Kaushik Bharati, PhD
The World TB Day (24th March, 2016) is knocking at the door! The theme of this year’s World TB Day is “Unite to End TB”. This day is aimed at building public awareness about the global epidemic of tuberculosis (TB) and efforts to eliminate the disease. Therefore, this is a day for introspection and to do a reality check on how India’s TB eradication program in doing and how far we really are from the goal of TB eradication in our country.
TB is a very serious infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB) and is spread by droplet transmission (coughing and sneezing) from infected patients. India is responsible for over 26% of the total TB cases reported globally, and therefore is a serious public health issue in our country. As per 2011 data, of the 8.8 million TB cases reported annually worldwide, 2.3 million were from India alone!
Following a thorough evaluation of the National Tuberculosis Control Program (NTCP) jointly by the Govt. of India, WHO and the Swedish International Development Agency (SIDA), the Revised National Tuberculosis Control Program (RNTCP) came into existence in 1997. RNTCP is based on the Directly Observed Therapy, Short Course (DOTS) strategy which is recommended internationally. More than a billion patients, spread across 35 states and union territories, and over 600 districts have benefitted from the program, and has additionally saved 2.3 million lives.
What are the Hurdles Faced in TB Eradication?
Poverty and Malnutrition
TB is not only a disease of poverty, but also leads to poverty. This is because TB patients are severely debilitated and unable to work and thereby become unemployed, which leads to poverty. Coupled with malnutrition, where vulnerability to TB increases manifold and where the patients are not able to tolerate the drugs, leads to a very sorry state of affairs indeed. Therefore, these hurdles also need to be addressed by the program managers in order to ensure the success of the TB program.
Poor Health Infrastructure
The miniscule allocation of the budget (2% of GDP) to healthcare has led to a poor health infrastructure in the public sector, which is reflected in particular, by the poor state of the primary health centres in most parts of rural India. It is to be noted that without a robust primary health system, it will be difficult to reach the TB patients who reside in remote rural areas, and therefore, will impact the success of the TB program.
In patients who are HIV+ and are co-infected with TB, the chances of developing active TB increases 20-40 times more than that of uninfected individuals under similar environmental and socio-economic conditions. Importantly, TB is the leading cause of death in HIV-infected patients and accounts for over a quarter of the approximately 2 million AIDS-deaths reported annually. In fact TB is the most common opportunistic infection in AIDS patients, and these infections are synergistic and bi-directional i.e. one augments the other, and is exacerbated by a weakened immune system.
Emergence of MDR and XDR TB
Multi-drug resistant (MDR) and extremely drug resistant (XDR) TB is a relatively recent problem where the microbe is resistant to most of the common anti-TB drugs. In case of MDR TB, resistance is observed against Rifampicin and Isoniazid only. While in case of XDR TB, resistance is not only to the above drugs, but also to Fluoroquinolones, as well as the second-line injectable anti-TB drugs such as Amikacin, Kanamycin and Capreomycin. Therefore, with the emergence of MDR and XDR TB, along with the limited number of effective anti-TB drugs in the physician’s armamentarium, coupled with the fact that new drugs are few and far between, poses a major threat to the success of TB programs worldwide.
How Far Are We From Eradication?
The WHO “STOP TB” strategy envisions that TB will be eliminated as a public health problem from the face of this earth by 2050. Eradication of TB in India by 2050 will be difficult, in the absence for coordinated efforts to mobilize funds, proper planning, program evaluation and a strong political leadership.
Lack of sustained financial support and political will are the key challenges towards TB eradication in India. Importantly, the emergence of MDR and XDR TB requires more financial support towards treatment and research for newer drugs.
However, it is heartening to know that a number of initiatives have been taken by the Govt. of India to address these issues. A major policy change has been the establishment of the National Strategic Plan (2012-2017). This 5-year plan by the Govt. of India envisions a TB free India, through universal access to TB diagnostics and treatment for all TB patients. It extends the reach of the RNTCP services to all TB patients, including those with drug resistant TB, and even those seeking treatment in the private sector. Moreover, a collaborative effort between the RNTCP and National Health Mission (NHM) has been initiated, with a goal to improve primary health care in rural areas.
It remains to see if the goal of TB eradication by 2050, as proposed by WHO, can be reached by India.