Abstract
The Honourable Prime Minister of India set a target of year 2025 for elimination of TB from the country, 5 years ahead of the Sustainable Development Goal of 2030. Last few years, India has made significant improvements, towards elimination of tuberculosis from the country in the form of bold policies and unprecedented political commitment. While COVID-19 has resulted in setbacks for TB elimination efforts, it has also offered an opportunity to revisit and structurally redesign the public health infrastructure/system in our country. The dream of TB elimination is possible with active participation of all stakeholders and community at large coupled with accelerated development of new diagnostics, drugs, and development of a new TB vaccine. COVID-19 pandemic has shown that vaccines can be developed in a year, contrarily, the lack of a TB vaccine is deterrent in the efforts towards a TB free world. A progress towards TB elimination would require potential contribution of novel TB vaccine. Now, is the time for mobilization towards a TB vaccine to make an impact towards our end TB goal.
Keywords: Tuberculosis, SDG, TB incidence rates, TB vaccine, TB elimination
As per WHO Global Tuberculosis (TB) Report 2020, India ranks 39th globally in terms of the TB incidence rate i.e. the number of new TB cases per lakh population. In terms of the Multi drug resistant TB incidence rate, India also ranks 39th globally. However, owing to India's overall population, these rates translate to very large numbers. An estimated 26 lakh TB cases occurred in India in 2019 and 4.36 lakh people succumbed to the disease in the same year. Approximately 1200 people die of Tuberculosis every day. Considering the huge load of this deadly disease, Central TB Division (CTD) of Ministry of Health & Family Welfare, had developed National Strategic Plan (2017–2025) in line with UN's Sustainable Development Goal 3 of 2015 and on 13th March, 2018, at “Delhi End TB Summit”, the Honourable Prime Minister of India set a target of year 2025 for elimination of TB from the country, 5 years ahead of global target of 2030.
In the last few years, the country has made significant strides in improving the public health system and health indicators across the country. These advances are unprecedented both in terms of their scale and reach and bear a rich testimony to the sincere commitment towards a healthy and more productive India. The Ministry of Health & Family Welfare has also taken definitive steps towards elimination of tuberculosis from the country with tailwinds in the form of conducive plans, policies, and commensurate resources to match unprecedented political commitment.
The National Tuberculosis Elimination Programme has significantly scaled up access to free rapid molecular diagnostics, treatment and nutritional support to patients. Relentless efforts have led to a record increase in TB notifications and considerable improvements in time-to-diagnosis, adherence, and treatment outcomes. This reflects that the Programme now has better access to TB patients and the ability to provide free treatment to patients from both public and private sectors. The programme has also advanced leaps and bounds in the services being provided for TB, with substantial ramping up of diagnostic capacities for TB with rapid molecular diagnostic facilities available in all districts of the country. Going forward, they will be further decentralized to block levels. High quality anti TB drugs, use of digital technology, multisectoral and community engagements, and integration of TB services within all levels of the health system, are all aligned to detect cases early and prevent the emergence of new cases of TB by expanding TB care and services to rapidly decline TB incidence and mortality in the country.
Between January and February 2020, the National Tuberculosis Elimination Programme was on an up-hill trajectory notifying more than 4,11,000 patients (∼6% more than in the corresponding months of 2019). And then COVID-19 hit the world full force and unleashed a devastation unprecedented in modern times. The national lockdown imposed in March and April resulted in tumbling notifications by almost 38%, and NTEP worked hard to mitigate the impact of this new threat to regain the lost momentum. Central TB Division had sent a number of advisories which included TB and COVID-19 bi-directional screening among ILI/SARI patients and COVID-19 patients, at various health facilities of the country to detect TB cases among the COVID-19 affected persons and vice-versa. This practice of bi-directional screening yielded better diagnosis in both TB and COVID-19 patients which helped to reduce the transmission of both the diseases.
