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| EDITORIAL |
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| Year : 2021 | Volume
: 9
| Issue : 2 | Page : 47-50 |
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Tuberculosis elimination in India by 2025: Dream or reality?
Rashmi Sharma1, Pradeep Kumar2
1 Department of Community Medicine, GMERS Medical College, Ahmedabad, Gujarat, India
2 Department of Community Medicine, Dr MK Shah Medical College, Ahmedabad, Gujarat, India
| Date of Submission | 04-May-2021 |
| Date of Decision | 31-May-2021 |
| Date of Acceptance | 02-Jun-2021 |
| Date of Web Publication | 11-Jun-2021 |
Correspondence Address:
Dr. Pradeep Kumar
A1/7, Swagat City, Adalaj, Gandhinagar - 382 421, Gujarat
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mjhs.mjhs_34_21
Tuberculosis is probably the oldest disease known to humankind. Globally, efforts are being made to eliminate the disease by 2030, while the Government of India has committed to achieve this in 2025 (5 years before). A critical evaluation has been made of the strategic plan outlining various activities to attain this goal.
Keywords: National Strategic Plan 2017–2025, Revised National Tuberculosis Control Program, Tuberculosis Elimination
How to cite this article:
Sharma R, Kumar P. Tuberculosis elimination in India by 2025: Dream or reality?. MRIMS J Health Sci 2021;9:47-50 |
| Introduction | |  |
Tuberculosis (TB) Elimination as defined by the World Health Organization (WHO) means “<1 case of TB for 10 lakh population. WHO's “END TB Strategy” adopted by the World Health Assembly (2014) aims by 2035, a 95% reduction in the TB incident cases and related deaths compared with 2015, and zero TB-affected families facing catastrophic costs due to TB by 2020. However, the same under the Sustainable Development Goals was decided to be achieved by 2030.[1] The Government of India has set a goal to achieve TB elimination 5 years before the global target, i.e., in 2025. Let us examine few of the facts in this regard.[2]
From [Table 1], it is clear that India reports the highest number of incident new TB cases, new multidrug-resistant (MDR) TB cases, and TB-related mortality. Considering its vast and heterogeneous population and presence of enabling and social risk factors, this task seems to be very ambitious.
In India, notifications of newly diagnosed with TB rose by 74% from 1.2 million to 2.2 million between 2013 and 2019. Despite this, there was still a large gap (2.9 million) between the number of people newly diagnosed and reported largely due to a combination of underdiagnosis and underreporting of people diagnosed with TB (people with TB cannot access health care or are not diagnosed). Five countries, namely India (17%), Nigeria (11%), Indonesia (10%), Pakistan (8%), and the Philippines (7%) accounted for more than half of the global gap in this regard.[1] All these countries including India need intensified efforts to reduce underreporting and improve access to diagnosis/treatment.
However, information about the disease scenario is incomplete partly due to “poorly regulated and highly privatized health sector” in India. Case studies have shown that the current quality of care is poor, especially in the private sector where over one million TB patients seek care annually. All three components of TB elimination, namely reduction in incidence, mortality, and catastrophic expenditure need to target this huge private sector. Efforts are being made too rope in this sector more so with the launching of National Strategic Plan (NSP) (2017–2025);[3] however, they are unable to show the desirable results.
The current rate of annual decline of TB cases globally is 1.5% and needs to be increased to 15%–19% per year to achieve the WHO's target for global elimination of TB by 2030. It will be difficult to achieve unless suitable strategies to address the current situation are designed and implemented.[4] Similarly, India to eliminate TB by 2025 (5 years ahead of the global target) needs to increase current decline rate of <2% per year to >10%–15% per year for the next 8 years.
TB patients are lost at every stage of care seeking. Detection, access to care, and posttreatment follow-up, though all well defined in the program, are far from satisfactory. The pool of undiagnosed and un/mistreated cases continued the epidemic and TB remained a leading cause of illness and death, especially among persons living with HIV/AIDS. India accounts for maximum MDR TB cases in the world (27% or around 125,000–150,000). While the current cost of a DS TB treatment in India is around 50 USD, cost of the MDR-TB treatment including bedaquiline and other second-line drugs is around 3500 USD. Considering around 150,000 cases of MDR-TB in India, the government has to take a hard and analytical look at the costs of rolling bedaquiline out. If it is to be made part of the national program, the price of the drug has to be brought down substantially.[5]
National Tuberculosis Control Program (NTCP) was launched for the first time as a vertical and district-centric model focusing BCG vaccination and treatment of TB cases in 1963.[6] Since then, it has undergone several changes in terms of approach/strategies. Revised NTCP launched in 1997 was considered as a most revolutionary step toward TB control but has not been free from its criticism. As early as in 2012, it was blamed for excessive deaths and emergence of DR TB.[7] Another study reported excess mortality among successfully cured TB cases under the program within 2–3 years after they are released from the program and one reason was poor posttreatment follow-up of such patients by the program functionaries.[8] Every health program suffers due to its weak component of follow-up/monitoring. The above two studies document this poor monitoring/FU (especially posttreatment) very well. So long (1) deficit workforce issues are not addressed and (2) monitoring/FU are not included in the programmatic review, it cannot be resolved.
