Aug 22, 2024 09:27 PM IST
India, struggling with inadequate diagnostics and underfunded TB programs, faces the world’s largest TB epidemic, making elimination by 2025 unlikely despite efforts.
Optimism is the madness of insisting that all is well when we are miserable.
— Voltaire
In response to the World Health Organization (WHO) End TB strategy calling for tuberculosis (TB) deaths to be reduced by 95% by 2035, the government had declared that India would eliminate TB ten years earlier, by 2025. Yet, TB resolutely remains the country’s biggest health care challenge. The latest WHO Global TB Report reveals that India has the world’s largest TB epidemic; at 2.6 million, the country accounts for the highest number of TB cases (26% of the global total) as well as multi-drug resistant (MDR-TB) cases (135,000, 37% of the burden). Sadly, it also continues to have the most TB deaths annually, and the disease results in a staggering economic loss of $23.7 billion a year. Even these figures are considerable underestimates as not all patients are notified. Some of the reasons why India is unlikely to eliminate TB in the next decade are summarised here.
Even as we know that accurate diagnosis and prompt treatment initiation clearly matter, we continue to struggle with poor diagnostics. Modern molecular diagnostics needs to become more widespread. A study from Mumbai highlighted an unacceptably long average delay between a patient’s first symptom and treatment initiation: 69 days for a drug-sensitive TB patient and 192 days for an MDR-TB patient. The sooner treatment commences, the quicker the cycle of airborne transmission is halted.
With under-investment in public health and the TB programme, the public sector is over-stretched. Because of the deficiencies perceived or encountered in the public sector, 50-80% of Indian TB patients choose to incur large out-of-pocket expenses and seek treatment with unengaged and unregulated private practitioners. A study we did a decade ago showed that less than 5% of private physicians could prescribe the correct drugs and doses for a TB patient, as most prescribed inappropriate tests and drugs that would worsen the patient’s condition and serve to amplify drug resistance.
From MDR and XDR (extensively drug-resistant) to TDR (totally drug-resistant), India has the largest number of DR-TB cases in the world, some with the most alarming resistance patterns. This form of TB is extremely difficult and expensive to treat and is a substantial threat. Access to new drugs so desperately needed to vanquish MDR-TB, such as bedaquiline, delamanid, and pretomanid, is difficult, contributing to thousands of preventable deaths. An exciting new regimen called BPaL, would allow MDR treatment to be shortened from 20 to just six months. Worldwide, over 40 countries have introduced it, but India has not. Recent reports suggest that BPaL’s introduction in India is imminent. However, the programme’s roll-out must be expedited, and it must be ensured that the regimen is made available to all MDR-TB patients at the earliest.
Even though an estimated 500 million people in the country (mostly children and vulnerable household contacts) are infected by the bacteria, treatment of latent TB infection (LTBI) is a low priority. Identifying and treating them with simple prophylactic drugs before they get active disease would have a huge impact. Rifapentine, a pivotal drug to treat LTBI, despite being manufactured in India, is not yet available. It would simplify the treatment from six months to just 12 doses over three months.
Furthermore, health conditions like diabetes, smoking, and pollution are strongly linked to an increased risk of TB. The social determinants of health are also worrying. Poverty and malnutrition are linked to TB and may be responsible for up to 40% of incidence in the country.
All is not gloom and doom, however. The Indian TB programme has made progress in the last decade, with improvement in notifications and cure rates and a reduction in TB incidence and death rates. A nutritional support scheme (Nikshay Poshan Yojana) recognises the important contribution of malnutrition and provides patients with a small monthly sum of ₹500. The appointment of Soumya Swaminathan as principal advisor for the TB Programme was a move in the right direction that brought great cheer to this writer.
Sadly, TB is so deeply rooted in India that elimination in the next decade is unlikely. For this to happen, intent must be backed by greater political will, commitment, and accountability. Far more investment is needed in health in general and TB in particular. Nearly 400,000 Indians will die of TB this year, almost each of these preventable if patients had access to the diagnostics, drugs, and support available to those in western countries. We could choose to live in a world with no TB deaths.
Zarir F Udwadia is an international expert and WHO consultant on TB.The views expressed are personal
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