Experts from the global TB community welcome the government’s move to eradicate TB from India by 2025, but also fear that it is too ambitious
Tuberculosis (TB) is a global pandemic and continues to be a huge public health threat in India. It currently has 27 per cent of the world’s new TB cases, which is around 2.8 million. According to World Health Organisation (WHO), the country holds the dubious distinction of being the TB capital of the world as around 480,000 people died due to the disease in 2014. As per Stop TB, 1:4 people with TB worldwide is an Indian.
Although the annual incidence of TB has reduced from 289 persons per 100,000 in year 2000 to 217 per 100,000 in 2015, eliminating TB would necessitate a dramatic reduction to less than one person per 10,00,000.
Leaders from the healthcare domain inform that eradicating TB is more of tackling social determinants as the risk factors of TB are tobacco use, exposure to secondhand smoke, diabetes, HIV, malnutrition, overcrowded living conditions, under-diagnosis and the use of unclean fuels for cooking and heating. As a large number of people get treated late or are unsuccessfully treated, or remain untreated, the disease become a menace of huge proportions.
Ending TB @ 2025 – A collective endeavour
Therefore, it is time to get our act together to combat TB. As Prof Madhukar Pai, Associate Director, McGill International TB Centre, Canada, told Express Healthcare, “A big question for the TB community now is this: How do we hold our leaders accountable for their big declarations and commitments? The world is watching whether India will follow up on prime minister’s commitment with the substantially increased budget that is required, and rapidly execute the ambitious TB Free India campaign. 2025 is just seven years away and the clock is ticking.”
However, many other health experts are more optimistic and assert that with political will, right systems and partnerships in place, India can make significant overall progress in its fight against the disease. They indicate that the recently held Delhi END TB summit was a platform set to end the dreaded disease, and inform that appropriate strategies are being implemented in line with the National Strategic Plan (NSP) 2017-2025 for TB Elimination in India. But, the devil is in the details.
“India has been fighting TB for a number of years, but now the country has seen a paradigm shift with a new strategy and bold commitments. The battle to end TB will need increased resources, bold policies, innovations, research and unprecedented scale of implementation. We have recently seen the budget for TB going up, and strong policies being enacted on notification, private sector and active case finding. Implementation of policies with uniform good quality in a large and diverse country like India will be a challenge,” informs Dr Suvanand Sahu, Deputy Director, Stop TB Partnership, a global network of organisations working to eliminate TB.
Dr Henk Bekedam, WHO Representative to India, informs, “Health is being accorded priority, and it is evident from the National Health Policy 2017 and the Ayushman Bharat – National Health Protection Mission (NHPM), which aims to benefit more than 10 crore vulnerable families. These initiatives cumulatively cover all bases and will indeed prove transformational in India’s end-TB efforts.”
Dr Bekedam explains, “A strong political commitment by Government of India recognising TB as a major public health problem and its major public health programme end TB by 2025, five years ahead of the global Sustainable Development Goals (SDG) target of 2030, is a well-defined action plan, backed by the NSP 2017-22 for ending TB, which outlines bold policies and new strategies with a nearly four-fold increase in funding for its implementation. Detect, treat, prevent and build form the key pillars of India’s TB elimination strategy. The NSP, whilst focussing on finding, testing and treating TB, also adopts a multi-pronged strategy with a special focus on forging strong partnerships, empowering communities and creating awareness, as a step towards behaviour change, including delayed care seeking behaviour, treatment completion.”
Major steps to End TB
- Based on the need expressed in the National Strategic Plan continue to increase the budget for the TB programme at the federal level and also at the state level to ensure no funding gap exists.
- Scale up new rapid molecular diagnostics and new drugs and treatment regimen.
- Ensure uniform good quality diagnostic and treatment services in both public and private sectors.
- Scale up quickly the direct benefit transfers to patients and improve it further to ensure that out-of-pocket costs to patients and their families are reduced.
