An all-hands-on-deck approach to fight TB in India
Investment, collaboration, and technology are key to achieving the goal of becoming TB-free. This will require time, effort, and commitment from all stakeholders. The time is now
At 2.6 million cases, India has the highest burden of Tuberculosis (TB) in the world, accounting for at least one-fourth of the global cases. The just released National TB Prevalence in India Report (2019-21) also suggests that the prevalence of microbiologically confirmed TB among those 15 years and above of age in India is 316:100,000 population. The highest Pulmonary TB prevalence of 534:100,000 is in Delhi, and the lowest of 115:100,000 in Kerala.
TB has been one of the biggest public health challenges in India. However, India is committed to end TB by 2025 — ahead of the year 2030 — the target set under the Sustainable Development Goals (SDGs). This, despite the set-backs due to the coronavirus pandemic that derailed the health care system in the country and across the globe.
The TB National Strategic Plan (NSP) 2020-2025 is an endorsement of the government’s re-doubled commitment to make India TB-free by 2025. The new NSP provides a new set of goals that will accelerate the national response to TB elimination. The key interventions highlighted in the NSP include population screening for TB, high standard of care in private sector, achieving high rates of treatment success, and the use of technology for diagnosis.
TB is not only a public health issue. It is also strongly linked to socio-economic development, nutrition, and lifestyle. There is deep social stigma attached to the disease resulting in discrimination, social rejection as well as a loss of livelihood. Driven by the factors that are beyond the scope of health alone, eliminating TB from the country, hence, calls for enhanced commitment, investment, and collaboration.
India has made impressive strides in bringing down TB-related mortality and infection rates over the years. However, considering the diversity and variation in the burden of disease, there is a need for active engagement of non-traditional stakeholders such as corporations, civil society, young people, community-based organisations (CBOs), and community members, all of which can play a critical role in winning the battle against TB.
This year’s theme, “Invest to End TB; Save Lives” calls for the need to invest in the fight to end TB. This will have to be not only financial but by way of human resource as well. While we have seen an overwhelming political commitment at the highest level, there is need to strengthen existing partnership and build new ones. Adopting innovative initiatives and success stories from different states that have been able to bring down the disease prevalence could be one way to overcome TB.
Technology has been used extensively for surveillance, diagnosis, treatment, and monitoring, but we have also seen some very successful initiatives by various State governments such as adoption of more than 38,000 pediatric TB patients in Uttar Pradesh by the Governor, government officials and corporate houses to provide them support and prevent stigma and discrimination. In Bihar, TB elimination has been taken up as a Jan Andolan on the lines of Poshan Abhiyan while in Karnataka, Kshay Rog Mukt Gram Panchayats (TB Free Gram Panchayats) are being encouraged to involve the elected representatives in TB elimination at the grassroots level. Learning from and replicating successful initiatives can be another way of dealing with the disease. Chhattisgarh was the first state to introduce nutrition for TB patients, and this initiative is included in the National Tuberculosis Elimination Programme.
Another major challenge faced by the national program is the lack of health-seeking behaviour of the population that creates a high risk of transmission. Patients with undiagnosed TB act as reservoirs for the disease. The National TB Prevalence in India Report points out that a majority 63.6% of TB patients did not seek care for their symptoms. There are about 400,000 missing TB cases annually who pose a serious threat to the society. Delay in the diagnosis and dropping out of treatment may worsen the disease condition, increase the out-of-pocket expenditure, and also increase the risk of TB transmission in the community.
Considering this scenario, investments and resources need to be targeted for high burden states, and high-risk groups, with greater emphasis on health education and advocacy to increase awareness among the community. Here, training and using champions to eliminate stigma and discrimination, and engaging with the community by setting up TB Forums and Patient Support Groups will go a long way in awareness generation.
A significant investment of financial and human resources would be required to capacitate young people, making them “change agents” using technology as an enabler. Training TB survivors as champions and launching IEC campaigns by involving celebrities do leave an impact as we have seen in the case of Polio Campaign and mental health after well-known movie stars associated themselves with these two public health campaigns. We already have campaigns such as `Be the Change for TB’ and some more with powerful messages can bring about the change in people.
Advances in technology is being leveraged for rapid and accurate diagnosis, treatment adherence, IEC activities, training of community volunteers and staff. In addition, AI tools are also being explored in many areas.
But, this cannot be done by the government alone. Multi-sectoral partnerships can help in leveraging strengths and synergies and using technology for improved surveillance to address the issue of missing cases. Partnerships can help to build capacities of medical practitioners and healthcare workers to deal with TB patients.
If the goal of making India TB Free by 2025 is to be achieved, a solution-driven approach would be required to bring multiple stakeholders together for collaborative action against tuberculosis. Limiting the stakeholder contribution to monetary investment is not enough to free India of TB. Complementing actions would also be required to invest time, effort, and commitment from all stakeholders.
Dr Rajendra P Joshi is deputy director general (TB), Central TB Division
The views expressed are personl