Tuberculosis (TB) is an infectious disease found in every part of the world and it is one of the biggest killers of humans. It continues to be a major public health issue of global concern. India carries one of the largest global burdens of the disease. Central and state governments are committed to ending the disease by 2025, five years ahead of the global target under the Sustainable Development Goals (SDG) 2030.
Global burden of TB
TB is an infectious airborne disease caused by mycobacterium tuberculosis (M.tb). The World Health Organization (WHO) estimates that some 1.8 billion people, or a quarter of the global population, are infected with TB. Approximately 1.3 million children get sick with TB each year. Last year, TB was noted as the world’s second leading cause of death from a single infectious agent, after Covid-19. It caused almost twice as many deaths as HIV/AIDS. In 2022, as many as 10.6 million people were infected from TB and 1,400,000 died due to it. TB results in 3,500 deaths every day.
Tuberculosis is shaped by social, economic and health-related risk factors. These are undernutrition, diabetes, HIV infection, alcohol use disorders and smoking. According to WHO, on the global scale in 2020, an estimated 1.9 million incident cases of TB were due to undernutrition, 740,000 to HIV infection, the same number to alcohol use disorders, 730,000 to smoking and 370,000 to diabetes. There are regional and national variations. For instance, a high incidence is noticed among the urban population living in slums.
The 30 countries that bear a high TB burden account for 87 per cent of the world’s total cases. Of these, two-thirds of the global total burden was found in eight countries. India accounts for a large share at 27 per cent of the total global cases followed by Indonesia (10 per cent), China (7.1 per cent), the Philippines (7 per cent), Pakistan (5.7 per cent), Nigeria (4.5 per cent), Bangladesh (3.6 per cent) and the Democratic Republic of the Congo (3 per cent).
WHO commends India
The WHO’s ‘Global TB Report 2023’ credited India for its activities and interventions to be a TB-free country. WHO has appreciated India for its progress in reducing the incidence of tuberculosis by 16 per cent and mortality due to it by 18 per cent since 2015 (till 2022).
India has been commended for its intensified case detection strategies that have led to the highest-ever case notification of cases 2022; at more than 2.422 million TB cases. Such notifications surpassed the pre-Covid levels. A record was undertaken in 2023, with 2.55 million TB cases notified. Of these, 1.71 million TB cases were notified in the public sector and 840,00 by the private sector. At 33 per cent of the total notifications, this was the highest ever. The increase by more than eight times over the past nine years in the private sector notification has come through as a result of a focused and targeted engagement with the private sector through various interventions. Additionally, the treatment coverage has expanded to 80 per cent of the estimated TB cases, a hike of 19 per cent over the previous year.
In an encouraging observation, the WHO report also acknowledges that the pace of decline in India is almost double the pace at which global TB incidence is declining, which is 8.7 per cent. In addition, WHO has also made a downward revision of the TB mortality rates (from 494,000 in 2021 to 331,000 in 2022). The reduction of over 34 per cent is based on cause-of-death data for 2014–2019 collected from the sample registration system (SRS).
Initiatives to free India of TB
It is important to note that even though TB is very infectious, it is entirely preventable and a curable disease when detected in a timely manner and the treatment is fully completed.
Saddled with the burden of the highest level of global TB incidence, India has decided to tackle the menace in a mission mode. The United Nations and WHO have committed to end the TB epidemic. TB is part of SDG Target 3.3 which states: ‘End the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases by 2030’. But Prime Minister Narendra Modi announced in 2018 that India will drive out TB from the country by 2025, five years ahead of the global target. This has spurred the policy makers and the agencies working towards a TB free India to work with focussed energy. At the Stop TB Partnership meeting at Varanasi in March 2023, reaffirming India’s commitment towards ensuring a TB-free society, the Prime Minister said that “the commitment and determination with which India dedicated itself to tackling TB after 2014 is unprecedented.”
India’s efforts are important as this is a “new model for the global war on TB”, said Prime Minister Modi.
India’s efforts have won global accolades. Dr Lucica Ditiu, executive director of Stop TB Partnership, praised India’s scale in tackling TB and the TB-Free India initiative. She expressed the belief that India will end TB by 2025, and this will make a huge dent in the global TB burden.
With less than two years for India to meet its target of being TB Free by 2025, the approach going forward is to focus on prevention of the disease and to saturate coverage of services in the detection and treatment of TB. It is encouraging to note that with continuous efforts of the governments, support agencies and the communities, the number of missing TB cases in India has reduced from 1 million in 2015 to 0.26 million in 2023.
With the goal of achieving Sustainable Development Goals (SDGs) related to TB by 2025, Union Ministry of Health & Family Welfare is implementing the National TB Elimination Programme (NTEP) with the following objectives:
1. Early diagnosis of TB patients, prompt treatment with quality-assured drugs and treatment regimens.
2. Engaging with the patients seeking care in the private sector.
3. Prevention strategies include contact tracing in high-risk/vulnerable populations.
4. Airborne infection control.
5. Multi-sectoral response for addressing social determinants.
Pradhan Mantri TB Mukt Bharat Abhiyaan
To give a mission mode approach to the fight against TB, the Pradhan Mantri TB Mukt Bharat Abhiyaan was launched in September, 2022. The objective was to design activities and interventions to ensure how to meet the SDG target regarding TB by 2025. This required a community level engagement where various agencies, communities and the governments worked in tandem together. The initiative brought together people from all backgrounds into a ‘Jan Andolan’ and escalated the progress toward TB elimination. This also leveraged Corporate Social Responsibility (CSR) activities.
