Introduction
Tuberculosis (TB) remains a threat to global public health, one of the leading infectious causes of death globally. Worldwide, TB is the 13th leading cause of death and the second leading infectious killer after COVID-19 (above HIV/AIDS). In 2021, an estimated 10.6 million people got infected with TB and 1.6 million people died (including 187,000 people with HIV). The largest number of new TB cases (46%) occurred in the WHO South-East Asian Region, followed by the WHO African Region (23%) and the Western Pacific (18%). Eight countries accounted for more than two thirds of the global total: India, Indonesia, China, the Philippines, Pakistan, Nigeria, Bangladesh and the Democratic Republic of the Congo. India accounts for 27% of the global estimated 10 million cases and 25% of the estimated 1.6 million deaths.1
As per India Tuberculosis Report 2023, a record high notification of 24.2 Lakh cases, which is an increase of over 13% as compared to 2021, and a case notification rate of approximately 172 cases per lakh population was achieved. The treatment initiation rate among the notified cases for 2022 was 95.5% while the presumptive TB examination rate (PTBER) for the country rose to 1281 per lakh population (68% increase) from 763 in 2021.2
Finding Missing Millions
As per a UN report,3 approximately 10 million people developed TB in 2018, out of which only around two-thirds were detected and reported. About three to four million people suffering with TB are missed by health systems every year because they are not diagnosed, treated, or reported. TB is an entirely preventable and curable disease, but it will continue to spread while the missing four million people remain undiagnosed and untreated.
The main reasons for these missing cases include limited or no access to healthcare for diagnosis and treatment, lack of awareness about availability and accessibility of treatment, inhibition from seeking treatment due to stigma, not tested/ diagnosed by health system due to lackadaisical approach of health systems, and patients treated for TB without being notified to national TB programs.
Nearly 75% of these missing TB cases are living in 13 countries including Bangladesh, Democratic Republic of Congo, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Tanzania, and Ukraine.
In 2015, India had 23% of the global burden of active tuberculosis (TB) patients and 27% of the world’s “missing” patients, which included those who might not have received effective TB care and could potentially spread TB to others.4, 5 As per World Health Organization (WHO) estimates, India had nearly 1 million “missing” TB patients, who had not been reported to the national TB program and therefore might not have received effective TB care. As per national TB prevalence survey (2019-2021), for every 2.8 TB cases prevalent in the community, 1 case gets notified and 1.8 cases get missed.
Figure 1
Picture courtesy: Subbaraman R, Nathavitharana RR, Satyanarayana S, Pai M, Thomas BE, Chadha VK, et al. The Tuberculosis Cascade of Care in India’s Public Sector: A Systematic Review and Meta-analysis. PLoS Med (2016 13(10): e1002149.
Bridging the gap
So to bridge this gap of missing TB cases, the National Tuberculosis Elimination Programme (NTEP) under the Ministry of Health & Family Welfare, Govt of India has already implemented National Strategic Plan 2017-2025, that rests on four strategic pillars of “Detect-Treat- Prevent-Build.” These are also required for realising the vision of achieving the TB elimination, defined as mortality reduction by 90% (3 per lakh population), Incidence reduction by 80% (44 per lakh population) and zero catastrophic cost as compared to baseline rates of 2015. However, the current rate of Annual Decline in Incidence of TB in India is 2.5% while the required rate of annual decline, for achieving the elimination of TB by 2025, should be 15%. So to achieve this target, the programme has taken many steps some of which are listed as follows:
For Detection: Decentralization TB screening to AB-HWC levels, scaling up Molecular Diagnostics to the Peripheral Levels, Early Detection of DRTB by using Universal DST, Vulnerability Mapping & Active case finding, Private Sector Engagement, Introduction of Comprehensive Diagnostic Algorithm etc.
For Treatment: Introduction of Daily regimen –Fixed Dose Combination and Injection free treatment regimens, scaling up of Newer drugs/regimens, Sustaining Treatment Success Rate of > 90%, Public Health Measures (PHA) like Counselling of patients and family members, Contact investigation, Chemoprophylaxis, HIV testing, Blood sugar testing, Ni-kshay Poshan Yojana benefit etc., and adherence support especially ICT based adherence e.g. 99 DOT, MERM (Pill box), SMS Reminders etc.
For Prevention: Contact Tracing & TB Preventive Treatment, Airborne Infection Control in community & Health Facilities, Sustaining COVID appropriate behavior, enhancing Community Mobilization & making it a People’s Movement
For Building and strengthening the programme: Human Resource Development, Capacity Building, Digital Interventions, Multisectoral Collaboration, Procurement & Supply Chain Management etc.
Newer Initiatives: Pradhan Mantri TB Mukt Bharat Abhiyaan, Subnational Certification for TB Free India, Patient Provider Support Agencies (PPSA) etc.
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