World TB Day: Equitable access to treatments, adherence and timely diagnosis still a challenge in India

World Tuberculosis Day 2023: It is noteworthy that due to the COVID-19 pandemic in 2021, TB services and the response were severely affected especially in countries like India.

World TB Day | World Tuberculosis Day 2023 |
World TB Day 2023: Fluorography, x-ray and different pills in blisters on white background. (Image Credits: Pixabay)

World Tuberculosis Day 2023: Tuberculosis is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs. Every year, March 24 is marked as World TB Day to raise awareness about the disease and its impact on people across the world.

The United Nations Sustainable Development Goals (SDGs) include ending the TB epidemic by 2030. The World Health Organisation’s ‘end TB strategy’ aims to reduce the global incidence of TB to the levels achieved by high-income countries by 2030.

On the occasion of World TB day, Prime Minister Narendra Modi embarked on his Varanasi visit by addressing the One World TB Summit at Rudrakash Convention Centre. During his address, Modi emphasised the threat of Tuberculosis to humanity and how India is on its path to winning the battle against the disease. Moreover, the summit is joined by international delegates from across 30 countries.

“In the last 9 years, India has worked together on many fronts in this fight against TB. India has done a great job in the fight against TB through people’s participation,” he said during the event.

Status of TB in India

According to the 2022 report on Tuberculosis by the World Health Organisation (WHO), In 2020, 87% of new TB cases occurred in the 30 high TB burden countries. 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.

It is noteworthy that due to the COVID-19 pandemic in 2021, TB services and the response were severely affected especially in countries like India. According to WHO, India along with Indonesia, Myanmar and the Philippines accounted for most of the estimated increase in TB deaths globally.

In 2021, the country reported 2,950,000 TB cases, 54,000 HIV-positive TB incidence, and 494,000 deaths.

“Tuberculosis (TB) is a major public health problem in India, having the world’s highest burden both in terms of the number of cases and deaths. India accounts for 28% of all TB cases worldwide. It’s urgent that we focus on strengthening our health systems and investing in TB prevention. India has set an ambitious goal to eliminate TB by 2025 and the government has made significant efforts to eradicate TB. However, the momentum was lost due to COVID-19 pandemic. Now, we must focus on prioritizing the health system and investing in TB prevention, detection, and treatment,” LM Singh, Managing Director-India, Vital Strategies told Financial

According to Singh, the burden of death and disease from tobacco consumption and TB present a significant public health problem in India.

“Together they are responsible for extraordinary loss of life, poor health, and dire economic burden.  To eliminate TB, we must control tobacco use. Efforts to eliminate TB require collaboration between public and private stakeholders, as well as political will, funding, and investment in research and development of new TB drugs and vaccines. To support India’s strategy to END TB, Vital Strategies has released public education resources, which can help researchers to develop effective TB campaigns,” Singh told Financial

‘Rise in TB cases among children’

According to Dr Kuldeep Grover, Head of Critical Care & Pulmonology at the CK Birla Hospital (R), Gurugram. Dr. Grover also told Financial that unlike viral infections, TB cases do not appear on a daily basis because its early symptoms include more coughing, which is frequently ignored by people.

“We are seeing a rise in TB cases in children at CK Birla Hospital, which is three cases in a week. Unlike viral infections, TB cases do not appear on a daily basis because its early symptoms include more coughing, which is frequently ignored by people. The pulmonary and extrapulmonary TB cases have increased to about 20.25 percent post-COVID. This has been seen most frequently in children who are malnourished, weak, and take longer to thrive in general after recovering from viral infections, particularly COVID-19,” Dr. Grover told Financial

Dr. Grover also said that they have had patients or children admitted to the pediatric ICU for extended stays who required steroids to recover.

“Hospitalization is mostly recommended for children who have developed secondary infections as a result of pulmonary tuberculosis worsening, decreased cell-mediated immunity, or increased exposure to TB bacteria from an infected person,” he added.

Dr. Grover also pointed out that the secondary infection of TB leads to TB in the brain and bones, which could be very harmful and must require hospitalisation.

