05 August 2024 – The Indian Express

Situation of Tuberculosis in India

• On March 24, the world celebrates the discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis, by Dr. Robert Koch in 1882. The World Health Organisation (WHO) estimates that 3,500 people worldwide lose their lives to tuberculosis (TB) every day, and that 30,000 people contract TB bacilli.

• 27% of TB cases worldwide are reported from India alone. This is shocking considering that tuberculosis (TB) is a disease that can be detected and treated, and that TB diagnosis and treatment guidelines have long been a component of the current healthcare systems.

In retrospect, India’s battle against tuberculosis began even prior to its independence:

• The International Union Against Tuberculosis was joined by India in 1929. The establishment of clinics, training of healthcare professionals, and support of TB education and prevention are the goals of the King George V Thanksgiving Fund for TB control.
• The Ministry of Health was tasked with supervising the TB division, which was founded by the Union government in 1947 following independence and housed under the Directorate General of Health Services.
• The WHO assisted the government in establishing the National TB Institute in Bengaluru in 1959. The National Tuberculosis Control Programme (NTP) was subsequently developed in 1962.
• The Revised National TB Control Programme was created in 1963 when the NTP’s flaw was discovered. In 2023, five years ahead of the Sustainable Development Goals, India’s National TB Elimination Programme is spearheading the drive to eradicate tuberculosis by 2025.
• One of the Sustainable Development Goals for health set forward by the UN is to put an end to the tuberculosis epidemic by 2030.
• The World Health Organisation recognised India’s achievements in November 2023 on two fronts: lowering the incidence of tuberculosis by 16% between 2015 and 2022 (almost twice as fast as the worldwide trend) and lowering the mortality rate of tuberculosis by 18% in the same time frame.
• In order to reach the target of eliminating tuberculosis by 2025, the prime minister announced initiatives like TB Mukt Panchayat and the launch of a shorter, three-month course on preventive treatment during his speech at the One World TB Summit in Varanasi.
• The PM also declared that a 3-month preventive therapy for anyone at risk of tuberculosis would be made available to everyone in the country. This will shorten the treatment period from the previous six months and switch from a daily pill schedule to a once-weekly medication schedule.

What is TB, or tuberculosis?

• Mycobacterium tuberculosis, a member of the Mycobacteriaceae family with over 200 species, is the causative agent of tuberculosis (TB).
• Certain Mycobacteria infect a variety of animals, while others cause diseases including Leprosy and tuberculosis in humans.
• Although extra-pulmonary TB can sometimes affect other organs, pulmonary TB in people mostly affects the lungs.
• As early as 3000 BC, TB was known to exist in Egypt, making it a very old disease. The illness is curable and treated.

Rate of Infection:

• Ten million people get tuberculosis each year. TB is the leading infectious disease killer in the world, taking the lives of 1.5 million people year despite being a preventable and curable illness.
• TB is the primary cause of death for HIV-positive individuals and plays a significant role in the development of antibiotic resistance.
• Although TB is prevalent worldwide, the majority of cases occur in low- and middle-income nations. Eight countries—Bangladesh, China, India, Indonesia, Nigeria, Pakistan, Philippines, and South Africa—are home to around half of all TB patients.

Therapy:

• A health professional or trained volunteer will offer the patient with information, supervision, and support during the normal 6-month course of 4 antimicrobial medications used to treat tuberculosis.
• Anti-tuberculosis medications have been in use for many years, and in every nation investigated, strains that are resistant to one or more of the medications have been identified.
• Bacteria causing multidrug-resistant tuberculosis (MDR-TB) are resistant to isoniazid and rifampicin, the two most potent first-line anti-TB medications. With second-line medications like Bedaquiline, MDR-TB is manageable and curable.
• Bacteria that do not respond to the most potent second-line anti-TB medications create extensively drug-resistant TB (XDR-TB), a more severe type of multidrug-resistant tuberculosis (MDR-TB) that frequently leaves patients with no other alternatives for therapy.

What Are the Various Problems with Treating India’s TB Burden?

