The number of privately treated tuberculosis cases in India: an estimation from drug sales data

Abstract

Background: Understanding the amount of tuberculosis managed by the private sector in India is crucial to understanding the true burden of the disease in the country, and thus globally. In the absence of quality surveillance data on privately treated patients, commercial drug sales data offer an empirical foundation for disease burden estimation.

Methods: We used a large, nationally representative commercial dataset on sales of 189 anti-tuberculosis products available in India to calculate the amount of anti-tuberculosis treatment in the private sector in 2013-14. We corrected estimates using validation studies that audited prescriptions against tuberculosis diagnosis, and estimated uncertainty using Monte Carlo simulation. To address implications for numbers of patients with tuberculosis, we explored varying assumptions for average duration of tuberculosis treatment and accuracy of private diagnosis.

Findings: There were 17·793 million patient-months (95% credible interval 16·709 million to 19·841 million) of anti-tuberculosis treatment in the private sector in 2014, twice as many as the public sector. If 40-60% of private-sector tuberculosis diagnoses are correct, and if private-sector tuberculosis treatment lasts on average 2-6 months, this implies that 1·19-5·34 million tuberculosis cases were treated in the private sector in 2014 alone. The midpoint of these ranges yields an estimate of 2·2 million cases, two to three times higher than currently assumed.

Interpretation: India'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.

Funding: Bill & Melinda Gates Foundation.

Figure

Implications of treatment volume in 2014 for tuberculosis burden managed by the private sector in India Estimates are shown for the number of patients with tuberculosis treated by the private sector (see colour bar for numbers in millions), under different scenarios for the average duration of treatment in the private sector, and the proportion of private-sector tuberculosis diagnoses that genuinely have tuberculosis. The diamond illustrates a moderate parameter regime, in which 50% of diagnoses in the private sector genuinely have tuberculosis, and the average treatment duration is for 4 months. This corresponds to an estimated 2·2 million patients being treated in the private sector in 2014.