“The children who get admitted are largely the ones who have had COVID and are still recovering from it. Currently, more cases are coming to OPDs with symptoms of excessive coughing, and they have been addressed and treated, preventing hospitalization. We have been prescribing standard 5-point TB medicines to children aged 7 to 12 years for treatment. Apart from this, it is advised for the parents to provide adequate nutrition to their child, as it adds to the paramount value of children, and to get their new-born child vaccinated with the BCG (Bacillus Calmette–Guérin) vaccine,” Dr. Grover told Financial

He also emphasised that parents should not ignore symptoms in their children and should keep a close eye on them; for example, if they have had symptoms such as cough for more than two weeks, sudden fever that usually rises in the evening, lack of appetite, weight loss, and symptoms that do not improve with antibiotics, they should immediately consult a doctor.

Poor lifestyle choices affecting immunity 

The prevalence and existence of TB have been the same for many years, and they remain unchanged. It is a chronic disease that has a prevalence rate of around 4 per 1,000 of the population, and the incidence of fresh cases is somewhere around 1 per 1,000 of the population.

“This figure remains the same throughout the year. We are getting at least 10-15 patients a week (1-2 cases per day) at the hospital. Due to the ongoing H3N2 and COVID virus, these numbers are expected to increase in the upcoming days. In my 40 years of experience,  the absolute number of tuberculosis cases has increased due to rising population and overcrowding. There have been many variations in the cases, and the numbers are increasing gradually. The reason for these increasing numbers includes more people are suffering from comorbidities like heart or kidney disease or diabetes, and many are undergoing transplants. The immunity of the population is also getting low due to the adoption of poor lifestyle choices,” Dr Ashok K.Rajput, Consultant – Pulmonology & Sleep Medicine, CK Birla Hospital, Delhi told Financial

According to Dr. Rajput, poor diet, obesity, and lack of physical activity are also responsible for low immunity. Overpopulation is also another factor that is responsible for the rise in numbers, especially in cities like Delhi as it makes transmission of the virus very easy, he said.

“TB can be controlled if the standard of living is improved. Developed countries have worked on improving their living standards, which explains why they are able to control TB cases better. In terms of a good lifestyle, one should focus on better food options to get enough nutrients that will help build immunity. At the same time, cities must have planned infrastructure to ensure there is no overcrowding, and unhygienic practices like spitting or smoking,” he added.

What is the way ahead?

According to Dr. Bornali Dutta, Director – Pulmonary Medicine, Respiratory and Sleep Medicine, Medanta, Gurugram, active case finding is critical to achieving TB elimination, as it identifies and treats more patients, leading to a reduction in TB incidence and eventually helping people become TB-free.

“We hope to continue making progress towards our goal of eliminating TB in India by 2025. Urban areas, particularly homeless clusters near Yamuna Pushta in New Delhi, are TB hotspots due to a high incidence of drug abuse, alcohol, tobacco use, and other illnesses. All urban clusters are considered hotspots as they spread the infection. While active case finding initially increases TB incidence, it eventually leads to a reduction in the number of TB cases. This has been observed in our program, where the curve flattened and reduced over 2-3 years, leading to a decrease in TB incidence. We believe that with our approach, we can help more people become TB-free and contribute to achieving TB elimination in India,” Dr. Dutta told Financial

According to the WHO’s World Tuberculosis Report (2022), India has performed far better on major matrices than other countries. To tackle this challenge, the Pradhan Mantri TB Mukt Bharat Abhiyan, with the slogan TB harega, desh jeetega, has been launched. To ensure community participation and ownership, the ‘Ni-kshay Mitra’ donor scheme has also been introduced.

According to reports, two vaccines that offer new hope are currently undergoing clinical trials. Health experts also emphasise that the scope of Ni-kshay Mitra needs to be expanded to enhance its impact.

The government is also working towards addressing the issue of drug-resistant tuberculosis that remains a major problem in India. Drug-Resistant TB Centres have been set up in major cities to provide specialized care to patients with drug-resistant TB. Moreover, it has also introduced new drugs and regimens for treating drug-resistant TB, which are more effective and have fewer side effects.

On March 23, the Indian Patent Office rejected the application of American pharma giant Johnson & Johnson to extend its monopoly on a key TB drug – bedaquiline, which is set to expire in July. The drug is considered a key medication against multi-drug resistant TB. This development will help Indian pharmaceutical companies in launching generic versions of the drug and ultimately bringing down the cost of the drug. Reportedly, several generic drug makers are set to start making copy-cat versions of the drug which was set to lose patent in July.

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First published on: 24-03-2023 at 13:56 IST