Context

Tuberculosis (TB) remains the biggest killer disease in India, outnumbering all other infectious diseases put together — this despite our battle against it from 1962, when the National TB Programme (NTP) was launched.

Background

• In 1978, the Expanded Programme on Immunisation (EPI) began, giving BCG to all babies soon after birth and achieving more than 90% coverage.

• In 1993, the Revised National TB Control Programme (RNTCP) was launched, offering free diagnosis and treatment for patients, rescuing them from otherwise sure death.

• However, treatment is not prevention. Prevention is essential for control.

The effectiveness of these programmes

• Yet, when evaluated in 1990, the NTP and the EPI had not reduced India’s TB burden.

• Why did the NTP and the EPI fail?

  Visionary leaders had initiated a BCG vaccine clinical trial in 1964 in Chingelpet district, Tamil Nadu.

1. Its final report published in the Indian Journal of Medical Research in 1999.

2. It held that BCG did not protect against TB infection or adult pulmonary TB, the ‘infectious’ form.

3. BCG immunisation does prevent severe multi-organ TB disease in young children, and must be continued but will not control TB.

• By 2014-15, the RNTCP was found to be very successful in reducing mortality, but failing to control TB. Why?

1. From when a person becomes infectious to when he/she turns non-infectious by treatment, there is a gap of several weeks during which the infection saturates contacts in the vicinity

2. Delays in care seeking and diagnosis are the result of lack of universal primary health care.

Tamil Nadu Pilot Model to control TB infection

• Tamil Nadu is planning to implement new strategy in one revenue district, Tiruvannamalai.

• To ensure public participation — a missing element in the RNTCP — the new model will be in public-private participation mode.

• The Rotary movement, having demonstrated its social mobilisation strengths in polio eradication, will partner with the State government in the TB control demonstration project.

• Tiruvannamalai, a pioneer district in health management, was the first in India (1988-90) to eliminate polio using the inactivated polio vaccine (IPV).

• The Directorate of Public Health and Preventive Medicine and the National Health Mission will lead all national, State and district health agencies, district and local administration, departments of education, social welfare and public relations and government medical college.

• The Rotary will ensure the participation of all players (health and non-health) in the private sector.

Other steps to control TB infection

• The Rotary will spearhead public education for behaviour modification, starting in all schools and continuing through to adults.

• Progression to TB disease from infection can be prevented by giving World Health Organisation-recommended short-term ‘preventive treatment’.

• Infection is silent, but diagnosable with the tuberculin skin test (TST).

• Cohorts of schoolchildren (5, 10 and 15 years) can be tested and those TST positive given preventive treatment.

• On March 13, 2018, the Prime Minister, who was inaugurating the End TB Summit, declared that India would end TB by 2025.

Way Forward

• A strategy of simultaneously using all biomedical and socio-behavioural interventions can help in controlling infection.

• Ending TB by 2025 is impossible but pulling the TB curve down by 2025 and sustaining the decline ever after is a possibility.

• Tamil Nadu, an erstwhile global leader in TB research during the 1960s through the 1990s, will now become the global leader in TB control.