Tuberculosis in India
Prevalence of Tuberculosis in India
Tuberculosis (TB) remains one of the world’s deadliest communicable diseases and also one of the world’s biggest single infectious cause of death among adults. In 2015, an estimated 10.4 million people fell ill with TB and 1.8 million died from the disease. TB is a leading cause of death among HIV-Positive people, as per an estimation 35 percent of HIV-Positive deaths were due to TB in 2015 (WHO Report, 2015). Rate of death due to TB is slowly declining each year and as per the estimation of WHO about 49 million lives were saved between 2000 and 2015 through effective diagnosis and treatment. However, with the available medicines and treatment process, most deaths from TB are preventable. Therefore such a high death toll from the disease is certainly unacceptable and efforts need to be accelerated if the countries have to meet the set Millennium Development Goals (MDGs) in concern to TB which is to ‘halve prevalence of TB disease and deaths due to TB between 1990 and 2015’ and ‘detect 70% of new infectious cases and to successfully treat 85% of detected sputum positive patients’ (Goal 6, Target 8, Indicator 23 & 24) . India has the highest burden of TB in the world. As per WHO report, India had registered 2.8 million cases of TB incidences (new cases per year) in 2015 (217 per 100000 population), and number of registered deaths (excludes HIV+TB) due to TV was 48,000 (36 per 100000 population).As per the RNTCP Annual status Report (2017), 1.75 million TB patients had notified in 2016 including both from public and private health sector and 33,820 drug resistant TB patients are notified additionally.
National Family Health Survey (NFHS-3) (2005–06) has pointed out few facts about the prevalence of disease in India, they are:
- The risk of TB is much higher for men (526/100,000) than women (309/100,000), and much higher for rural residents (469/100,000) than urban residents (307/100,000). Prevalence of TB is also higher among people above 60 years (998/100,000) than their younger counterparts. Prevalence in the oldest age group is about twice as high as prevalence in the population age 15-59 (519/100,000) and about nine times as high as prevalence among children below age 15 (110/100,000). Both sex and age differentials are more pronounced in rural areas than they are in urban areas.
- The risk of TB is more than four time higher among the households using straw, shrubs, or grass for cooking (924/100,000) than among the households using electricity, liquid petroleum gas, natural gas, or biogas (217/100,000). Higher TB prevalence is found among the households cooking in the house without having a special room for cooking (518/100,000), compared with households that have separate kitchen (294/100,000).
- Number of persons suffering from medically treated TB ranges from a low of 96 per 100,000 persons in Jammu and Kashmir to a high of 1,096 per 100,000 persons in Arunachal Pradesh. In Karnataka, 136 per 100,000 persons are suffering from medically treated TB, which is quite lower than the national average of 418 per 100,000.
- People’s ignorance about aetiology and transmission of TB is one of the major cause of lack of accessing the available services to cure TB. As per the survey, 85 percent of women and 92 percent of men aged between 15 to 49 years have heard about TB but only about half among them know that it’s spread through the air by coughing or sneezing.
It can be concluded from the above mentioned points that the prevalence of TB differs between sex, age, settlements, type of households and states. Another aspect that need to be discussed here is the high prevalence of tuberculosis among socio-economically disadvantage groups. Studies across the world have proved that ‘Socio-Economic Status’ have negative relation with tuberculosis & . A study by NTI, Bangalore has stated that TB prevalence was significantly higher among people living below the poverty line than those above it, among people without land, and among those living in kutcha houses. Also, other indicators of poor socio-economic group – poor level of education, poor nutrition and over-crowding (higher number of people in a house), increases the risk of getting TB. Like poor education is associated with poor knowledge about the cause and transmission pattern of the disease, poor nutrition leads to low immune system and thus the increases the vulnerability, and over-crowding results in increase in the risk of disease transmission . Thus, it can be safely said that improving the socio-economic condition of the general population will help in reduction of the tuberculosis incidents.
History of TB Control Programme in India
The Mudaliar Committee report in 1959 recorded that disease control programmes of India had made some substantial achievements in controlling certain virulent epidemic diseases, like malaria, cholera, smallpox etc in a decade after independence. However, the tuberculosis program lagged behind as for a million and half estimated open cases of tuberculosis there were not more than 30,000 beds available (CEHAT, 2001) . This had initiated the National Tuberculosis Control Programme (NTCP) in the country. NTCP, established in 1962, was designed for domiciliary treatment using self-administered standard drug regimens. A large network of District TB Centers was created with trained staff and infrastructure throughout the country.