- Implement the comprehensive approach of “search-treat-prevent” which is already in the national strategic plan. More needs to be done to operationalise prevention and preventive therapy for those at risk.
- Considering the diversity of India put in place a system for achieving TB-free villages and cities, encouraging health competition between states and local areas.
- Prioritise research and innovation, including research into new diagnostics, drugs and vaccine.
- Most important of all set up a system of monitoring progress by the state chief ministers
Echoing similar thoughts, José Luis Castro, President and CEO, Vital Strategies, who had done a mass media campaign ‘TB Cough’ for Ministry of Health and Family Welfare (MoH&FW), says, “We know that it is possible to dramatically reduce TB prevalence – countries like the UK and the US did so in the last century, and there have been some impressive examples of progress in certain parts of India. India can certainly make significant overall progress in its fight against TB.”
Experts also emphasise that India should apply lessons learned from the polio eradication programme, as there are similarities and dissimilarities between polio and TB. Like polio, TB also needs a massive and intensive public health response.
Lessons from polio eradication
The polio experience of civil society participation and doing things in a mission mode is something that the TB programme should adapt. Epidemic control measures such as case investigation, laboratory surveillance and protecting susceptible contacts are principles that can be applied to both polio and TB, global experts inform.
“There are good lessons India can take from its work to eradicate polio, but TB is a tougher challenge in a number of ways. Most importantly, there is a very effective vaccine that protects people from contracting polio so that they never get sick in the first place, and we don’t have the same kind of effective vaccine yet for TB. Instead, there needs to be a multi-pronged strategy to address TB. Control and elimination of TB relies on making a diagnosis, starting the patient on the right medicines, and ensuring adherence and completion of treatment. There are significant levels of under-diagnosis – estimates say perhaps as many as a million people in India – increasing poorer outcomes and unintended spread of TB. Perceived stigma discourages some TB sufferers from accessing care, but this isn’t a barrier for polio sufferers. Also, we are seeing an increase in patients with drug-resistant TB cases that are both harder to diagnose and harder to treat,” says Castro.
Although learning from its previous polio experiences and success, eradication of tuberculosis in India by 2025 will not be easy — as the emergence of multi-drug resistant TB is a major hurdle, which needs to be addressed.
Surgical attack on DR-TB
Drug-resistant TB is an important issue that needs to be addressed within the context of ending TB. As India has the highest number of people with drug-resistant TB. India needs to quickly reach the stage of universal drug-susceptibility testing.
“Every TB patient should have a drug resistance profile which will determine the best treatment regimen and therefore better treatment outcomes. New drugs are now available and already included in the India TB programme guidelines – it needs scaling up. Efforts should be made for early diagnosis and effective treatment of drug-resistant TB, as well as preventing further spread by good airborne infection control practices,” states Sahu.
As per an estimate by Union Health Ministry, an estimate of 1,47,000 people suffer from MDR TB in India. A month ago, Preeti Sudan, Secretary, Health, MoH&FW, wrote a letter to the Medical Council of India (MCI), to incorporate the obligatory requirement of establishing DR-TB centre at each medical college, as per revised national TB control programme guidelines.
A health ministry official, on condition of anonymity, revealed that as of now only 147 MDR-TB treatment centres are available and with the addition of this new clause, the ministry hopes to create enough centres for treatment. The ministry is coming up with several innovative interventions, particularly on drug-resistant TB. The state governments have been asked to identify two blocks in each district to make it TB-free within a year, as a part of its disease elimination strategy. Districts will be ranked on disease prevalence so that an exact idea of disease distribution is mapped. A target of 2025 has been set and the ministry is hopeful to achieve the target.”
Meanwhile, the government officials inform that participation of private sector and aid of technology play an crucial role in diagnosis and treatment of TB patients in India.
Role by private healthcare players
According to healthcare professionals, most of India’s population rely on private healthcare services for treatments and hence the sector plays a major role to diagnose and treat TB patients. Unfortunately, many private practitioners delay treatment of TB patients and a series of tests are conducted, which are mostly inaccurate. In order to put them into order, MoH&FW has recently criminalised non-reporting of TB cases to the government, which is helping to track unregistered patients.
