Pai et al put up a timely assessment of India’s ambition of achieving tuberculosis elimination by 2025.1 However, the authors seemed to have overlooked the major developments that have been introduced recently in the country. Inclusion of the updated facts could have enriched the discussion, I believe.
In January 2017, a door to door campaign for active case finding for tuberculosis has been started by the Central TB Division (CTD).2 The scheme, if proved successful, has the capacity to effectively reduce the mean delay of two months between appearance of symptoms and initiation of treatment. This, along with introduction of bedaquiline at six referral sites and enhancing the use of cartridge based nucleic acid amplification test across the country, is expected to boost the performance of Revised National TB Control Programme in near future. In fact, CTD has already decided to start daily regimen in 104 districts, spread over five states.3
Now, apart from the budget, the future would also depend on successful vigilance on the dispensing pattern of anti tubercular drugs from private and informal sectors. A study earlier has demonstrated the use of steroids and fluoroquinolones by the pharmacists for probable cases of tuberculosis.5 With the warning against the silent rise of drug resistant tuberculosis and a projected 275% increase in the risk of multi-drug resistant tuberculosis in India over next 20 years, the...
Pai et al put up a timely assessment of India’s ambition of achieving tuberculosis elimination by 2025.1 However, the authors seemed to have overlooked the major developments that have been introduced recently in the country. Inclusion of the updated facts could have enriched the discussion, I believe.
In January 2017, a door to door campaign for active case finding for tuberculosis has been started by the Central TB Division (CTD).2 The scheme, if proved successful, has the capacity to effectively reduce the mean delay of two months between appearance of symptoms and initiation of treatment. This, along with introduction of bedaquiline at six referral sites and enhancing the use of cartridge based nucleic acid amplification test across the country, is expected to boost the performance of Revised National TB Control Programme in near future. In fact, CTD has already decided to start daily regimen in 104 districts, spread over five states.3
Now, apart from the budget, the future would also depend on successful vigilance on the dispensing pattern of anti tubercular drugs from private and informal sectors. A study earlier has demonstrated the use of steroids and fluoroquinolones by the pharmacists for probable cases of tuberculosis.5 With the warning against the silent rise of drug resistant tuberculosis and a projected 275% increase in the risk of multi-drug resistant tuberculosis in India over next 20 years, the surveillance system for detecting cases and ensuring completion of treatment would have to play the major roles in coming days.6
References
1.Pai M, Bhaumik S, Bhuyan SS. India's plan to eliminate tuberculosis by 2025: converting rhetoric into reality. BMJ Global Health 2017;2:e000326. doi:10.1136/bmjgh-2017- 000326
2.Aditi Tandon. Soon, TB services on doorstep: Polio-like campaign to address TB burden from Jan 16. The Tribune, Jan 4, 2017. (Available from
http://www.tribuneindia.com/news/nation/soon-tb-services-on-doorstep/345735.html, last accessed on 22nd March, 2017)
3.Revised National Tuberculosis Control Programme. TB India 2016 annual status report. 2016. (Available from http://www.tbcindia.nic.in/index1.php?lang=1&level=2&sublinkid=4569&lid=3174, last accessed on 22nd March, 2017)
4.Anandhi CL, Nagaraj VK, Kumar R. Knowledge and practice pattern of non-allopathic indigenous medical practitioners regarding tuberculosis in a rural area of India. Indian J Tuberc 2002;6:553–55.
5.Satyanarayana S, Kwan A, Daniels B, et al. Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study. Lancet Infect Dis 2016;16:1261–68.
6.Law S, Piatek AS, Vincent C, Oxlade O, Menzies D. Emergence of drug resistance in patients with tuberculosis cared for by the Indian health-care system: a dynamic modelling study. Lancet Public Health 2017:2:e47-55.
This RUTF trial from India has compared the efficacy of RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM).
I would like to draw attention of the authors on following issues.
1.The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
2.In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less th...
This RUTF trial from India has compared the efficacy of RUTF (centrally produced and locally produced) with augmented energy-dense home-prepared foods (comparison group) for home based management of uncomplicated severe acute malnutrition (SAM).
I would like to draw attention of the authors on following issues.
1.The study reports that 40% children affected with SAM in the study did not recover even with a prolonged (16 weeks), supervised treatment with RUTF and other supportive measures like deworming, antibiotics at the initiation of treatment and increased access to healthcare for morbidity. The recovery rate was 17.3% with the use of locally produced RUTF and 12.1% with centrally produced RUTF at 16 weeks after the end of treatment phase. With such low recovery rates, is it prudent to make a recommendation for the policy that “Children with uncomplicated SAM can be managed at home with RUTF instead of through inpatient hospitalization”?
