In India eradication of TB is still major health challenge. Even after year's of effort, we are still dealing with 24 percent of the world’s total number of TB cases. The question is, where did we go wrong?

 

 

Per a report by the Indian Society for Clinical Research or ISCR, nearly 480,000 to 500,000 people die due to TB every year. Also, India has the largest number of cases of multi-drug resistant TB worldwide, which indicates that India might not reach its goal of being TB-free by 2025. However, it is found that the mortality rate associated with TB has decreased in India when compared to the past decade. 

 

We have explored some of the reasons why India is still dealing with cases of TB: 

1. Mismanagement

In 1962, India had launched National TB Programme (NTP) which was unsuccessful due to inadequate funding. The NTP had failed to execute its goals which resulted in low rates of diagnosis and treatment completion, and high levels of mortality. Based on the results of the NTP, another initiation named Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997. This program introduced the global DOTS (Directly observed Therapy) strategy that covered individuals with TB till 2006. The RNTCP has expanded the diagnosis and treatment services covering the entire nation. But, the RNTCP services did not extend to the rural areas, where half of the Indian population resides. 

 

The factors that lead to mismanagement of TB are inadequate funding with limited capacity to treat drug-resistant TB and unregulated private sector. Furthermore, while the patients with undiagnosed TB move from one health care provider to another, they continue to spread the infection. 

 

In 2006, RNTCP had launched DOTS-Plus initiative to deal with multidrug-resistant TB (MDR-TB). But, less than 1% of MDR-TB patients have access to this treatment. Apart from this, continued use of re-treatment regimen (2HRZES/HRZE/5HRE) which is not evidence-based leading to the amplification of the risk of developing drug resistance. WHO no longer recommends this re-treatment regimen, but despite that, the health sector in India continues to prescribe the regimen for treatment failure patients in RNTCP. 

 

2. Lack of novel diagnostic tools and treatment modalities

 

Lack of rapid diagnosis and treatment is one of the primary reasons for TB in India. India is in need of newer technologies and treatment modalities that control TB, and this epidemic cannot be eliminated otherwise. But, India still relies on sputum culture test and X-rays which were developed decades ago that identifies only half of the TB affected individuals.  Additionally, this test cannot detect drug-resistance TB which is more prevalent in India. 

 

Delivering the novel tools for diagnosing TB will help identify a significant number of infected individuals that allows enhancement of appropriate treatment modalities. Furthermore, these novel diagnostic tools can also be used for testing the individual’s susceptibility to TB medications and identifying the latent TB infection. 

 

The improved diagnosis is essential to reduce the delayed identification of multidrug-resistant TB, transmission and severity of the disease, drug resistance and chances of inappropriate treatment. In India, although there are rapid tools for diagnosing the disease, it has been reported that the affluent societies are only using these tools. These newer devices cannot benefit the individuals unless they have the ability for rapid detection or increased optimisation of the treatment. 

 

3. Increasing prevalence of MDR-TB

 

Multidrug-resistant TB is now a global health challenge. It is estimated that there were about 480,000 new cases of multidrug-resistant TB (MDR-TB) and also 100,000 people with rifampicin-resistant TB globally in 2015. In India, the incidence of MDR-TB is on the rise thus, affecting the progress achieved. 

 

The resistance towards the previous TB treatment is considered to be the major risk factor for MDR-TB. However, it is found that the treatment-naïve patients are also at risk of MDR-TB due to infection with resistant strains or spontaneous mutations of the bacteria. Also, the incomplete or inadequate treatment is one of the reasons for the high prevalence of MDR-Tb in India. That’s why there is a need for modification in the DOTS strategy to include the second-line drugs in the appropriate treatment regimen and also to reduce the delayed identification of the drug-resistant cases. 

 

4. TB and Poverty

Many studies have established the association between TB and poverty. The factors responsible for facilitating the transmission of TB include poverty, malnutrition, overcrowding, and food insecurity. The socio-economic status of the patient determines the accessibility and continuation of the TB treatment. Additionally, patients with TB have a decreased physical ability to work which affects their annual wages and therefore, makes them incapable of affording treatment. 

 

In children, the malnutrition affects the immune system and genetic expression which increases the susceptibility to infection and also disease progression. According to WHO, about 1 million children (< 15 years) are infected with TB worldwide in 2015. 

 

In India, RNTCP provides free diagnosis and free treatment for TB that benefits the poor. But, according to a survey, the people who are in need of these services were not able to access or utilise them. This resulted in the patients with TB approaching facilities outside RNTCP and incurred with high expenditure which led to the discontinuation of the treatment. 

 

Conclusion

 

People should be educated regarding the burden of TB, types of diagnosis and treatments used to eradicate the infection, and disease progression. Currently, the India’s TB program-RNTCP has been showing its commitment to resolve the problem by rolling out the TB services in the entire country. Irrational use of anti-TB drugs outside the RNTCP has contributed to the emergence of drug-resistant TB. Therefore, the Government of India should put an effort in improving the health system performance to address the challenges of TB and also drug-resistant TB. 

 

The Government of India needs to adopt rapid diagnosis and a shorter treatment regimen for TB and multi-drug resistance TB to reach the goal of a TB free nation by 2030.