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. According to the World Health Organization’s “Global Tuberculosis Report 2018“, India accounted for 27% of the 10 million people, who had developed TB in 2017, besides making up 32% of global TB deaths among HIV-negative people, and 27% of combined TB deaths. The Lancet report says that India’s goal to end the epidemic by 2025 was too “ambitious”, “unrealistic”, and, therefore, unattainable.

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TB Situation in India:

According to WHO 2018 Global TB Report,

• India accounted for 27% of the total new TB infections in 2017- the highest in the world
• There has been a 1.7% reduction in tuberculosis cases and 3% reduction in deaths from 2016
• India has 24% of the world’s drug-resistant TB burden- the highest in the world
• There was also 8% reduction in rifampicin–first-line TB drug–resistant tuberculosis (RR TB) and MDR-TB

India’s efforts to eliminate TB:

• In 2018, Indian government launched Joint Effort for Elimination of Tuberculosis (JEET), to increase the reporting of TB cases by the private sector.
• National Strategic Plan (NSP) for TB Elimination (2017-2025) was launched in 2017. The government also called for the elimination of TB by 2025, five years prior to the international target (2030).
  • The NSP plans to provide incentives to private providers for following the standard protocols for diagnosis and treatment as well as for notifying the government of cases.
  • Further, patients referred to the government will receive a cash transfer to compensate them for the direct and indirect costs of undergoing treatment and as an incentive to complete treatment.
• “Nikshay,” (2012) an online tuberculosis reporting system for medical practitioners and clinical establishments was set up. The aim is to increase the reporting of tuberculosis, especially from the private sector.
• In 1992, the WHO devised the Directly Observed Treatment-Short Course (DOTS) strategy and advised all countries to adopt the strategy to combat the menace of tuberculosis. The DOTS strategy is based on 5 pillars:
  • political commitment and continued funding for TB control programs
  • diagnosis by sputum smear examinations
  • uninterrupted supply of high-quality anti-TB drugs
  • drug intake under direct observation
  • accurate reporting and recording of all registered cases
• The Indian government has been implementing Programmatic Management of Drug Resistant TB (PMDT) services, for the management of multi-drug resistant tuberculosis (MDR-TB) and TB-HIV collaborative activities for TB-HIV

Challenges to achieve TB free India by 2025:

• Poor socio-economic conditions:
  • Poverty remains a stark reality in India with associated problems of hunger, undernourishment and poor and unhygienic living conditions.
  • According to GTB Report, 2018, a majority of TB patients (6lakhs) in India are attributable to undernourishment.
• Underreporting and misdiagnosis:
  • According to GTB Report 2018, India is one of the major contributors to under-reporting and under-diagnosis of TB cases in the world, accounting for 26% of the 3.6 million global gap in the reporting of tuberculosis cases.
  • Biomarkers and other diagnostics that identify individuals at highest risk of progression to disease are inadequate.
• Treatment:
  • Inequitable access to quality diagnosis and treatment remains a major issue in combating tuberculosis. Further, the private sector which contributes a major part of TB care is fragmented, made up of diverse types of healthcare providers, and largely unregulated.
  • Standard TB treatment is not followed uniformly across the private sector, resulting in the rise of drug resistance.
• Follow-up treatment:
  • Though the reporting of TB cases has increased lately, the reporting of treatment outcomes has not been robust.
  • The absence of consistent follow-up of treatment regimens and outcomes may result in relapse of cases and MDR-TB and XDR-TB. India has already been facing the problem of increasing MDR-TB cases
• Drugs:
  • The drugs used to treat TB, especially multidrug-resistant-TB, are decades old. It is only recently that Bedaquiline and Delamanid (drugs to treat MDR-TB) has been made available. However, access to such drugs remains low.
• Funds:
  • The RNCTP remains inadequately funded. There has been a growing gap between the allocation of funds and the minimum investment required to reach the goals of the national strategic plan to address tuberculosis.
• Issues with RNCTP:
  • Weak implementation of RNCTP at state level is another major concern. The Joint Monitoring Mission report of 2015 pointed out that the RNCTP failed to achieve both the main goals of NSP 2012-2017- Providing universal access to early diagnosis and treatment and improving case detection.
  • Major issues with RNCTP include: human resource crunch, payment delays, procurement delays and drug stock-outs
• R&D:
  • R&D for new methods and technologies to detect the different modes of TB, new vaccines, and new drugs and shorter drug regimens have been slow, as compared to other such diseases like HIV/AIDS.
• Social Stigma:
  • According to a study which assessed social stigma associated with TB in Bangladesh, Colombia, India, India had the highest social stigma index.
  • Patients often hesitate to seek treatment or deny their condition altogether for fear of social discrimination and stigmatization.

Way forward:

• It is important to address the social conditions and factors which contribute to and increase vulnerability to tuberculosis. Concerted efforts should be made to address the issues of undernourishment, diabetes, alcohol and tobacco use.
• Increased political will, financial resources and increasing research to develop new ways to diagnose, treat and prevent TB will help achieve the goal.
• Private sector engagement in combating TB needs to be strengthened. The private sector should also be incentivised to report TB cases. Example: The Kochi Model– Increasing TB cases reporting from private sector
• There is an urgent need for cost-effective point-of-care devices that can be deployed for TB diagnosis in different settings across India.
• Universal access to drug, susceptibility testing at diagnosis to ensure that all patients are given appropriate treatment, including access to second-line treatment for drug-resistant TB.
• To ensure public participation — a missing element in the RNTCP —in public-private participation mode.
• Mass awareness campaigns like ‘TB Harega Desh Jeetega’ can play an important role in breaking social taboos regarding TB.

 Conclusion:

India has the highest TB burden in the world. Given our inter-connected world and the airborne spread of TB, we need collective global action. Ending TB in India will have massive global impact in addition to saving the lives of tens of millions of India’s people over the next 25 years. Even if ending TB by 2025 is not complete, pulling the TB curve down by 2025 and sustaining the decline ever after is a possibility.