2.In this trial, researchers aimed to achieve an intake of 175 kcal/kg body weight/ day for the enrolled children and collected consumption data for both the RUTF groups which were largely comparable. But they fail to do so for the comparison group stating greater difficulty in capturing valid information. Authors need to explain if this has led to a less than robust comparison of outcomes between the two RUTF groups and the augmented energy-dense home-prepared foods group as energy intake in the comparison group is not known.
3.It will be useful if the authors provide opinion about efficacy of centrally produced RUTF in comparison to locally produced RUTF in treating SAM as adequate data in this regard are available to them in the study to do so. This information will be relevant from programmatic point of view as programmes for treatment of SAM in some states of India are using centrally produced RUTF.1
4.The study has reported that centrally produced RUTF was not efficacious in comparison to nutrient-rich homemade foods to treat SAM. It will be useful if authors can provide some underlying factors for this finding, just like they have explained many other findings in the discussion.
Reference:
1. National Health Mission – Government of Rajasthan. Poshan. Available at: http://nrhmrajasthan.nic.in/POSHAN.asp
Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
Reading Between the Lines of the RUTF trial, India
Nita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied in the augmented home foods category, but had to be cooked, also underplays this issue and complicates the results, as does the fact that peer support was different in each arm (though statistically insignificant) and this was adjusted for in the results, without offering details on these differences and adjustments.
Nonetheless, results show that the differences between A- HPF and RUTF-C were not significant. RUTF-L (being different from RUTF-C only in texture) was found to be inexplicably better than A-HPF, achieving a 57% recovery rate compared to 43% in 16 weeks. However, 16 weeks after the intervention, the overall numbers of children cured had dwindled to 15%.
Thus, the data clearly shows that the overall impact across all three arms is low, with over 40% children remaining in SAM even after a prolonged period of intervention in the strongest arm. Even these gains are unacceptably temporary. In addition, the element of supervised feeding ‘several times a day’ by a paid peer counselor seems quintessential to the results across the arms. Far from encouraging the use of RUTF in India, all these facts seem to suggest that, given a certain equivalence of quality, the choice of product is largely irrelevant for the community management of malnutrition.
The question this paper should rather be discussing is, whether it is logical, practical, acceptable and cost- effective to have individualized paid workers offering supervised feeding of RUTF-L several times a day at sparsely scattered households, to be able to achieve only moderate and highly unsustained gains in treating SAM.
Instead, the existing alternative hypothesis for SAM prevention and managementiii ; supporting families through comprehensive childcare programmes that organize care, health and nutrition using local resources, needs to be taken seriously and tested if required.
Word count: 498
i Sachdeva HPS, Kapil U, Gupta A, Prasad V. “Sustainable developmental solutions or product- based illusions for addressing severe acute malnutrition?” Paper submitted to the World Nutrition Conference2016, held in Cape Town, South Africa from 30th August to 2nd September 2016. Available http://www2.tulane.edu/publichealth/internut/magic-bullets-workshop.cfm
ii Prasad V, Holla R, Gupta A. Should India use commercially produced ready to use therapeutic foods (RUTF) for severe acute malnutrition (SAM)? Social Medicine 2009; 4(1): 52-5.
iii Prasad V, Sinha D. Potentials, Experiences and Outcomes of a Comprehensive Community Based Programme to Address Malnutrition in Tribal India. International Journal of Child Health and Nutrition, 2015, 4, 151-162

Abdur Sarker et al have highlighted an incredibly important aspect of Bangladeshi society that acts as a pivotal part of achieving Universal Health Coveage (UHC). They have clearly highlighted aspects such as the promotion of health equity and access within cooperatives, however, two aspects of such societies have not been discussed, namely technology and education.
Reading Between the Lines of the RUTF trial, India
Show MoreNita Bhandari et al are to be congratulated for publishing the much-awaited findings of the trial conducted in India for home-based management of uncomplicated severe acute malnutrition; comparing the efficacy of ready-to-use-therapeutic-food (RUTF); centrally (RUTF-C) and locally produced (RUTF-L), with augmented home-foods (A-HPF). The rigorously conducted trial offers significant insights to this highly debated and discussed area of work i ii . However, its policy recommendations seem evasive and ill founded on the evidence.
It is hardly in question that children with SAM benefit from being fed calorie-dense and protein rich foods, including RUTF. What the authors note, however, is that the rate, ease and extent of achieving ‘cure’ is far lower than that seen in African studies. In fact, this is the first trial where the advisory committee – the Data Safety Monitoring Board has had to recommend a treatment period as long as 16 weeks. It also has had to recommend the introduction of paid workers that visited each household ‘several times’ through the day to personally supervise feeding, to be able to achieve even this impact across the arms. This corresponds to an understanding that malnutrition cannot be sufficiently countered in the field without supporting care-givers in practical ways. In fact, comparing ready-to-use foods with the raw material that was supplied...
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