According to the new regulations, any clinical establishment, pharmacies, chemists and druggists dispensing anti-TB medications should provide details of the patient, prescription and medical practitioners concerned should notify TB cases to the local public health authority, viz. district health officer or to the chief medical officer. If they failed to do it, strict action would be taken against them under Section 269, which refers to a negligent act likely to spread infection of disease dangerous to life and Section 270 to a malignant act likely to spread infection of a dangerous disease. The former hands out imprisonment up to six months and the latter up to two years.
“The notification will bring to light the real burden of TB and help each state governments to monitor TB patients,” an MoH&FW official informs, on condition of anonymity.
Informing that quality of TB care in private sector varies and in many cases sub-optimal, Castro says, “The Revised National Tuberculosis Control Programme (RNTCP) explicitly attempts to address this challenge by improving reporting efforts from the private sector. Accurate surveillance of all cases in the country, those in the public and private sectors, is key to controlling the disease. India has a large number of private practitioners, and if they could be engaged in the national TB control programme in an effective way, they could contribute significantly to TB elimination.”
Creating a huge impact
Not just private practitioners, technology has also played a bigger role and has wider implications to eradicate the disease. In certain innovative projects like 99DOTS by Microsoft Research India has been able to save TB patients with low-cost tech innovations.
“99DOTS, is a low-cost approach for monitoring and improving TB medication adherence, using inexpensive augmented packaging and basic mobile phones already owned by a majority of patients. It takes the treatment to homes and hands of patients,” said Sriram Rajamani, Distinguished Scientist and MD, Microsoft Research India Lab to Express Healthcare.
In a close collaboration with the Central TB Division, National AIDS Control Organization, and several implementation partners, 99DOTS has been scaled to every public-sector TB-HIV co-infected patient in India.
“Government of India has fully embraced 99DOTS as a low-cost method for monitoring medication, which was standardised in the National Strategic Plan, 2017-2025. As on May 2018, over 100,000 patients have been registered and monitored using 99DOTS. A recent call for collaborators received applications from 10 other countries across the world to pilot 99DOTS in their context and replicate it. Each of these proposals aim to adapt 99DOTS to the local context and deploy with 2,000 patients to demonstrate to national TB programme their impact and scalability,” he said.
He also informed that the private sector needs to be invested in supporting government programmes to eliminate TB. The spread of drug-resistant strands is a global health epidemic with implications for countries with and without high prevalence of TB currently.
“New technologies for diagnostics, adherence support and engagement for patients who are suffering from a curable disease are emerging to join the united effort to end TB. With a strong coalition of a dedicated community in both public and private sectors, with medical and technology expertise, focussing on patient-centric ways to empower programmes to deliver quality care, the mechanisms to combat TB are stronger today than before and continue to evolve,” Rajamani added.
An ambitious goal
Experts realise that India’s goal to eradicate TB by 2025 is a tall task. “Although, India has significant strengths like a formidable government structure which can be leveraged, and partnerships with national, international NGOs, community organisations and a large reservoir of expertise in diagnosis and treatment, elimination by 2025 is a very ambitious goal, but it is worth striving for,” Castro highlights.
Informing that 2025 target is bold and courageous, Pai said, “Anyone who understands TB knows the 2025 goal is not realistic. But, the international TB community appreciates the ambition displayed by India. It is great to aim high and even if India doesn’t reach that goal, it would still represent progress if the TB Free India campaign is implemented.”
However, effective policies, well-trained healthcare workers, awareness, empowered patients, and enabled healthcare workers to identify, counsel and programmes to prioritise and target, will bring in the momentum to end TB menace, voice health experts.
We have a long road to traverse before we eliminate an ancient disease that has plagued humans for thousands of years. It is to be hoped that with dedicated commitment from all stakeholders and concerted efforts, we would soon turn the tide against TB and vanquish it forever.
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