The long-term vision of NSP (2012–2017)[3] for Tuberculosis Control is “TB free India” and has a goal of universal access to quality TB diagnosis/treatment for all patients with four strategic pillars of “Detect– Treat– Prevent– Build.”
Early detection followed by treatment not only decreases poor outcomes and social/economic hardships of patients/their families but also decreases the risk of disease transmission to others. Notification of all TB patients from all care providers (establishments managed by government or private or NGO or individual) to local health authorities is made mandatory since 2012 and with subsequent amendments in 2015 and 2018, all laboratories and chemists are also included. However, studies do not show promising results and notifications from the private sector remain poor. Government officials claim that not many private practitioners/hospitals notify the disease hindering accurate data on TB cases. The huge private sector in the country, treating at least 50% of TB cases, needs to be engaged rapidly and effectively. Further, every TB patient is reached out by the local health authority to facilitate incentives/support such as mandatory notification of all TB cases, integration of program with general health services, expansion of diagnostics services and programmatic management of drug-resistant TB, single-window service for TB-HIV cases, and national drug resistance surveillance. Integration of the program with general health system shall be neither horizontal nor vertical but diagonal. Medical officer at tuberculosis unit currently looks after the work of TU as additional work along with their routine duties at UHC/CHC. More dedicated staff apart from senior treatment supervisor and TB health visitor are needed if we want to achieve TB elimination within the deadline. As once cases of DS TB/DR TB/MDR TB/X DR TB are screened, stabilized, and put on treatment, MOs along with field staff can monitor the same in follow-up visit to ensure social and family support for achieving better compliance. Looking to the load of cases a counselor is also needed at 1 per TU to address the psychosocial needs of cases by interacting them with during their visits at DMC or through frequent home visits.
NIKSHAY is a surveillance system (https://nikshay.gov.in) for both government/private facilities with future enhancements for patients support, logistics management, direct data transfers, adherence support, and support interface agencies to expand the reach. Under public–private partnership, private providers are given (1) incentives through direct beneficiary transfer (DBT) for case notification and ensuring treatment adherence/completion and (2) ensuring free drugs and diagnostic tests to patients either through the provision of “programme-provided “or reimbursement of market-available ones. A cost reduction of select diagnostics is achieved by “Initiative for Promoting Affordable and Quality TB Tests” through a network of 131 private sector laboratories to provide four quality TB tests at or below the “ceiling prices”. Treat is initiation and sustenance of all TB patients as incomplete treatment may result in drug resistance. Some of the initiatives are screening of all patients for rifampicin resistance and availability of daily fixed-dose combinations of first-line drugs in appropriate weight and age bands for all forms of TB and with the support of directly observed treatment. Nikshay Poshan Yojana is a centrally sponsored scheme of financial incentive at Rs. 500/- per month for nutritional support to notified TB cases through DBT for the duration for treatment. Health system strengthening is recommended by building/strengthening enabling policies, empowering institutions, and human resources. Contact tracing includes screening of all close contacts, especially household (HH) type. In reverse contact tracing for a pediatric TB case, search is made for any active TB case in the HH. Preventive therapy is recommended to children (<6 years) who are close contacts of a TB patient. Children are evaluated for active TB by a medical personal and after excluding active TB, the child is given INH preventive therapy. In addition, it is also extended to all HIV-infected children who either had exposure to an infectious TB case or are tuberculin skin test positive (≥5 mm induration). A child born to a mother (diagnosed to have TB in pregnancy) will receive prophylaxis for 6 months, provided congenital TB is ruled out.
NSP strategy has also intensified activities in key population such as diabetics, tobacco/alcohol/substance users, sexual minorities, undernourished, and economically and socially backward communities including those from hilly and difficult terrains. Some more key populations include pregnant women, pediatric population, prison inmates and its staff. Some of the interventions introduced are scaling up airborne infection control measures at health facilities, treatment for latent TB infection in contacts of confirmed cases, and addressing social determinants through intersectoral approach.
