War against tuberculosis in India: an overview

Context:

• Prime Minister Narendra Modi recently said India has set a target for complete elimination of Tuberculosis (TB) by 2025, five years ahead of the global target of 2030.

What is Tuberculosis?

• Tuberculosis, or TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs.
• It is transmitted from person to person via droplets from the throat and lungs of people with the active respiratory disease.
• India has the highest burden of TB with two deaths occurring every three minutes from tuberculosis (TB).

Present status of Tuberculosis (TB) :

• Tuberculosis (TB) is one of the top 10 causes of death worldwide.
• In 2016, 10.4 million people fell ill with TB, and 1.7 million died from the disease (including 0.4 million among people with HIV). Over 95% of TB deaths occur in low- and middle-income countries.
• Seven countries account for 64% of the total, with India leading the count, followed by Indonesia, China, Philippines, Pakistan, Nigeria, and South Africa
• In 2016, an estimated 1 million children became ill with TB and 250 000 children died of TB (including children with HIV associated TB).
• TB is a leading killer of HIV-positive people: in 2016, 40% of HIV deaths were due to TB.
• Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat.
• WHO estimates that there were 600 000 new cases with resistance to rifampicin – the most effective first-line drug, of which 490 000 had MDR-TB.
• Globally, TB incidence is falling at about 2% per year.
• An estimated 53 million lives were saved through TB diagnosis and treatment between 2000 and 2016.
• Ending the TB epidemic by 2030 is among the health targets of the Sustainable Development Goals.

Factors causing its wide spread:

• Infection with TB bacilli is the necessary cause of TB, a disease that mimics other diseases, confusing doctors and delaying diagnosis.
• Lack of efficient primary health care.
• Low socio-economic status.
• Unregulated pharmaceuticals.

Who is most at risk?

• Tuberculosis mostly affects adults in their most productive years. However, all age groups are at risk. Over 95% of cases and deaths are in developing countries.
• People who are infected with HIV are 20 to 30 times more likely to develop active TB (see TB and HIV section below). The risk of active TB is also greater in persons suffering from other conditions that impair the immune system.
• One million children (0–14 years of age) fell ill with TB, and 250 000 children (including children with HIV associated TB) died from the disease in 2016.
• Tobacco use greatly increases the risk of TB disease and death. 8% of TB cases worldwide are attributable to smoking.

Government initiatives:

• The Union Health ministry has a target of eliminating TB by 2025. With this in view it has adopted the Revised National TB Control Program in line with WHO’s DOTS program
• TB has been made a notifiable disease and a web based surveillance system has been develop
• Contact screening and preventive isoniazid therapy are being conducted
• Care giver has been legally entrusted with the responsibility to ensure proper dosage is taken by the patient
• Making TB a notifiable disease (May 2012), including anti-TB drugs under Schedule-H1 (August 2013); and developing a case-based, web-based TB surveillance system.
• National Strategic Plan for 2017- 25 for TB elimination in India is a good step in eliminating TB in India. It is crafted in line with other health sector strategies and global efforts, such as the draft National Health Policy 2015, World Health Organization’s (WHO) End TB Strategy, and the Sustainable Development Goals (SDGs) of the United Nations (UN).

Revised National TB Control Programme (RNTCP):

• Revised National Tuberculosis Control Program (RNTCP) is the state-run tuberculosis(TB) control initiative of the Government of India.
• As per the National Strategic Plan 2012–17, the program has a vision of achieving a “TB free India”, and aims to achieve Universal Access to TB control services.
• The program provides, various free of cost, quality tuberculosis diagnosis and treatment services across the country through the government health system.
• It seeks to employ the WHO recommended tuberculosis control strategy, DOTS(Directly Observed Treatment, Short Course), to the Indian scenario.

Why disease still persists in India?

Despite above measures, TB still remains a spectre haunting India because,

• Inefficient medical infrastructure to implement the DOTs programme across the country.
• Non- reporting of TB causes by the private sector due to pressure to adhere to DOTs treatment without providing any training to do so.
• Lack of involvement of NGOs as an interface between patients, private clinic and government authorities and hospitals to provide for seamless flow of medicines and treatment processes.
• No institutionalised mechanism to help them update their knowledge and skills about changing diagnostic algorithms, even the use of anti-TB drugs in appropriate doses for the correct duration.
• There is an undue expectation from private providers that they will follow the DOTS administration to ensure treatment adherence.
• No uniform prescription and non-writing of prescription had elevated resistance level of TB bacteria.
• The private practitioners were never approached or oriented by the local TB programme
• Irregular medication and not completing the prescribed drug to full period when symptoms reduce.
• Awareness among people and no early detection will spread the disease.
• Lack of responsibility among local TB program implementing agencies and negligence on their part to involve private practitioners and NGOs.

Solutions:

• Control and regulated use of anti biotics.
• Creating more awareness among people.
• Try screening and limiting patients with drug resistant TB to prevent further spread among family and community.
• Cheap and better diagnostic facilities to prevent ad-hoc use of anti-biotics.

Way ahead:

• Foster relations with private sector via NGOs help to transmit knowledge and increase reporting of TB cases in the future.
• Tailor DOTs and RNTCP programmes for specific regions
• Partnership with the private sector is essential for early diagnosis of TB.
• Universal primary health care, a basic human right, and a diagnostic algorithm for early diagnosis are essential for TB control.
• Drug susceptibility tests have to be made universal and mandatory
• TB is closely associated with malnutrition, open defecation, slums etc. Steps must be taken to eradicate these problems.
• Information Technology (IT) tools for monitoring the programme and treatment adherence. Community engagement is the hallmark and it is becoming a social movement to end TB in India,
• Build empowered institutions and human resources to streamline implementation.