Response to Dr. Dhondup Tashi and Dr. Desel’s article

Response to Dr. Dhondup Tashi and Dr. Desel’s article
By Email[Saturday, March 19, 2016 20:12] By Dr. Lobsang Tsering

Dr. Dhondup Tashi and Dr. Tenzin Desel have brought up issues on TB and Hepatitis B in their article in “”. Since May 2015, I am heading the TB division in the DOH-CTA as the TB Program Manager and since August 2015, I have also taken over the Hepatitis B Control Program of DOH in the capacity as the head of the Public Health Division. So what surprised me is that the two doctors have not approached me even once to inquire about the activities of DOH in TB and Hepatitis B.

I am not a political person and I have no political affiliations to any party and for that matter to any regions and religious subgroups. In fact, I have not voted in the preliminaries last year and I am not voting this time also. I am a technical person and I just want to do my job. So it becomes imperative on my part as the Hepatitis B and TB Project Officer of DOH-CTA, that I should clarify few things here and put the facts across to the readers. I will limit myself to Hepatitis B and TB. The current activities/interventions related to Hepatitis B and TB that DOH is implementing or plan to implement in the near future are based on the best practises recommended by the world bodies like WHO and evidences available from the research literature across the world and also from our in-house studies/findings.

Hepatitis B First:

The most cost effective intervention to minimise the burden of the Chronic Hepatitis B infection and its long term impact (complications) like Liver Cancer and Liver Damage is to prevent Hepatitis B disease transmission through Universal Immunisation of Hepatitis B of all infants. This intervention is recommended by WHO and Government of India has also endorsed this. DOH is providing free Hepatitis B vaccination to all Under-5 children for the last many years and there is a plan to strengthen this in the near future based on internal and external evaluation of the DOH-Immunisation Project. There is the Taiwan experience to prove the effectiveness of this intervention. In 1985, Taiwan had Hepatitis B prevalence rate of around 10% (the current estimated prevalence rate of Tibetan community in exile in India). They started Universal Infant Hepatitis B immunisation around 1985 and the current Hepatitis B prevalence rate is less than 1% (comparable to that of developed countries). The limitation to this approach is that it takes few decades for the effect/impact to manifest. DOH has decided to shorten this time duration by taking up the School Hepatitis B screening and vaccination project in a big way from 2014. So far, we have covered about 25 schools and by April 2016, if funding is approved by donor, we will be covering about additional 2000 students of Tibetan Homes Foundation and by 2017 another 6000 students from TCV schools. With this School Hepatitis B project, we hope to cover about 80% of all school going children by 2017 as a “Catch-up Vaccination” activity. With these two interventions i.e. Under-5 free vaccination and School Hepatitis B Vaccination Project, we hope to reduce the Hepatitis B prevalence rate by half (less than 5%) within 15 years’ time. I can stick my neck out on this projection. The above two interventions are the most cost effective evidence based and current best practises. And as Dr. Dhondup la and Dr. Desel la had wanted, the above two interventions are the “definite ways” of reducing the burden of Hepatitis B in our community in the fastest possible manner with the current available technologies. There are other Hepatitis B related activities by DOH which I will not elaborate due to lack of space. Since the two doctors are practising clinicians, they have their bias in their priorities, but I being a public health practitioner, I cannot have that luxury. I have to go by the best practices and the evidences available around the world. They talk about treating people with chronic Hepatitis B infection (Free anti-viral and investigations) and giving free TB medicine to all the MDRs (currently DOH is providing subsidy to MDR TB medicines). I hope and wish that could be done. I wish our resources were limitless. Donor money is for specific activities. DOT-PLUS medicines (MDR/XDR TB) are given free at the government of India (GOI) facilities for TB patients who wish to enrol in the DOT-PLUS program of GOI.

We are trying our best to see how patients who genuinely require anti-viral medicine for Hepatitis B infection get those medicines and I am trying to get a corpus fund for that purpose. Maybe individuals especially Tibetans living abroad can initiate some fund raising activities and contribute to this corpus fund to be maintained by DOH-CTA. We have circulated to all our hospitals regarding the latest WHO guidelines on the management of hepatitis B infection.