Keeping the Medical Aspect Only in Mind:

• The greatest shortcoming has been failing to grasp the actual experiences of those living with and overcoming tuberculosis. It is all too easy for us to assume their needs, challenges, and expectations.
• As is frequently the case with medical professionals and public health experts, the system has occasionally erred by overly medicalizing this ailment.
• It has repeatedly failed to acknowledge tuberculosis (TB) as a humanitarian catastrophe with wider social and environmental effects, implications for gender, and economic consequences.
• disproportionately impacting the section that is marginalised:
• While tuberculosis (TB) can afflict anyone of any class, religion, ethnicity, or socioeconomic background, those who are most marginalised in society—such as children, the impoverished in metropolitan areas, convicts, and those living with HIV/AIDS—are disproportionately affected.
• The illness is now more than just a medical emergency. According to some estimates, this economic problem causes billions of dollars’ worth of losses for India annually and forces families and communities into debt and poverty.

Inappropriate Use of Antibiotics:

• Drug resistance in tuberculosis is still a man-made problem. Drug resistance develops as a result of the bacillus being subjected to selective evolutionary pressure brought on by the uncontrolled use of antibiotics and noncompliance with treatment plans.
• The major causes of this high level of drug resistance are inadequate regulatory frameworks for drug control and patient noncompliance with prescribed treatment plans.

Measuring the Amount of TB That Is Drug-Resistant:

• Data on the percentage of patients with TB who have both multidrug-resistant (MDR-TB) and rifampicin-resistant (RR-TB) TB (also known as MDR/RR-TB) TB, which is resistance to both rifampicin and isoniazid.
• This aids in the development of the control strategy, the allocation of resources for diagnosis and treatment, and the availability of the trained personnel required for drug-resistant tuberculosis.

Re-evaluating the Methods of Screening:

• The “National TB Prevalence Survey in India” by the Indian Council of Medical Research and a Lancet investigation both demonstrated that, although screening for symptoms is a good idea, it is not very effective.
• Research indicates that individuals with infectious tuberculosis (TB) often carry the disease and may potentially be spreading it, even in the absence of any outward signs. Finding these patients can be done quickly and effectively with X-ray imaging.

Tests Limited by Exorbitant Expenses and Problems with Accessibility:

• The shortcomings of the antiquated sputum microscopy test are resolved by the more recent molecular assays, which are quick, precise, and can even identify medication resistance. Additionally, India has greatly increased its capacity for molecular diagnostics.
• In India, the number of NAAT (nucleic acid amplification test) equipment increased from 651 in 2017 to over 5,000 in 2022. However, because of their high cost and accessibility problems, the usefulness of these tests is restricted.

Difficulties with Sputum-Reliant Molecular Testing:

• First of all, not everyone—especially small children—may find it as simple to generate sputum. Second, sample transportation is still difficult, particularly in isolated and steep areas.
• Testing coverage significantly increased during the COVID-19 pandemic when easier nose swabs, saliva, and self-collection were used as a replacement to nasopharyngeal swabs.

Twofold Burden of TB and Diabetes Mellitus (DM):

• Unfavourable TB treatment results, including treatment failure, relapse/reinfection, and even mortality, are more likely when DM is present. Patients with co-occurring DM and TB may also have different radiological results, treatment outcomes, prognosis, and TB symptoms.
• The combined burden of DM and TB has a substantial negative influence on people’s health and survival as well as their families, communities, and the healthcare system.

What Actions Need to Be Done to Help the TB Crisis?

Setting the needs and interests of communities and patients first:

• Within the care paradigm and the health care system, patients’ and communities’ needs and interests must come first. This idea emphasises the necessity of a person-centered approach to TB care and management and is repeated by survivors, communities, health professionals, and politicians.

Adopting a Person-Centric Perspective:

• the emergence of powerful advocates among TB survivors who have actively campaigned to include the concerns of impacted communities in talks. They have pushed for reforms in a number of areas, forcing governments to modify their strategies in order to address these demands from the local population.
• One notable development is the limited but noticeable progress that has been made in the area of nutritional support.

Close the Distance Between Ground Reality and Policy Intent:

• The intention of policy and the actual situation on the ground must be reconciled. For example, India should give priority to focused initiatives meant to enhance and increase the availability of tuberculosis diagnosis and treatment.
• Expanding TB testing facilities is necessary, especially in underserved and rural areas. Additionally, free, reasonably priced, and high-quality TB medications should be made available.
• The optimal course of action is molecular testing, however fewer than 25% of symptomatic individuals receive this kind of testing initially.