A review of the programme in 1992 concluded that the NTCP was unable to reduce the required impact because of low priority, managerial weaknesses, over dependence on X-rays for diagnosis and inadequate funding. Incomplete treatment was the norm rather than exception due to low rates of treatment adherence and lack of supervision. Thus, in 1992, the Government of India (GOI) evolved a Revised National Tuberculosis Control Programme (RNTCP) with an objective of achieving a treatment success rate of 85 percent of new smear-positive cases and a 70 percent case detection rate . The programme was based on the DOTS (Directly Observed Treatment, Short-course) strategy which have five major components: i) sustained political and administrative commitment to increase human and financial resources, ii) good quality diagnosis, iii) good quality drugs, iv) right treatment given in a right way, and v) systematic monitoring and accountability.
The programme began as a pilot in 1993 in a population of 2.35 million and thereafter increased in phased manner. A full-fledged programme was started in 1997 and rapidly expanded with excellent results. By the end of 2000, 30% of the country’s population was covered under the RNTCP, and coverage had increased to 50 percent by the end of 2002. By the end of 2003, 778 million population was covered, and at the end of year 2004 the coverage reached to 997 million. By December 2005, around 97% (about 1080 million) of the population had been covered, and the entire country was covered under DOTS by 24th March 2006 with the assistance from the World Bank. RNTCP and its recent progress in DOTS expansion had been encouraging. The programme has consistently achieved treatment success rate of more than 85%, and case detection close to the global target. However, only in 2007, RNTCP for the first time has achieved the global target of 70% case detection while maintaining the treatment success rate of more than 85%.
After focusing on the expansion of providing quality DOTS services to the entire country in the first phase (1998-2005) of programme, RNTCP entered the second phase in 2006. The second phase of the programme aimed towards consolidating the gains made to date, to widen services both in terms of activities and access, and to sustain the achievements for decades to come in order to achieve ultimate objective of TB control in the country. Components included in the second phase of RNTCP are:
- Pursue quality DOTS expansion and enhancement through patient centric approach.
- Address TB-HIV, MDR-TB and other challenges by scaling up TB-HIV joint activities, DOTS Plus, and other relevant approaches.
- Contribute to health system strengthening, by collaborating with other health programmes and general services
- Involve all health care providers, public, nongovernmental and private, by scaling up approaches based on a public-private mix (PPM), to ensure adherence to the International Standards of TB care.
- Engage people with TB and affected communities to demand and contribute towards effective care. This will involve scaling-up of community TB care, creating demand through context-specific advocacy, communication and social mobilization.
- Enable and promote research for the development of new drugs, diagnostic and vaccines. Operational Research will also be needed to improve programme performance.
The emergence of resistance to drugs used to treat tuberculosis (TB), and particularly multidrug-resistant TB (MDR-TB) has compelled the government to introduce RNTCP- DOTS Plus in 2010. Specific measures are being taken within the RNTCP to address the MDR-TB problem through appropriate management of patients and strategies to prevent the propagation and dissemination of MDR-TB. The programme also incorporated strategies to treat patients of extensively drug-resistant tuberculosis (XDR-TB).
In 2005, GOI launched National Rural Health Mission (2005-12) with seven major goals to provide effective health care services to rural population throughout the country with special focus on 18 states which have weak public health indicators or weak infrastructure. In 2013, under the umbrella of National Health Mission, the services of NRHM were extended to urban centers also, especially to urban poor, through the National Urban Health Mission (NUHM).NRHM/NHM has integrated all related, inter-linked and standalone schemes in the health sector including RCH, National Disease Control Program (NDCP), Integrated Disease Surveillance as well as new initiatives proposed under NHM and National Commission on Macro Economics and Health (NCMH).
Under one of the broad goal of prevention and control of communicable and non-communicable diseases, the NHM (also in NRHM) provided flexible pool for control of communicable diseases, which includes RNTCP also. The flexible pool has facilitated the states in preparing state, district and city specific Programme Implementation Plans (PIPs). As RNTCB came under the purview of NHM, the fund for it is also routed through the NHM to the state.
In 2016, the programme has expanded TB care services and made landmark changes in the strategy of diagnosis and treatment of TB. An additional 500 CBNAAT machines were installed through the year, expanding the rapid molecular diagnostic facilities to 628 laboratories. A new drug Bedaquiline was introduced for treatment of MDR-TB at six identified sites.Single window delivery of HIV-TB services was expanded at all Anti-retroviral Treatment (ART) centres in the country. Along with it, ICT enabled treatment adherence support system (99 DOTS) was also extended for HIV-TB patients (RNTCP Annual Status Report, 2017).