Can India eliminate TB by 2025?

With about 2.8 million cases, India is unfortunately the tuberculosis capital of the world. While the annual incidence 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 1 person per 10,00,000.

At the ‘End TB Summit’ in Delhi earlier this month, the Prime Minister launched a campaign to eliminate the disease by 2025, five years ahead of the global deadline. Several steps have been taken by the Government to escalate the fight against TB, including the launch of a new National Strategic Plan in 2017. The thrice-weekly treatment regimen has also been changed to a daily fixed-dose drug regimen. Further, in Budget 2018-19, ₹600 crore was allocated for providing nutritional support to TB patients.

Apart from scaling up access to new diagnostics and drugs, addressing the determinants of TB, combating social stigma, engaging private practitioners as well as strengthening research must be undertaken on a war footing if we are to achieve the target.

Going beyond policies

Various factors, including overcrowding, poor hygiene, malnutrition and lack of access to clean cooking fuels, contribute to India’s enormous TB burden. According to the National Family Health Survey-4 (NFHS-4), the prevalence of medically treated TB increased from 289 persons per 100,000 among households which had fewer than three people sleeping per room to 380 per 100,000 among households with seven or more people sleeping in a room. Similarly, among households that depend on straw, shrubs or grass for cooking, TB prevalence was as high as 567 persons per 100,000 compared to 206 per 100,000 for households that use clean fuels.

In this context, several flagship programmes of the Government including the Pradhan Mantri Ujjwala Yojana, Swachh Bharat Abhiyan, Housing for All, and the National Nutrition Mission have a critical role to play in preventing TB. Communities will also need to be engaged for reversing tobacco use and alcoholism, key drivers of the TB epidemic, through the health and wellness centres announced in the budget.

While tobacco use has decreased, only three in 10 users reported that they tried giving up the habit in the 12 months prior to the NFHS-4 survey. Moreover, only half the respondents who were tobacco users and had visited a health provider in the 12 months preceding the survey had been advised to stop smoking.

Integrating private sector

Estimates suggest that over 50 per cent of TB patients are treated by private practitioners. Patients often visit multiple private providers before reaching a Directly Observed Treatment Short-Course (DOTS) centre. Delayed diagnosis and initiation of treatment not only jeopardises the patient’s chances of making a timely recovery but also increases the risk of transmission to others. Further, there is considerable heterogeneity in the knowledge levels of private practitioners about the protocols for TB diagnosis and treatment. A study revealed that out of the 228 private doctors in Chennai, 160 prescribed 27 different regimens.

TB was declared a notifiable disease in 2012, following which reporting by the private sector increased to 14.8 cases per 100,000 population in 2015, compared to only 0.3 per 100,000 in 2013. To increase the notification rates further, the Health ministry has taken a landmark decision to make non-reporting of TB patients a punishable offence.

Developing a comprehensive set of national guidelines is another step that could strengthen private sector engagement in TB. Further, efforts should be made to map and categorise private practitioners based on the nature of their education, experience and services provided.

This will help integrate all types of providers with the Revised National TB Control Programme, including those trained in alternative systems of medicine and private chemists. The latter play an especially important role in dispensing advice and drugs to patients as they typically belong to the local community and can be contacted easily. Till 2015, however, only 75,000 private pharmacies in the country had been engaged for TB control out of a universe of 850,000.

We urgently require rapid and cost-effective point-of-care devices that can be deployed for TB diagnosis in different settings across the country. Additionally, new drug regimens are necessary for responding to the spread of drug-resistant strains as is an effective vaccine for preventing TB in adults. Operational research for optimising service delivery is also critical because it is often the case that diagnostics and drugs do not reach those who need them the most. The India TB Research and Development Corporation launched in 2016 must play a pivotal role in accelerating these efforts.

Ending social stigma

TB is not a health issue alone. It is a broader societal challenge. A study that assessed social stigma associated with TB in Bangladesh, Colombia, India and Malawi found that India had the highest overall stigma index. Patients often hesitate to seek treatment or deny their condition altogether for fear of losing social standing. According to NFHS-4, one in every five men and one in every six women would prefer to keep the TB positive status of a family member a secret.

The consequence is that TB becomes a death sentence for many even though it is a fully curable illness. Women are disproportionately affected with estimates suggesting that 100,000 Indian women are asked to leave their homes every year after being diagnosed with TB. In fact, the stigma is so severe that NGOs often camouflage their TB treatment centres as medical centres.

While mass awareness campaigns like ‘TB Harega Desh Jeetega’ can play an important role in breaking social taboos, local communication channels such as community radios and street plays must also be leveraged. Furthermore, children should be engaged through anganwadis and schools for disseminating accurate messages about TB to their families.

Eliminating TB by 2025 is a stretch goal no doubt but one that is not impossible if the public and private sectors come together to make the requisite investments in financing, research, human resource and technology. If anything, setting a target that is five years ahead of the global deadline signals much needed intent and ambition.

The writer is with the Office of Vice Chairman, NITI Aayog. The views are personal

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