One of the milestones for 2025 WHO and STOP TB strategy group for TB is “No affected families facing catastrophic costs due to tuberculosis”. DOH is trying to find means to do that in a sustainable way. I personally feel that in the interim, we should consider how all the TB patients who are in the “Unemployed” occupation category are treated in a holistic way. It means that we should not only give free MDR TB medicines to those “unemployed” occupation group who are genuinely financially weak but also address their basic physiological requirements i.e. food and shelter at-least till their TB treatment is complete. The “unemployed” occupation group is at the highest risk of not completing their treatment i.e. they might be lost during follow-up.

TB Issue:
Everyone recognises that TB is a big challenge and there is no easy solution. Since 2010, we have started a new strategy whereby we are able to reduce the time period between TB diagnosis and MDR treatment by a large fraction (one day to two months depending on X-pert or culture/DST result) by introducing new diagnostics like Gene-Xpert and sending DST (Drug Sensitivity Testing) as soon as the person is diagnosed with TB to Hinduja hospital. Some of the developing countries’ National TB Control Programs are facing difficulties in establishing such a system in place at the grass root level. The credit for this strategy goes largely to Dr. Tseten (CMO of Delek hospital), AISPO and JHU. DOH has been funding some of the recurrent cost of the above activities.

Since 2015, we have taken two major initiatives

1) we have strengthened the annual School TB screening (ACF) activities and because of this the yield (TB case detection rate during the active case finding) has increased as compared to the previous years. This means that we are better able to pick up TB cases in the schools which otherwise would remain undetected for some time. Dr Tenzin Desel had stated in the article that there were 35 MDR cases in 2015. Out of those 35 cases, 5 cases i.e. about 14 % of the cases were detected during the new improved school TB screening activity of 2015. This means that in 2015, about 14% of the MDR cases registered with Delek hospital were detected/picked up much earlier than would have if there were no ACF program.

2) We have strengthened the TB data/information system so that we will be able to make better evidence based decisions in future.

3) We are devising ways to strengthen the DOT system and by the end of 2016, I can assure you that with inclusive discussion with the all the stakeholders, we will be able to develop a robust system that could be comparable to any benchmarks.

From this year (2016) onwards, we plan to do more aggressive active case finding and the new proposed project in collaboration with Government of India, Central TB Division, include intensified case finding through “Annual Active Case Finding” of schools, monasteries and youth hostels plus community outreach (i.e. at households level through house to house visits) covering a population of 60,000 – 80,000 people within 2-3 years. The above activities would pick up the undetected/undiagnosed TB cases lying within the population and that will reduce the future disease transmission and propagation of TB in the Tibetan population.

TB data for the years 2012-2014, collected from seven Tibetan hospitals, shows that “student” occupation group makeup 41.16% of the Tibetan TB patients showing the need for strengthening of the “Annual School TB Screening” which we have done already. Apart from the “biomedical” approach to TB control, there is a serious need to think and do something about the socio-cultural and environmental determinants of TB. For e.g. we need to find out how and where our students live on daily basis. Many of us know that our hostel systems are highly overcrowded. I have seen some rooms where more than 25 people stay in a single room with not more than a foot space between two beds. The issue here is if a room with 25 students with poor ventilation (air circulation) where one of the residents develops TB, the risk of TB from that hostel room for the other 24 students residing in that room becomes great. On the other hand, consider a situation where there is a room and only two persons stay and if one of them develops TB, the risk of TB from that room is only for one person. There is an urgent need to reduce overcrowding in school living environment and also devise simple low cost technologies to improve air circulation/ ventilation in places where our children live (hostel, classroom, dining hall, prayer hall etc). We have already started working in this direction. I am already in discussion with DOE-CTA secretary about this. I have talked to Mr. Tsewang Yeshi la and also the General Secretary of TCV schools about this and hope to develop ways of collaborating in these areas. We hope to cover THF and CST schools also in this endeavour.

I admire the passion of Dr. Dhondup Tashi la and Dr. Tenzin Desel la. But they got some of the facts related to TB and Hepatitis B wrong. What I stated above are facts and can be corroborated by a five minute visit to the DoH-CTA, Dharamsala.

The writer (MBBS, MPH, PGDBDM) is Head- Public Health Division & Program Manager-TB Control Program, DOH-CTA, Dharamsala.

The views expressed in this piece are that of the author and the publication of the piece on this website does not necessarily reflect their endorsement by the website.