What it will take India to beat TB

Every year, on March 24, World TB Day is observed to raise awareness about tuberculosis (TB) and its impact on people the world over. The United Nations Sustainable Development Goals (SDGs) include ending the TB epidemic by 2030. The World Health Organisation’s ‘end TB strategy’ aims to reduce the global incidence of TB to the levels achieved by high-income countries by 2030. Recognising the importance of this, the Indian Prime Minister has advanced the target to eliminate TB in India by five years, to 2025.

As we approach this target, the discussions and debates among the public health community regarding the feasibility of achieving this ambitious task within the timeframe have become intense.

According to the WHO’s World Tuberculosis Report (2022), India has performed far better on major matrices than other countries. Nonetheless, it still accounts for 28% of the total global TB cases and 36% of TB-related deaths. India’s TB incidence for the year 2021 is still very high at 210 per lakh population, compared to 256 in the baseline year of 2015, mainly because the efforts could not be sustained during the Covid-19 pandemic. According to a WHO report, the pandemic has also resulted in a reduction of globally reported cases (which implies that there is an increase in the number of people with undiagnosed and untreated TB) and a simultaneous rise in drug-resistant TB cases by 3%.

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Recognising the challenges ahead, the Pradhan Mantri TB Mukt Bharat Abhiyan, with the slogan TB harega, desh jeetega, has been launched. To ensure community participation and ownership, the “Ni-kshay Mitra” donor scheme has also been introduced. The effort is supported by the governance machinery right from the state governors’ offices.

A National TB Prevalence Survey, the largest in the world, has been carried out to assess the prevalence of TB at the national and state levels. Two vaccines that offer new hope are currently undergoing clinical trials. In addition, a recently developed modelling framework by the Central TB Division with support from WHO India offers a platform for understanding the disease burden modulated by various interventions.

This modelling framework is built on detailed models developed over a decade to estimate the potential impact of different interventions, including private sector engagement, active case finding, adherence support, and preventive therapy. This framework is further simulated to allow the user to explore different scenarios for TB interventions to see the projected impact on incidence and mortality. Interventions include reducing care-seeking delay, improving TB diagnostic outcomes, and reducing post-treatment relapse, to name a few. Yet, the question remains: Can we, as a country, achieve this ambitious target?

The introduction of a vaccine that will reduce the risk of contracting and developing active TB is one such intervention. The success of the nationwide Covid-19 vaccination programme gives us hope that the financing and inoculation of this vaccine to the entire eligible population within the stipulated timeframe are not going to be the limiting factors. Much would depend on how quickly the clinical trials are completed, vaccine production and availability are ensured, and public awareness about them is created.

If the targeted vaccination does not happen in time, do we still stand a chance of reaching the goal? Active case finding by stepping out of the verticality of the programme and strengthening the health systems by finding and treating undetected TB patients on a war footing in a limited time period is a strategy that offers a ray of hope.

This would mean reaching all rural and remote locations, urban slums, and ensuring that all primary health centres have access to modern diagnostic tools and trained healthcare workers to screen patients, read reports, and guide them to the correct treatment; referral and backward linkages for follow-up; and an uninterrupted supply of medicines at all levels. An active engagement with the private sector will help improve diagnostic standards, and strengthen the mechanism of free supply of required medicines.

The one thing that the programme needs to do well is to actively engage with the community. The scope of Ni-kshay Mitra needs to be expanded so that with the active support of the community and civil society organisations, people’s participation is ensured.

(The writer is faculty, Azim Premji University.)