation from drug sales dataIndia's private sector is treating an enormous number of patients for tuberculosis, appreciably higher than has been previously recognised. Accordingly, there is a re-doubled need to address this burden and to strengthen surveillance. Tuberculosis burden estimates in India and worldwide require revision. Full-Text PDF Open AccessCorrectionsAtre S. Tuberculosis burden in India's private sector. Lancet Infect Dis 2016; 16: 1328–29—In this Correspondence, the author's affiliation has been corrected to Johns Hopkins University, Centre for Clinical Global Health Education (CCGHE), Baltimore, MD, USA; and Department of Pulmonary Medicine, Dr DY Patil Medical College, Hospital and Research Centre, Pimpri, Pune 411018, India. This correction has been made to the online version as of Dec 14, 2016. Full-Text PDF Tuberculosis burden in India's private sector – Authors' replyWe thank Sachin Atre for his interesting and thought-provoking comments on our Article.1 We affirm that the findings of our study are not an alternative to the rigorous disease burden estimation published by WHO, but rather an alert about the potential tuberculosis burden being managed by India's private health-care sector. A crucial objective of our study was to highlight the difficulty in reconciling earlier estimates of the tuberculosis burden in India with the sheer amount of tuberculosis treatment that is taking place in the private sector. Full-Text PDF" @default.
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