Developing More Humane TB Care:

• In order to enable frontline healthcare providers to provide comprehensive care that not only covers treatment needs but also social, economic, and mental health needs and is closer to patients’ homes, it is necessary to strengthen community-based TB care models.
• This is significant because, in addition to the negative effects of treatment, survivor narratives describe the stigma, prejudice, and mental stress they experience.

Using a Multi-Sectoral Perspective:

• A multi-sectoral strategy is needed to address the socioeconomic drivers of tuberculosis (TB). Reducing poverty will also enhance nutritional status, increase air quality, promote well-ventilated dwellings, and decrease tuberculosis.
• India can make great progress towards TB eradication and enhancing the general health and well-being of its people by addressing the underlying root causes of the disease.

Using Technology:

• Improving TB treatment initiatives in India may be possible by utilising creativity and technology. The use of AI and digital health tools for TB surveillance, adherence, and diagnosis has the potential to completely transform the nation’s approach to providing and receiving TB treatment. Our best chance of finally curing this airborne illness is to invest in the development of more effective vaccines.
• The field of X-ray technology has made great strides. These days, we have AI-powered software that can scan digital X-ray images and accurately identify suspected tuberculosis (TB) in addition to portable hand-held equipment.

Applying an 8-Point Plan to Reduce the Burden of Tuberculosis:

• Early Detection: This is crucial because of the aetiology of tuberculosis. Frequently disregarded and misinterpreted for other prevalent illnesses, symptoms cause delays in reporting. It is imperative to conduct mandatory screening for the relatives and acquaintances of every index case, which calls for the provision of laboratory resources and effective follow-up protocols within healthcare institutions.
• Accurate Treatment Classification: Due to the rise in DR-TB cases, it is critical to determine the resistance status at the time of diagnosis in order to provide treatment plans based on the patients’ phenotypic susceptibility.
• therapy Sustaining and Adherence: Long-term, consistent therapy is necessary for tuberculosis (TB), in contrast to other bacterial infections. This frequently results in non-compliance, which may be brought on by a discernible improvement in health status, a migration across States and districts, or a change of home.
• Zero Mortality: In order to meet the targets by 2025, it is imperative to reduce the death rate from tuberculosis (TB), whether it be DR-TB or non-pulmonary TB.
• Availability of Appropriate Medicines: The TB control programme requires guaranteed medical supplies. However, in addition to identifying treatment facilities for all DR-TB cases requiring in-patient care, procurement issues for DR-TB drugs, such as bedaquiline and delamanid, must be addressed.
• Integration into Larger Health Systems: To guarantee that (a) no symptomatic cases are lost, (b) no patients miss their dosages and are non-compliant, and, crucially, (c) the screening of contacts for all positive cases of pulmonary TB cases (DR or non-DR), it is imperative to strengthen referral networks both within and between different levels of public health systems and private health systems.
• Dynamic Notification System: Health system staff will have less work to do if there is a strong notification system. The National Tuberculosis Elimination Programme (NTEP) uses Ni-Kshay, a web-enabled patient management system for tuberculosis control. Despite its evolution, Ni-Kshay still has to be improved in order to capture real-time tuberculosis data across sectors, practitioners, time, and locations.
• Examining Population Mobility and Migration: When talking about illness and seeking medical attention, the positive parts of life are sometimes disregarded, especially when it comes to tuberculosis (TB), which carries a stigma due to social and cultural norms. It’s interesting to note that after a TB diagnosis and treatment, positive cases experience a speedy recovery that allows them to return to their regular activities. Thus, at the policy level, the national treatment of tuberculosis must be portable.

What Kinds of TB Initiatives Are There?

Worldwide Initiatives:

• The World Health Organisation (WHO) has started a collaborative project called “Find. Handle. Everybody. Stop TB Partnership and the Global Fund are working to “EndTB.”
• The WHO publishes the Global Tuberculosis Report in addition.

• India must make a determined effort to prioritise patient-centered care, address socioeconomic determinants of health, and welcome innovation in order to eradicate tuberculosis. India can combat tuberculosis and pave the path for a healthy future for all of its people by implementing a person-centered, holistic strategy.

• All that has to be done is enhance implementation and introduce new technology with greater initiative. It is imperative to guarantee that novel technologies are expedited and implemented promptly, and that sub-district capacity is established to enable the execution of diagnostic tests as required.