Various information and communication technology (ICT)-based adherence support mechanisms such as mobile-based “Pill-in-Hand” adherence monitoring tool, interactive voice response, short message service (SMS) reminders, specially designed electronic pillboxes or strips with Global Systems for Mobile connection and pressure sensor, patient compliance toolkit: a mobile app to report treatment compliance using video, audio, or text message, automated pill loading system, innovatively designed ICT-enabled smart cards, and SMS gateway are some more innovations addressing the issue of treatment compliance.
A necessary cause of TB is its organism Mycobacterium tuberculosis without its presence the disease cannot occur. However in India, its presence is universal. Surveys in the past based on tuberculin positivity in adult unimmunized population showed that majority of them harbored the infection (not disease).[9] Therefore, despite the near-universal presence of TB organisms, other enabling factors such as poverty, slum living, overcrowding, illiteracy, undernutrition, and habits (smoking) and reinforcing factors such as repeated exposures are more important and decisive in disease causation.[10] Therefore, TB is rightly mentioned as a social disease, as social class measured by income, education, occupation, and housing increases the susceptibility to poor health rather than any specific effect. Once this fact is accepted, TB elimination will not be the responsibility of only the health sector as other departments involved with poverty alleviation, employment generation, education, etc., will also have an important role to play. A joint action plan for TB elimination prepared along with Ministry of Tribal Welfare is an example in this regard as it provides for additional resources in tribal blocks/districts.[11] Alleviation of poverty, hunger, and illiteracy will automatically lead to overall socioeconomic development which, in turn, will eliminate TB and many other similar diseases. In addition to chemotherapy, we need to bring in the social determinants (major drivers behind the TB epidemic) in our focus. Operational researches are needed in this area and their conclusions are to be put into the public health policy and action.
Primary prevention will remain the best strategy for achieving this goal as it is most effective and less resource intensive but give results in long/medium run. All developed countries (the US and Western European) attained TB elimination, thanks to overall socioeconomic development fuelled by industrial revolution along with improvement in literacy and economic status. It happened in the developed world long before the discovery of BCG vaccine and anti-TB drugs, whereas country like ours is trying to do so largely through secondary prevention through chemotherapy. Needless to say, this approach is less effective and more resource intensive. Any laxity on the part of system/patient in seeking the therapy results in the loss to follow-up, default and treatment failure lead to the emergence of MDR and extensively drug-resistant TB cases.
| Impact of COVID 19 on Tuberculosis Elimination | | |
Pandemic of COVID-19 for last 1½ year and unprecedented engagement of health sector in its management has adversely affected all non-COVID activities as all resources have been directed to the COVID management and TB control is no exception. Due to lock downs, restrictions in movement, psychological fear of contacting the disease in health-care facilities, diversion of health-care workers for and management of COVID-19, utilization of diagnostic facilities like CBNAAT machines for COVID work, conversion of hospitals for care of these patients, financial diversion, etc., have created issues in the NTEP to focus on TB control in India.[12] Case notification and other areas of the program to achieve End TB by 2025 have suffered. Following the imposition of a national lockdown In India, weekly and monthly TB case notifications fell in both public and private sectors, by >50% between March and April 2020. Subsequently, there was some recovery by the end of June 2020 but not to pre-March levels. Now with the advent of second wave of COVID-19 (more extensive and fatal), things have again gone to haywire. Sharp fall of disease notification is likely to have a medium-term impact on the number of people who develop TB in terms of reporting to system and accessing treatment. In the absence of effective mitigation strategies, economic contractions and loss of income more so among daily wage earners or migrant labor are likely to worsen the scenario. Global TB report 2020[3] predicts worsening of at least two key determinants, namely per capita GDP and undernutrition. It also suggests that the number of people developing TB could increase by more than 1 million per year in the following years. Loss of income or unemployment could also increase the proportion of people with TB/their HHs facing catastrophic costs.
Policies of using a mask, physical distancing, and no spitting (in public places) may help to reduce airborne transmission responsible for TB and other airborne diseases.[13] However, this effect could be offset by longer durations of infectiousness, increased HH exposure to TB infection, worsening treatment outcomes, and higher levels of poverty. This pandemic has also highlighted the importance of infection control in health-care facilities for its workers and people seeking care. If some of the desired changes in behavior and policies persist, it may bring in the use of digital technologies for remote advice (reducing need for visits to health facilities). Furthermore, if COVID appropriate behavior (mask, social distancing, and hand hygiene) is sustained on long-term basis, it can help in cutting the chain of disease transmission.
| Conclusion | | |
The aim of TB elimination in India by 2025 has been very ambitious and has become even more difficult with the advent of COVID pandemic. But then, aims, though realistic, should be high to ensure full efforts. This goal is not realistic and undoubtedly very high will make everyone to work hard in this direction to ensure some noteworthy achievements.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1]
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