TB free India by 2025: hype or hope

KEYWORDS:

• NTEP
• national strategic plan
• MDR-TB
• TB laboratory networks
• end-to-end care management

1. Renewed opportunity

Tuberculosis (TB) has been in existence since times immemorial and continues to remain a major public health problem [1,2].^, The centuries old paradigm has been focused on the containment of the disease [3]. However, advancements in medical science have led scientists and public health experts realize that it is possible to eliminate TB [4,5]. Availability of newer diagnostics and drugs in line with the progress made by different countries have provided additional impetus to end-TB [4,6].

TB continues to remain a public health challenge in India and World Health Organization Global TB Report 2019 estimated nearly 2.7million cases in India in 2018. The program reported 2.4 million cases in 2019 out of which 6% (0.15 million) belonged to the Pediatric age group and 66255 were MDR TB cases [7]. A total of 94% cases of DSTB and 85% of cases of MDR TB were put on treatment [7]. BCG vaccination at birth to all children is an ongoing activity under Universal Immunization Programme and with a focus on prevention nearly 4 lakh PLHIV and 4.2 lakh children less than 6 years were initiated on TB Preventive Therapy in 2019 [7]. However, given these achievements, issues of overcrowding, poverty, malnutrition, and the current SARS-COVID pandemic continue to propound challenges to deal with.

2. Bold ambition

India has demonstrated successes in establishing robust public health infrastructure. Further, India has trained personnel and strengthened additional measures to bolster ending communicable diseases, including TB [8]. The clarion call by the Hon’ble Prime Minister given on 13 March 2018 at ‘End TB Summit’ in New Delhi has given an unprecedented push to end TB in India, by 2025, 5 years ahead of global timeline – 2030 [9]. To reflect the aspirational goal, the program has now been renamed as National TB Elimination Programme (NTEP) [7]. A National Strategic Plan was prepared to steer the efforts and operationalize the plan to achieve the said goal [10]. Having underscored the bold ambition, it should also be noted that the program and the system as a whole is cognizant of the detrimental effects of the SARS-COVID pandemic and is realigning the activities to meet the goals realistically.

3. Robust ecosystem

India has successfully created one of the largest TB laboratory networks in the world with 6 National Reference Laboratories, 31 Intermediate Reference Laboratories, 50 certified laboratories for Liquid Culture and Drug Susceptibility Testing (DST) services, and 64 certified laboratories for Line Probe Assay (LPA) services along with 20,356 Designated Microscopy Centers [9]. These laboratories have contributed to a significant increase in TB detection and enabled access to appropriate treatment for patients, based on their drug susceptibility patterns. Population-level tracing and active case finding using rapid molecular diagnostics is coordinated through the comprehensive real-time TB information management system, NiKshay (Ni = End, Kshay = TB), which has led to an increase in case detection from 1.5 million in 2015 to 2.4 million in 2019 [7,11]. These activities have resulted in reductions in the number of patients that remain undetected by the care cascade from 1 million to less than 0.5 million persons [7]. Furthermore, the scale-up of TB preventive therapy will cover all adolescent and adult contacts of TB patients and is projected to accelerate further declines in TB incidence.

4. Tangible policy interventions

Massive private sector engagement efforts coupled with legislative measures like mandatory TB notification have dramatically improved the overall reporting from the private sector from 38597 in 2013 to 678895 in 2019 [7,12]. Similarly, interventions in public health in the form of free drugs, diagnostics, cash transfers, and adherence support are resulting in favorable outcomes and are cutting the chain of transmission further [12,13].

5. End-to-end care management

The National Tuberculosis Elimination Programme (NTEP) focus on addressing comorbidities (e.g. HIV, diabetes, and tobacco use), vulnerable and marginalized populations, and active case finding strategies have aided in early detection of the disease and customized treatment for patients [14]. Likewise, integration with programs such as Non-Communicable Diseases (NCDs), school health systems, Nutrition Rehabilitation Centers, and Health and Wellness Centers, have contributed to significant increases in notification rates, reductions in disease transmission and a decline in TB incidence and helping the Government of India to effectively reduce TB transmission in a coordinated fashion [7]. Considerable progress has also been made in addressing Drug-Resistant TB with a focus on DST guided treatment, the introduction of newer drugs (like Bedaquiline, Delamanid), and injection-free regimens for DR TB [7].

