ISSN (Print) - 0012-9976 | ISSN (Online) - 2349-8846
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High Time to End Tuberculosis

The time to act is now if we want to eradicate tuberculosis by 2030.

The global burden of tuberculosis is in decline. However, with an estimated 10 million new cases of tuberculosis and 1.6 million dying from the disease globally in 2017, we still have a long way to go. A centuries-old disease, tuberculosis, previously known as “consumption,” is still the deadliest infectious disease in the world, with patients and their families facing stigma and incurring devastating socio-economic costs. The United Nations’ first-ever high level meeting on tuberculosis, held on 26 September 2018, has committed to accelerating efforts and increasing funding towards achieving the agenda of the Sustainable Development Goals to end the tuberculosis epidemic by 2030. India, which accounts for 27% of the world’s tuberculosis burden, had set its own target at the End-TB Summit in Delhi earlier this year: TB Free India by 2025. Considering the state of India’s healthcare, this may be an unrealistic target.

The under-reporting of tuberculosis cases has been a perpetual issue hampering efforts at estimating, controlling and treating the disease. Of the 10 million estimated cases worldwide, the number of cases actually reported is only 6.4 million, and India alone accounts for 26% of the 3.6 million global gap in the reporting of tuberculosis cases. Though the number of reported cases from India has seen a jump since 2013, largely attributed to increased reporting from the private health sector, the underreporting of tuberculosis cases that have been detected and the under-diagnosis of the disease itself make a treatable and curable disease like tuberculosis deadly and rampant.

In 2012, when it declared tuberculosis a notifiable disease, India had set up “Nikshay,” an online tuberculosis reporting system for medical practitioners and clinical establishments, with the aim to increase the reporting of tuberculosis, especially from the private sector. In the years since it was launched, Nikshay has faced many roadblocks on the ground, such as unawareness of the system, unwillingness to report due to misconceptions about it, inconsistency in reporting, and lack of incentives for those reporting cases. Though the private sector has begun notifying cases—when earlier there had not been any reporting on its part—Nikshay’s adoption and use has been slow, unlike countries such as China that have been able to more effectively lower the incidence rate of tuberculosis after putting in place similar online reporting mechanisms. In March 2018, in a gazette notification, the Indian government put in place provisions penalising the non-reporting of tuberculosis cases, along with making it mandatory for pharmacists/chemists to report tuberculosis cases and maintain records of the drugs dispensed to patients, allowing for self-reporting by tuberculosis patients, and providing cash incentives to those reporting cases.

The challenge is to use this system consistently and persistently, as is the treatment regimen for the disease. While the reporting of cases has increased, the corollary reporting on treatment outcomes has not been robust. In 2016, of all the tuberculosis cases notified, the treatment outcome data for 22% had not been reported. If there is no consistent follow-up of treatment regimens and outcomes, tuberculosis patients can easily slip through the cracks, resulting in cases of relapse, and multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis. Further, while treatments have been successful in 69% of the reported cases, in the cases of MDR tuberculosis, only 46% report successful treatment. The coverage and prophylactic treatment of vulnerable populations, such as children under five living in households with tuberculosis and HIV/AIDS patients, has been even slower.

With an estimated 1.7 billion or 23% of the world’s population having latent tuberculosis infection, it is important to take steps to prevent the spread of the disease in vulnerable populations and the emergence of new cases from this pool. Of the five risk factors for tuberculosis mentioned in the World Health Organization’s Global Tuberculosis Report 2018—alcohol, smoking, diabetes, HIV/AIDS, and undernutrition—it is undernutrition that poses the gravest risk in India, as it does in other poor, developing nations, especially among children. The prevention and successful treatment of tuberculosis is closely linked with the overall improvement in nutrition and health indicators, poverty, and access to healthcare. Further, the data on the disease with which we are working in India is more than 60 years old now, with the last national-level survey on tuberculosis having been conducted in 1955. Regular national-level surveys can help countries plan their disease control and prevention programmes better. India is slated to carry out such a survey only in 2019/2020; hence, it will be a few years before we can start working with more reliable data, rather than just estimates.

Considering the deadly and epidemic nature of tuberculosis, the development and spread of new methods and technologies to detect the different modes of this disease, new vaccines, and new drugs and shorter drug regimens have been slow, as compared to other such diseases like HIV/AIDS. It was only after 40 years that two new drugs to treat MDR tuberculosis, bedaquiline and delamanid, were recently made available. Also, the development of a vaccine for preventing the emergence of the disease in vulnerable and adult populations is sorely required. The research, development, trials, and the actual use of new methods and drugs take years, decades even. Unless the global community acts now, with India and other tuberculosis-affected countries at the forefront, the 2030 target to eradicate tuberculosis will be far from attainable.

Updated On : 9th Oct, 2018

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