India Improves in Tuberculosis Detection but Misses Major Death, Incidence Milestones
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India Improves in Tuberculosis Detection but Misses Major Death, Incidence Milestones

While India improved case detection for TB and was able to cover the losses made during the pandemic in this regard, it missed major milestones. India, incidentally, accounts for the highest TB burden across the world contributing 27% of all the TB cases followed by Indonesia (10%) and China (7.1%). The current report of 2023 gives figures on various indicators of TB for 2022.

For any country’s TB elimination programme, a major challenge is not to miss the cases and see to it that the majority of cases are registered or ‘notified’. A patient getting missed is not only harmful for the individual concerned but also her contacts as she might transmit the TB infection to them. So the governments across the world try to increase notification of new cases every year and close the gap between estimated TB incidence and vis-a-vis the number of cases actually newly notified.

According to the WHO report, India, Indonesia and the Philippines, which collectively accounted for a large share of the global reductions in the notification of newly diagnosed cases in 2020 and 2021 (the two pandemic years) – all of them recovered to above 2019 levels (pre-pandemic stage) in the year 2022. 

These three countries themselves had reported losses in notification in the two pandemic years to the tune of 60%

press release issued by the Union health ministry on the evening of  November 8 also pointed out the ‘achievement’ and said, ” [India] reversed the impact of COVID-19 on the TB programme.” 

As many as 13 countries, including India, according to the WHO report, which reported major case detection reductions in 2020 and 2021 rebounded to 2019 levels. However, the report also put a caveat to this achievement and its understanding. 

It highlighted that some of the ‘rebound’ in the case detection numbers and reported as a ‘new case’ in 2022 could probably be ‘a sizeable backlog of people who developed TB in previous years [of 2020 and 2021].’

In other words, the improved case detection levels for 2022 might not be the new cases found in 2022 per se, but some of them which fell through the cracks in 2020 and 2021. The backlog could be a result of shutdown of all essential services, including TB services, in the two pandemic years, and therefore, their diagnosis got delayed.

As far as year 2022 was concerned, the WHO reported, 10 countries continue to account for more than 70% of the cases missed. India was the top contributor to this share as it accounted for 18% of such cases. It was followed by Indonesia, Philippines, Nigeria and Pakistan. 

“From a global perspective, efforts to increase levels of case detection are of particular importance in these countries,” the report noted, highlighting the significance of improved diagnostic tools.

Major milestones missed

The Union health ministry’s release highlighted India’s success in reducing the TB incidence. “[The] efforts have resulted in reduction of TB incidence by 16% in 2022 (from 2015) almost double the pace at which global TB incidence is declining (which is 8.7%),” it said. 

However, it did not say India, though just like many other countries, was far off target to achieve the targeted goal and the success was far from insufficient.

Incidentally, the WHO, 2018, had come up with some interim TB targets to be achieved so as to eliminate the world’s top killer by 2030. The interim targets are known as first ‘End TB Strategy’ milestones.

One of such targets was the cumulative reduction in the TB incidence rate in 2025 by about half as compared to the 2015 levels. 

The press release said India could reduce the TB-related deaths by 18% in 2022 as compared to 2015 levels – almost at par with global reduction levels of 19%. However, this ‘achievement’, too, is far off the mark. 

The WHO’s target was to reduce TB-related deaths from 2015 to 2025 by 75%. Going by the current pace, most of the countries, including India, will most likely miss this goal as well.

Other challenges galore

Drug-resistant TB continues to be a major concern for the world. 

Resistance to rifampicin – the most effective first line drug against TB – is of greatest concern, according to the WHO. The form of TB that is resistant to rifampicin and isoniazid is defined as multidrug-resistant TB (MDR-TB). Both MDR-TB and rifampicin-resistant TB (RR-TB) require treatment with second-line drugs, which is not only very expensive, prolonged but also leads to various other direct and indirect consequences.

Usually, a patient may become resistant to the first line of drugs during the course of TB treatment due to missing drug doses either due to stock-out of drugs or improper adherence to the  medicine schedule. Some of the newly-diagnosed TB cases could also be that of DR-TB, as a resistant form of infection got transmitted from an infected DR-TB patient to an otherwise healthy person. 

Three countries accounted for 42% of the estimated global number of people who developed MDR or RR-TB in 2022: India (27%), Philippines (7.5%) and Russia (7.5%).

The WHO in 2021 issued updated guidelines for diagnostics. It recommended that rapid molecular tests should replace the tradition sputum microscopy tests as the former have high diagnostic accuracy and help in early detection of TB or to understand if the patient is resistant to a drug.

Now, the current TB report reveals that, in India, less than 20% of all the notified cases were detected through the WHO-recommended molecular kits against the least target of 80%. Globally, 55 countries have achieved this target. 

Expenditure on health, which is incurred out-of-pocket by patients’ households on their own, is a major deterrent in fights against all illnesses, including TB. If more than 10% of the annual household income is spent on treatment of any kind of illness, the WHO defines it as “catastrophic health expenditure”. 

In India, according to the report, more than 20% of the 140 crore population in 2022 had to incur catastrophic expenditure on health, according to the report.

For TB, if the money spent on direct medical expenditures, non-medical expenditures and indirect costs such as income losses that amount to more than 20% of total household income, it is termed ‘catastrophic’.  Globally, about 50% of all TB patients had to face this dire situation

While for India, the proportion of TB patients spending catastrophically on TB is not known, the WHO report highlighted that the percentage of TB patients facing such a situation is expected to be much higher than the percentage of the general population facing catastrophic expenditures on healthcare, for all the countries.

The current TB report also said India was able to reach the treatment coverage of 80% of all the estimated cases in 2022 – thus ensuring a large chunk of patients availed the medicine. 

The WHO, in its current report also did a downward revision of TB mortality figures for India which was published in last year’s global TB report. Government’s press release alluded to the “newer evidence” that the Indian government shared with the WHO after the publication of its report. The WHO specified that it revised the figures owing to  the new cause-of-death data that emanated from the country’s sample registration system. 

Source : Wire