6. Inter-sectoral approach

Inter-ministerial collaboration for ending TB in India is an ongoing process and multiple ministries are already on board (National Multisectoral Action Framework for TB-Free India, 2018). Engaging corporate partners, the establishment of more than 700 TB forums at the district level to tackle social determinants of TB such as malnutrition, poverty, overcrowding, indoor pollution, and sanitation are important steps taken by of Government of India to effectively reduce TB transmission, simultaneously [4,7].

Notable examples are the poverty alleviation measures and urban housing development initiatives in preventing overcrowding. Provision of free liquefied petroleum gas (LPG) to women below the poverty line (https://pmuy.gov.in/) has helped to reduce indoor air pollution. Sanitation drives (https://swachhbharatmission.gov.in/), Rural employment schemes, and Direct Benefit Transfer of subsidies and direct payments to bank accounts (https://pmjdy.gov.in/https://dbtbharat.gov.in/) are also likely to contribute to reduction of TB incidence in India. At the global level too, apart from TB specific targets, the Sustainable Development Goals (SDGs), including poverty alleviation, zero hunger, good health and wellbeing, reducing inequities, promoting economic growth, and other measures are expected to contribute to TB elimination [15].

7. Fostering citizen participation

Community involvement and empowerment is the cornerstone for ending TB. Involvement of celebrities, like Amitabh Bachchan, and industrialists such as Ratan Tata has boosted TB advocacy efforts and made them more relatable to a wider audience. This has advanced national TB control efforts, garnering support from the political leadership to invest further in TB control efforts, and public health in general.

The TB HaregaDeshJitega campaign (TB Will Loose, Country Will Win) initiated by the Government of India has created grassroots momentum and fosters citizen involvement at the community level. Ending TB cannot be achieved if preventive and community-level interventions are not implemented along with a multi-sectoral and community-led response. Challenging it may be, but it is a prerequisite to fulfilling the dream of creating a TB-Free India.

8. Silver lining

The COVID-19 pandemic has posed unprecedented health delivery challenges but has also provided India with an opportunity to structurally reimagine its core public health delivery systems, more so in the context of respiratory infections. The pandemic has also engendered a fundamental shift in the perception of one’s vulnerability among the masses, both individually and collectively, influencing wearing of protective masks, shunning spitting, practicing hygiene and handwashing, maintaining appropriate social distancing, and taking collective responsibility of one’s own and the community’s health. These will act as catalysts in transformation of the public to adopt sensible health-seeking behaviors, and to contribute to preventive efforts.

9. Conclusion

India’s ambitious goal to end TB by the year 2025 is daunting. The World Health Organization estimates that India contributed 2.7 million incident TB cases in 2018, representing a 9% reduction compared to 2015 [4]. Currently, India contributes 27% of the global burden of TB. We need to do more. India TB Research Consortium was formed to support research activities, diagnostics, treatment, and vaccine development which are necessary to achieve the set targets. The consortium is supporting a new recombinant BCG vaccine which is in phase-3 trials. The Consortium has also supported global validation of Tru-NAAT machines. These mechanisms will enable the TB program to rapidly implement the use of new tools and technologies toward ending TB. These mechanisms will enable the TB program in the rapid and early adoption of new tools and technologies toward ending TB.

These outcomes emanating from coherent policy planning, synergized execution, and creating a patient-centered support system provide a glimmer of hope. Thus far, 12 States/Union Territories have voluntarily committed to ending TB by or before 2025, and it is anticipated that this will act as a substantial driving force for other States to do the same. India has an established record of successfully eliminating major public health challenges, including smallpox and polio. The vision to end TB by 2025 may become a reality, provided all stakeholders act in unison, continue to build momentum, invest, innovate, and harmonize efforts through concerted action.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

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Funding

This paper was not funded.