The National TB Prevalence Survey resources were also re-purposed and optimally utilized to conduct three rounds of national SARS-cov2 sero-surveillance by ICMR in India. A large capacity of Nikshay Sampark (National TB Call Centre) was also re-purposed to serve as COVID-19 helpline. By December 2020, the Programme had almost closed the gap on TB treatment enrolment with a total of 18,05,670 patients notified, 11% more than the estimated projections made in April. The private sector too contributed significantly by notifying ∼5.49 lakh patients (31% of total notifications), 3% more than in 2019. More than 95% of total patients notified were put on treatment.
At the community level, large scale active TB case finding campaigns with massive screening and testing in campaign mode, engaging health outreach workers and community volunteers to facilitate surveillance of symptoms within households, doorstep delivery of drugs and doorstep collection of sputum samples, tele-consultations over phone and video, and ensuring uninterrupted supply of anti TB drugs are being undertaken. We have also supported the States with periodically updated advisories, directives, and guidance documents.
The sweeping global COVID-19 pandemic has reversed years of progress made in the fight against Tuberculosis. Currently India is in the midst of the second wave of the pandemic. This huge surge in cases has posed unprecedented challenges for the health system in general and particularly for the National Tuberculosis Elimination Programme. But we are committed to keep the TB Programme on the track and focus on continued TB services. Even in these trying times, the Central TB Division is implementing TB Mukt Bharat Abhiyan, a People's Movement for TB launched by the erstwhile Honourable Union Health Minister Dr Harsh Vardhan. The campaign aims to build awareness about TB, address the deep-seated stigma around the disease in the community, raise awareness about the available TB services under the program, and generate demand for TB services in the community by building strong political and administrative commitment at the grassroots level and through inter sectoral coordination and synergy with other public health programmes in the country. Earlier, “TB Harega Desh Jeetega” campaign was launched by the erstwhile Honourable Union Health Minister Dr Harsh Vardhan on 25th September 2019 to make every citizen of India aware about TB and kick-start an awareness campaign for the TB services throughout the country. This should effectively lead to better reach of TB services in remote areas of India.
The programme has identified key thematic areas to cover across the year with exhaustive activities at State/District and Facility levels to be undertaken. These are over and above the regular calendarized plans followed by States/UTs. A State Guidance Document has been developed to provide much needed direction for State TB Offices to implement the activities in line with the TB Mukt Bharat calendar together with the processes that need to be followed for implementation and their expected outputs and outcomes. Several development partners too have come forward in support of the Abhiyan with commitments in the areas of Advocacy, Communication, Sectoral engagements including the communities, treatment and management of TB, diagnostics, logistics and supply chains, Surveillance and Monitoring, use of Artificial Intelligence for improving patient care, Research etc. Many have started interventions across geographies, expanding activities under various aspects of the TB care cascade for a more patient-centric delivery of health services.
While COVID-19 has resulted in setbacks for TB elimination efforts, but as a silver lining to every dark cloud, it has also provided the chance to revisit and structurally redesign the public health infrastructure/system in our country. Dedicated Infectious Disease Hospitals being established as part of the pandemic preparedness and response, would contribute significantly to TB care and management. The measures undertaken by various states to control COVID-19 infection will alter the transmission dynamics of infectious diseases in the health facilities. The behavioural change acquired by the common citizens during this COVID-19 pandemic will further contribute to reducing transmission of all respiratory illnesses including TB. Adoption of technology and use of online platforms for trainings, meetings and reviews will allow staff getting better adapted to the use of these modalities. The scale-up of telemedicine and teleconsultations during the pandemic will provide additional channels of consultation on TB.
But, despite everything, an uphill task remains. The dream of TB eradication will not bear fruit without the active participation of all stakeholders and community at large. To end TB, we need to accelerate development of new diagnostics, vaccines, drugs etc. Today, the world lacks an effective TB vaccine. The COVID pandemic has shown us that united efforts can lead to vaccines in less than a year. We need a similar effort for a TB vaccine too, and soon. We must leverage all available opportunities to foster awareness and advance indigenous technologies along with learning and sharing of innovative research and development activities for TB drug discovery, diagnostics, and vaccine development. It is only through continued efforts by all of us in the scientific advancement of knowledge, that persisting challenges facing TB will find a resolution.
The National Tuberculosis Elimination Programme remains committed to the deadline of 2025 that India has set for itself.
Conflicts of interest
The authors have none to declare.