Tuberculosis in India

Context:

The United Nations’ high level meeting on tuberculosis, held on 26 September 2018, has committed to accelerating efforts and increasing funding towards achieving the agenda of the Sustainable Development Goals to end the tuberculosis epidemic by 2030.

Note

SDG 3.3: By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.

What is tuberculosis?

Tuberculosis, generally called TB is an infectious airborne bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs but can also damage other parts of the body.

There are two TB-related conditions:

1. Latent TB – the bacteria remain in the body in an inactive state. They cause no symptoms and are not contagious, but they can become active.
2. Active TB – the bacteria do cause symptoms and can be transmitted to others

Global scenario:

According to WHO’s 2018 Global TB Report,

• Worldwide, tuberculosis (TB) is one of the top 10 causes of death, and the leading cause from a single infectious agent (above HIV/AIDS)
• In 2017, 10 million people fell ill with TB, and 1.6 million died from the disease (including 0.3 million among people with HIV).
• Globally, TB incidence is falling at about 2% per year.
• MDR-TB remains a public health crisis, with more than 500,000 believed to have contracted TB resistant to rifampicin, the most effective frontline drug.The MDR-TB burden largely falls on 3 countries – India, China and the Russian Federation (together account for nearly 50% of the global cases)
• In 2017, about 8.5% of MDR-TB cases had extensively drug-resistant TB (XDR-TB)

Indian scenario:

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

TB Control Programmes in India

1961:District Tuberculosis Program was prepared by the Indian government, and Anantapur district in Andhra Pradesh state was the first model district TB centre (DTC). The programme aimed at integration of TB control schemes with the existing government health services.

1962:National TB Control Program (NTCP) was launched based on the District TB Centre model

1997: The Revised National TB Control Program (RNTCP) was launched. It adopted the internationally recommended DOTS strategy.

Note: 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

2012-“Nikshay,” 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.

2014-Standards for TB Care in India (STCI) was launched. It is an initiative to introduce uniform standards for TB care in all sectors.

2016-Anti-TB drug Bedaquiline was introduced under Conditional Access Programme (CAP) to improve outcomes of drug resistant TB treatment

2017- National Strategic Plan (NSP) for TB Elimination (2017-2025) launched. The government also called for the elimination of TB by 2025- five years prior to the international target (2030).

Note:

NSP 2017-2025:

• 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.

2018-At the End-TB Summit, Delhi, the TB-free India Campaign was launched to take the activities under the National Strategic Plan for TB Elimination forward in a mission mode for ending the epidemic by 2025.

2018– Indian government launched Joint Effort for Elimination of Tuberculosis (JEET), to increase the reporting of TB cases by the private sector.

Issues with TB Control in India and Reasons for its continued prevalence:

1. Social conditions and co-morbidities:the social conditions and co-morbidities that fuel the TB have been poorly addressed in India. Poverty remains a stark reality in India with associated problems of hunger, undernourishment and poor and unhygienic living conditions. According to Global TB Report, 2018, a majority of TB patients (6lakhs) in India are attributable to undernourishment

Note: Five major risk factors for TB:  alcohol, smoking, diabetes, HIV and undernourishment

2.Underreporting and un-diagnosis:According to Global TB 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

3.Diagnosis:Biomarkers and other diagnostics that identify individuals at highest risk of progression to disease are inadequate.

4.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, andlargely unregulated. Also, standard TB treatment is not followed uniformly across the private sector, resulting in the rise of drug resistance.

5.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

6.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 remain low.

7.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.

8.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

9.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.

10.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.

Best Practice:

Kerala: The Kochi Model- Increasing TB cases reporting from private sector

• In 2017, a collaboration with Indian Medical Association of Kochi city resulted in the formation of a ‘Consortium of Private Hospitals to End TB’ in Kochi. It is a public-private partnership which has brought together private hospitals with the government TB control system.
• The consortium envisages that all private hospitals would create an ‘after-sales care’ system in which every TB case will be notified, followed up regularly at periodic intervals, and retrieved to the hospital if need be, with or without support from the public health sector.

Way Forward:

1. 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.
2. Private sector engagement in combating TB needs to be strengthened. The private sector should also be incentivised to report TB cases.
3. There is an urgent need for cost-effective point-of-care devices that can be deployed for TB diagnosis in different settings across India.
4. it is important to invest more in R&D to come up with new drug regimens for responding to the spread of drug-resistant strains. Further, there is an urgent need to research on an effective vaccine to prevent TB in adults. The India TB Research and Development Corporation must play a pivotal role in accelerating the efforts.
5. Service delivery should be optimised so that the diagnostics and drugs reach to people who need them the most.

6.Mass awareness campaigns like ‘TB Harega Desh Jeetega’ can play an important role in breaking social taboos regarding TB and awaring people about the disease, precautions and its cure.

7. Coordinated efforts of all stakeholders is required otherwise the ambitious 2025 target to eradicate TB cannot be achieved.