On March 13, Prime Minister Narendra Modi, while inaugurating the India End-TB summit in New Delhi, announced that India commits to end or eliminate tuberculosis by 2025, five years ahead of the global target set under the UN Sustainable Development Goals (SDGs). The PM urged all stakeholders to commit themselves to achieve the goal through collective action. He said he had requested all chief ministers to join in the fight, that TB –free India could only be achieved if we aimed first to achieve the TB-free village, panchayat, district and the state.
Indeed, the goal is ambitious but not impossible. First, we need clarity as to what exactly we mean by ending TB? Does this mean zero TB cases, deaths and zero suffering due to TB? In terms of the SDG targets, on the other hand, “ending TB” only requires one to reduce TB incidence and death rates by 80% and 90%, respectively, that too in 15 years from the 2015 levels. While the WHO ‘End TB Strategy’ not only has a longer timeline, up to 2035, but its targets are 90% incidence and 95% death rate reduction by 2035.
In the global context, India is a critically important country because it is home to 26% of world’s TB cases and 33% of TB deaths. Each year 2.8 million new cases and 0.4 million deaths occur in the country. TB remains the top infectious killer, both globally and in India. Clearly, ending TB globally cannot be achieved unless India makes substantial progress in this direction.
During the 1990s, the world witnessed the rapid and unprecedented expansion of DOTS, the ‘directly observed treatment short course’ strategy, as advocated by the WHO. So, the time has now come for India to make an all-out effort to achieve the End TB goal!
To achieve this goal, India must address the following issues as a matter of priority:
First, it is imperative to focus on early detection and prompt treatment of all infectious cases. There is evidence to suggest that TB incidence is declining, albeit at a slow rate of 2% per year. This rate must be accelerated at a much faster pace, to nearly 20% per year more than ten-fold from the current rate. The main reason for the slow decline is that patients still remain out of reach. In fact, out of 2.8 million new cases, as many as one million are considered “missing” from the system and who continue to spread the disease in the community.
Urgent efforts must be mounted to actively search for cases in ‘hotspots’ such as prisons, slums, households which have contact with TB patients and clinics where HIV or diabetes patients visit. The idea is to make sure that treatment renders patients non-infectious, so as to break the chain of transmission. Any delay in detection and in treatment initiation is sure to transmit infection to several new people.
Horrifyingly, TB patients in India are today diagnosed after a delay of two months. Either rapid diagnostic tools such as gene experts must be made available in all districts or the programme should move towards improved point of care diagnostic tests that can be used at the most decentralised levels of health care and at the community level. Bridging the gap between disease onset and diagnosis is thus another challenge for the program to urgently address.
Second, a high visibility communication and advocacy campaign to generate awareness about the disease, its transmission, and importance of regular and complete treatment must be launched. During awareness generation activities, people should learn and practice cough hygiene – coughing persons should cover her/his mouth and not spit here and there.
Third, functional and accountable multi-sectoral partnerships should be established. Studies show that nearly 80% of new TB patients often tend to hop around in different health facilities, mostly in private sector, before being diagnosed. Systematic collaboration with the private health sector is therefore essential to ensure that TB patients seen in private health facilities also get free quality treatment and are followed up till completion of treatment.
Nearly 40% of our population is already infected with the TB Bacillus and have 10% lifetime risk to develop active TB disease. This can be prevented by improving their nutritional status to build their immunity.
Fourth, the quality of TB programme activities which can help prevent the emergence of drug-resistant cases must be improved. Programmes must emphasize quality diagnostic services and quality of anti TB drugs, and ensure universal access to all patients.
Regular supervision, monitoring and periodic evaluation of program performance are critical to measuring progress in achieving the target of TB elimination by 2025.
Last but not the least, a proper budget must be allocated. The cost of implementing the campaign, Rs 16,649 crores, is much higher than what has been available so far.
In conclusion, ending TB in the country by 2025 is a huge commitment, but the business-as-usual approach cannot work. Political will and commitment are imperative, as is the allocation of substantial financial and human resources, besides innovative and thinking out of the box ideas on how to capture all TB patients not currently in the system. Only time will tell whether India is able to mount such a credible and sustained response and fulfill the prime minister’s enthusiasm and commitment to achieve a TB-free India by 2025.