Dr. Gyan Pathak
Four years ago in March 2018, Prime Minister Narendra Modi while chairing the “Delhi End TB Summit” had said about ending TB in India by 2025, five years ahead of the TB-related SDG target by 2030. Now End World TB Day March 2022 has provided the occasion to see how far – and to what degree – India has progressed. India TB report 2022 released by the Union Ministry of Health and Family Welfare has however disheartened by telling us that 2021 witnessed a 19 per cent increase from the previous year in TB patients’ notification to reach 19,33,381 from 16,28,161 in 2020. Union Minister of Health and Family Welfare Mansukh Mandaviya has still reiterated to free the country from tuberculosis (TB) by 2025, but is contrary to evidence.
Since more than 40 per cent of the population carry the infection and about 10 per cent actually get the disease, it remains a matter of grave concern, which has been further exacerbated by the outbreak of COVID-19 in 2020, which had ravaged lives, uprooted livelihoods, crippled economy, debilitated heath infrastructure, and overwhelmed health facilities. All non-COVID-19 diseases were ignored which included TB. Fight against TB thus has encountered setbacks in decades of gains. Incidence of TB is quite high across the world, but out of the total cases, more than 26% are from India (31 per cent among children). This includes both multidrug-resistant TB and HIV TB cases.
The deterioration witnessed despite the National Tuberculosis Elimination Programme (NTEP) and the National Strategic Plan (NSP 2017-25) permeated in 2021 to the state and district levels yet again to encompass more objectives, after the new experience in the light of the COVID-19 crisis of 2020. Eighteen States have also committed to ending TB by 2025 by formally implementing State-specific Strategic Plans and have gone a step ahead to devise a District-specific Strategic Plan. Since 2017, active case finding (ACF) activities are being conducted across the States and UTs, and a special campaign was also introduced in January 2021 among risk groups – diabetes, chronic kidney and liver disease, patients on immunosuppressants, etc. To mitigate the impact of COVID-19 on TB services, a special ACF drive was launched to screen influenza-like illness (ILI) and severe acute respiratory infections (SARI) cases for TB, a drive that examined 17,52,903 samples for TB out of 2.23 crore people tested, and found 73,772 suffering from the disease. The caseload is obviously very high and needs to be further sped up on war footing.
In terms of DS-TB treatment performance in 2021, the report said that 95 per cent patients put on treatment, with success rate for notified patients were 83 per cent and 82 per cent for public and private sector hospitals respectively. It is therefore clear the government needs to put the remaining 5 per cent of the patients on treatment so that no patient is left without treatment and find out ways and means to increase success rate of treatment, to reach 100 per cent.
It shows that the last-mile service delivery for better access to treatment and quality care to TB patients, including DRTB patients and their close contacts, is yet to work efficiently though the programme has decentralized TB services to the Ayushman Bhara – Health and Wellness Centres (AB-HWC).
“Guidelines for Programmatic Management of Drug-resistant TB (PMDT) in India – 2021” have also been released, and a Shorter oral Bedaquiline (Bdq)-containing MDR/RR-TB regimen introduced and scald up across the country. Access to drugs, including newer drugs, to patients seeking care in the private sector is also free. However, DR-TB treatment performance in 2021, shows only 90 per cent of the diagnosed patients were put on treatment. The patients put on treatment for Pre-XDR-TB, XDR-TB, and H mono/poly patient were only 89 per cent, 89 per cent and 87 per cent respectively. Improvement is desired in obvious.
Prevention is one of the crucial pillars for elimination of any disease. Though the government has expanded the several provisions in 2021, and launched some, these need to be expanded to meet the target by 2025. Putting a little over 2 lakh PLHIV on active care and 1.2 lakh HHC of pulmonary bacteriologically confirmed TB patients put on preventive treatment is not enough in one year ie in 2021, since introduction of TPT in contacts of DR-TB patients has been introduced in only 12 states. It presents a case of further scaling up of preventive measures.
Malnutrition, diabetes, HIV, tobacco smoking, and alcohol also severely impact TB patients, and government is aware of that. It has also brought in multitude of initiatives, but any programme not well implemented does not bring the desired results. Malnutrition programme was being run in collaboration with the Ministry of Women and Child Development, but it is well known that it was disrupted during the pandemic. Now we need to reassess the situation on the ground and implement all the programmes relating to nutrition in right earnest. Organisation of “Poshan Mah’ for awareness is alright but nutritional support poor people and those who are newly pushed into poverty during the two years of the pandemic need urgent attention.
Alcoholism and tobacco smoking among TB patients is also a serious issue for which data were captured for only 72 per cent of total notified patients in 2021, out of which 7 per cent admitted alcohol use and 12 per cent tobacco. India needs to take the issue more seriously.
Childhood TB remains a staggering problem contributing to approximately 31 per cent of the global burden. The report pointed to a gap of 4-5 per cent in total notification against the estimated incidence. To that end, intersectoral coordination is critical for ensuring wide-reach of the programme to remedy this gap. We have Rashtriya Bal Swasthya Karyakram (RBSK) and Rashtriya Kishor Swasthya Karyakram (RKSK) which need to be further strengthened.
Awareness programmes, supervision and monitoring, patient support system for both medial and financial, and partnership with private sector hospitals need also be strengthened along with medical research and innovation, especially because many patients turning drug resistant. (IPA)
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