A novel initiative of Ni-kshay Mitras was started, where volunteers from various walks of society would become ‘Mitras” (friends) in helping TB patients in their journey of recovery. Niskhay Mitras can be individuals, NGOs, co-operative societies, faith-based organizations, private sector, political parties, and others who consent to support TB patients in the form of nutritional support, nutritional supplements, additional investigations, and vocational support for a minimum period of six months or maximum period of up to three years. TB patients often face stigma in the communities. Involvement of the community in the TB elimination campaign aims to alleviate the stigma related to the disease. Community engagement also will result in more awareness about the disease and ways to prevent it and manage it better. The disease itself and the long duration treatment has resulted in loss of jobs for many, and resulted in economic hardships. Ni-kshay Mitras also pledged to extend vocational support for the TB patients.
Till April 2024, more than 155,000 Nikshay Mitra have registered. Of the 1.345 million TB patients on treatment in the country, over 866,000 have consented to receive community support. The Union Health Ministry has launched a countrywide campaign encouraging everyone to come forward and register themselves as Ni-kshay Mitras and support local communities and patients. Among the renowned Ni-kshay Mitras, Governors/Lt. Governors of 27 State/UTs, Union Ministers, Ministers of State, Chief Ministers, State Health Ministers of many States/UTs have come forward to adopt TB patients. Many MLAs & local parishads have also become Ni-kshay Mitras. Several officers from the Cabinet Secretariat and Central Ministries have adopted TB patients to support them through various means.
Active case finding campaign
Several other measures have strongly boosted the anti-TB drive in India. Studies (Ho J. et al., 2016) have shown that TB case detection through passive case finding (PCF) could result in suboptimal detection of TB patients. The tendency is more so in low- and middle-income countries having a high TB burden. This is mainly due to geographic and/or socioeconomic barriers in accessing health facilities, which also often leads to diagnostic delays.
A ‘systematic screening’ of high-risk population subgroups has been advocated as part of the ‘End TB Strategy’ by the World Health Organization (WHO) to increase TB case detection and for timely treatment.
India launched the national community-based active case finding high-risk groups as part of the strategic plan of the National Tuberculosis Elimination Programme for reaching out to missing TB patients. Under this programme, proactive house-to-house searches of TB cases among these vulnerable populations are conducted. This includes people living with HIV, diabetics, undernourished, residential institutes like prisons, asylums, old age homes, orphanages, tribal areas, and marginalized populations. This activity has resulted in the diagnosis of an additional nearly 300,000 TB cases since its inception.
TB screenings
The Viksit Bharat Sankalp Yatra was started during November 2023. As part of this nationwide program, health camps were organised on routes taken by the awareness enhancement IEC Van in states/UTs where several health services were provided for the communities near their homes at the village level, including screening for TB.
Over 38 million individuals have been screened for TB at these health camps and over 1 million have been referred for TB testing. Additionally, over 1,00,000 individuals at the village level showed interest in becoming a Ni-kshay Mitra.
Upswing in TB notification
The specialised active case finding drives, combined with scaling up of molecular diagnostics up to the block levels, decentralised screening services through Ayushman Bharat Arogya Mandirs (earlier known as health & Wellness Centres, which number more than 164,000 across the country) and private sector engagement have significantly boosted the process to bridge the gap in missing cases. These kendras serve as the first point of contact for screening of TB.
India notified 2.42 million TB cases in 2022 which was appreciably higher than the pre-COVID level of 2019. In 2023, a total of 2.55 million TB patients have been notified in 2023.
TB Mukt Panchayat Abhiyan
The objective of TB Mukt Panchayats is to empower the Panchayats to realize the extent and magnitude of the problems associated with Tuberculosis, take necessary actions towards solving them and create healthy competition amongst panchayats and to appreciate their contribution.
As a part of capacity building, several regional workshops have been organised to orient state & district level officials on this initiative. All State and district level functionaries have been sensitized. Currently, verification is being undertaken and results will be announced subsequently. As on date, this has helped to secure over 5 million courses of TB preventive treatment drug. This has also encouraged the villagers to get themselves screened for TB at the Ayushman Arogya Mandirs.
Private sector notification
With a focused and targeted engagement with the private sector through interventions like Patient Provider Support Agency (PPSA), gazette notification for mandatory notification of TB cases, incentives for notification of cases and collaborations with professional bodies like Indian Medical Association (IMA), Indian Association of Paediatrics (IAP), Federation of Obstetric and Gynecological Societies of India (FOGSI), etc., there has been an increase in private sector notification by more than eight times over the past nine years. In 2022, as many as 733,000 TB cases were notified. In 2023, as many 842000 patients were notified from the private sector which contributed to 33 per cent (highest ever) of total notifications (as in February 2024). The programmatic collaborative efforts resulted in an eight times increase in cases reported from the private sector. These innovative private sector models have been global best practices.
