The World Tuberculosis Day is observed every year on March 24 to bring attention to the health, social, and economic impact of tuberculosis, and to intensify efforts towards eradicating this global epidemic. It commemorates the moment in 1882 when Dr Robert Koch made the ground-breaking discovery of the bacteria that causes tuberculosis, opening the door to improved disease detection and treatment. The goal is to raise public awareness and encourage initiatives that can help tuberculosis eradication in local communities.
‘Yes! We can end TB!’ is the theme for World Tuberculosis Day 2023. It looks to inspire hope and, encourage effective leadership, increased financial support, prompt adoption of new World Health Organisation guidelines, innovation, quick action, and cooperation across numerous sectors to combat tuberculosis. The goal is to unite people and communities in the fight to eradicate the dreaded disease.
Since ancient times, tuberculosis (TB) posed a serious threat to human health. According to the Centre for Disease Control, India is responsible for a fourth of all TB cases worldwide. TB is a long-standing illness that is still one of the top 10 killers globally. Although TB can affect other body organs, it typically affects the lungs and is brought on by the bacteria mycobacterium tuberculosis. It is an airborne illness.
National plan against tuberculosis
The National Strategic Plan for tuberculosis Elimination in India which spans from 2017 to 2025 provides a thorough road map for all key players in the fight against TB. These stakeholders include the Union and state governments, international organisations, research institutions, civil society organisations, and the private sector. The plan is coordinated by the Central TB Division, Ministry of Health and Family Welfare. The 2017-2025 plan offers ambitious and cutting-edge initiatives to move closer to the ultimate goal of TB eradication. It draws on the successes and knowledge from the previous NSP.
The results framework below outlines the central impact and outcome indicators and targets of the National Strategic Plan (NSP). These metrics are focused on four key priority areas which are: engaging with the private sector, addressing gaps in the TB care cascade, proactively identifying TB cases among socially vulnerable and clinically high-risk populations, and implementing targeted measures to prevent active TB development among high-risk groups.
As you can interpret from the above table, the trajectory in the recent years (2015-2022) has been evidently progressive. From the incidence rate in 2015 – 217 per 100,000 to a predicted 44 in 2025, India has a chance to prove to be one of the most efficient superpowers in terms of combating tuberculosis despite the stakes being high due to an ever-growing population.
One of the most successful programmes – National Tuberculosis Elimination Programme works on four strategic pillars: detect, treat, prevent, and build. These pillars work under areas like finding out cases which are multidrug resistant (MDR) to identifying tuberculosis patients from undiagnosed high-risk population. Early detection and treatment is the most important step towards the elimination of TB.
The NTEP showed a dip in the trajectory of the notification of tuberculosis patients due to Covid-19. This was a huge chink in the nation’s armour as the tuberculosis notification rate saw a substantial fall of 38% in the first two months of Covid-19 pandemic compared with the estimated statistic goal of 2020. But NTEP tried to regain lost momentum by tackling this fall by swift and robust measures due to which there was a boost in the cases notified by a total of 1.8 million, an increase of 11% from the projections made around April end.
The Nikshay app, a public-private partnership, has played a significant role in facilitating TB notifications and carrying out various public interventions towards this change. Additionally, the distribution of free TB drugs and diagnostic tests by the private sector has been a great incentive. The Nikshaya Poshak Yojana, a centrally sponsored scheme, provides nutritional support incentive of Rs 500 to each tuberculosis patient which has made a significant difference in people seeking healthcare and addressing the nutritional needs of the nation.
Social Initiatives against tuberculosis
Apart from government efforts, community-based and non-governmental institutions that operate as non-profit organisations also play a crucial role in identifying, treating, and eradicating tuberculosis. Community and non-profit entities also contribute.
Established in 1970, the Voluntary Health Association of India (VHAI) is a non-profit registered society. It consists of a federation of 27 state voluntary health associations, connecting over 4500 health and development institutions across the nation. VHAI has been executing Project Axshya since April 2010 in collaboration with the International Union against TB and Lung Diseases.
Axshya which means TB free is a significant nationwide tuberculosis initiative backed by the Global Fund to fight AIDS, TB, and Malaria – the primary global sponsor of TB programmes. TB Alert India is responsible for executing this initiative in Andhra Pradesh and Telangana. Since January 2018 to March 2021, Axshya’s efforts have extended to approximately one million households. Through Axshya Samvad, the project has reached almost five million individuals with TB information and services.
LEPRA, an NGO has been working on tuberculosis since 1996 in all key areas of TB control, including community mobilisation, direct delivery of services, involvement of private sector, capacity building, communication and advocacy, and research.
It is a member organisation in partnership for TB care and control in India and the initiative for promoting affordable and quality tuberculosis tests (IPAQT), NGO Health Consortium-India, it has close network and linkages with state NTEP of Telangana, Madhya Pradesh, Bihar, Sikkim, Odisha, and Andhra Pradesh. Some significant achievements of the workings of this NGO have been 7399 notified TB cases in all forms by non-NTP providers.
Multiple ministries have also been working towards Intersectoral collaboration (National Multisectoral Action Framework for TB-Free India, 2018) under which more than 700 tuberculosis forums are working at the district level to tackle social determinants of tuberculosis such as malnutrition, poverty, overcrowding, indoor pollution, and sanitation.
World Tuberculosis Day: The challenges
One of the biggest challenges the nation faces is that tuberculosis strains that are resistant to the two most potent anti-TB drugs, viz., Isoniazid and Rifampicin, are termed as multidrug-resistant TB (MDR-TB) strains. Both MDR-TB and XDR-TB are the emerging threats to the success of anti-TB programs.
A rapid diagnosis of drug resistance and optimal treatment with effective and less toxic regimens are important in the management of MDR-TB. Recently, the WHO published updated guidelines regarding the programmatic management of MDR-TB which focused on rapid diagnosis and effective treatment via advanced rapid molecular tests and oral regimens with new and repurposed anti-TB drugs. Using these recommendations might be helpful in the management of MDR-TB. Well-designed clinical trials and studies for further assessment of new agents and shorter regimens are needed.
Many factors still haunt the nation like the lack of awareness, the need for resources and its management, poor infrastructure, implementation of strategies for easy identification of TB hotspots and cases not being reported due to social stigma which makes it difficult for healthcare providers as well as patients. The lack of a well-formulated policy document exclusively for tuberculosis treatment and care can be stated as one of the key indicators of negligence by the policy makers and the system.
The impact of tuberculosis is felt at the level of the individual, family, society, and country. Immunity of the person contracted with TB reduces which makes him/her susceptible to other diseases as well and reduces life expectancy. The additional burden on the mental health of the individual and the family is immense in this case.
Addressing mental health issues and providing counselling support for tuberculosis patients should be made mandatory along with affordable and effective vaccines. Following good practices such as wearing a mask, avoiding crowds, no spitting can help reduce airborne transmission
Spreading awareness can go a long way towards managing the disease. Displaying of warning signs regarding symptoms of tuberculosis, namely coughing, sudden weight-loss, and haemoptysis is also important. Community participation and empowerment is the cornerstone in making India tuberculosis-free.
(Jyothi Rajaprakash, Drishty Chavan & Chaitrali Sathe is students of MPH program, MIT- World Peace University, Pune. The views expressed are personal.)