TB treatment success rate
Over the last nine years, despite one-third of notifications coming from the private sector, the programme was able to sustain a treatment success rate of above 80 per cent. In 2021, the success rate had reached 84 per cent and in 2022, it marginally increased to 85.5 per cent. In 2023, the success rate increased to 86.9 per cent.
Shorter, safer oral Bedaquiline-containing DR-TB regimens have been rolled out across all states and UTs. These drugs are given to multi-drug-resistant TB patients with or without resistance to fluoroquinolones as a part of shorter oral MDR/RR (multidrug-resistant/(rifampicin-resistant) -TB regimen or longer oral M (multidrug-resistant )/XDR (Extensively drug-resistant)-TB regimen as per the indication. In 2022, a total of nearly 31,000 patients were initiated on the longer all-oral M/XDR-TB regimen and 27,431 patients were initiated on the shorter MDR/RR-TB regimen (oral/injection based).
In 2023, over 63,939 patients were diagnosed with MDR/RR and out of them a little more than 58,527 initiated treatment. Amongst these, nearly 20,567patients were initiated on shorter oral MDR/RR-TB regimen (9-11 months) and close to 29,990 patients were initiated on longer M/XDR-TB regimen (18-20 months).
Nutritional support
Undernutrition is found to be a critical risk factor for TB with a significant impact on recovery of TB patients. The undernourished are more at risk to develop active TB compared to the healthier. According to WHO report (2017), people with active TB who suffer from undernutrition usually are linked to a two- to four-fold increase in mortality. There is also a five-fold risk of drug-induced hepatotoxicity.
In view of this potent correlation, the Government introduced a scheme of Nikshay Poshan Yojana (NPY) in April 2018 for providing Rs. 500/month as direct benefit transfer (DBT) to support the nutrition of TB patients for the entire duration of treatment. Till date, more than 10 million TB patients have benefitted. Cumulatively, till March 2024, more than Rs 2859.96 crore have been disbursed.
Diagnostic infrastructure has played a vital role in active TB case detection. Through concerted efforts, there has been a notable infrastructure scale-up of TB laboratory services. Designated Microscopy Centres (DMCs) have increased by 80 per cent (13583 in 2014 to 24449 in 2023) over the past 9 years. Also, 6196 new molecular diagnostic laboratories have been established till now. The number of drug-resistant TB treatment centers has increased from 127 in 2014 to 792 in 2022.
Disease-free certification
In order to monitor the trends of the TB epidemic at the State/UTs/District level, the Health Ministry has introduced a novel initiative of estimating disease burden through a methodology of community-level survey (Inverse sampling methodology) and tracking drug sales data in the private sector and measuring the level of under-reporting to the programme.
Through this methodology, State/UTs/District level estimates of TB disease are derived and measured against the baseline of 2015.
• In the year 2020, Kerala, UTs of Lakshadweep, Puducherry and 35 districts have successfully achieved various levels of reduction in TB incidence. The UT of Lakshadweep and the district of Budgam in J&K were declared as the first UT & the first district in the country to achieve more than an 80 per cent reduction in TB incidence. (SDG Targets).
• In 2021, 3 States (Kerala, DNHDD & Puducherry) received Silver (> 40 per cent reduction) & 5 States (Gujarat, Himachal Pradesh, Sikkim, Tripura, Ladakh) received Bronze (> 20 per cent reduction). Whereas 8 districts receive Gold (> 60 per cent reduction), 27 districts received Silver & 56 districts received bronze.
• In 2022, Karnataka received Silver ( > 40 per cent reduction) and Jammu & Kashmir received Bronze ( > 20 per cent reduction). Three districts were declared TB-free ( > 80 per cent reduction), 17 districts received Gold ( > 60 per cent reduction), 35 districts received Silver and 48 districts received Bronze.
Focus during India’s G20 presidency
Apart from these steps, under India’s G20 presidency in 2023, the Union Health Ministry has diligently advocated and addressed selected concerns of global importance, which included improving the effectiveness and reach of health services using digital solutions; strengthening cooperation to enhance pharmaceutical development and manufacturing capabilities. There was a sharp focus on “One Health” approach and Antimicrobial Resistance (AMR) during the deliberations in the Health Working Groups and the Ministerial meeting at Gandhinagar, Gujarat in November 2023. All of these have had strong resonance with India’s and the world’s fight against TB.
Combating TB requires a broad based action plan with timelines and accountability structures which would be monitored diligently, involving the communities and different stakeholders and partners. WHO has drawn up a multi-sectoral accountability framework for TB (MAF-TB) which was shared with countries in 2019. This is complemented by national action plans. It is for nations now to implement these action plans commensurate with the global targets and timelines to rid the world of the scourge of TB.
The writer is Addl. Director General (Media 7 Comms), Union Ministry of Health & Family Welfare, Government of India.