The government wants to eliminate TB, but the data is out of sync with the promise. Blame it on Covid
It was all about Covid-19 for the past two years. All other diseases have taken a back seat, including tuberculosis – the disease that Prime Minister Narendra Modi envisioned eliminating from the country five years ahead of the target.
Thanks to Covid-19, the data – at least for now – is not in line with the Prime Minister’s promise.
To put things into perspective, let’s start with the harsh reality.
According to the 2021 World Tuberculosis Report, India is among 10 countries that collectively account for 74% of the global gap between estimated TB incidence and the number of people newly diagnosed and reported.
The first contributor was India with 24%.
India is also on the three World Health Organization (WHO) global lists of countries with high prevalence of TB, HIV-associated TB and multidrug-resistant or rifampicin-resistant TB which will be used by WHO for the period 2021-2025.
Before the outbreak of the pandemic, India was on track to close the gap between the number of estimated and detected TB cases, and it may soon regain all of its “missing millions” of TB patients.
In 2019, TB case detection in India reached its highest level with 23.5 lakh of patients compared to about 26.9 lakh of cases.
However, progress was derailed from 2020.
Launching of Ashwasan campaign for active search for TB cases among the tribal population of DNH by Dr. Raghuram Rao (ADG-TB CTD), Mr. Suresh Meena (JS Health & MD NHM-DNH & DD) in the presence of Dr. Manoj Singh- SPO (TB & Leprosy) from PHC Kachigham, Daman today. #TBMuktBharat pic.twitter.com/z1vYXpncH4
— Central Tuberculosis Division | #TBMuktBharat (@TbDivision) July 8, 2022
Today, less than three years away from that deadline – 2025, five years before the target set by the 2030 Sustainable Development Goals (SDGs) – there are important lines of inquiry that must be pursued to follow how well positioned India is. TB program is to achieve this goal.
Even the Union Government’s Department of Health and Family Welfare is aware of the delay created by the outbreak of the pandemic and a lot of energy has been refocused towards achieving the goal.
“Covid has been very detrimental to our progress in the fight against tuberculosis. So many late diagnoses and missed notifications were found. A lot of work is pending and several resources have been diverted after discussions with the Minister of Health,” a government source said, adding that the Minister of Health has given strict instructions to “do whatever it takes. to achieve the target set by Prime Minister Modi.
Experts believe that a useful way to get to the heart of the TB discourse is to assess case notification data from high-burden states and compare it with the prevalence survey (the data that gives a better idea of the omnipresence of the disease in the country).
Analyzing the data in this way could give us a clearer picture of which states are performing below par and which are doing well.
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For example, the prevalence survey notes that India’s prevalence to notification ratio at the national level is 2.85, which means that India is missing 1.85 patients for every 1 notified case.
However, there are some states where India is missing more patients. This number is higher, for example, in Bihar, which has a ratio of 4.94 – where for every case reported, almost four cases are not detected/reported.
This is a crucial metric because it indicates how many cases exist or prevail compared to the cases that were ultimately notified to the system. Without finding and treating these missing patients, India’s goal of eliminating TB will remain a distant dream.
Table 1 shows the prevalence/notification ratio. Higher PN numbers in the third column indicate that more cases were missed.
CLOSING THE GAP IN PLANS AT WORK
The government has launched ‘Nikshay Poshan Yojana’ – a program to support the nutritional needs of TB patients on the assumption that good nutrition can support the progress of the treatment given.
Here, the patient receives Rs 500 per month.
How has India’s flagship nutrition support program performed?
Although an argument is that 500 rupees per month is not enough to meet anyone’s nutritional needs, even this mere amount is not disbursed.
The figures show the poor performance of the system at ground level.
For example: Uttar Pradesh has over 4 lakh patients notified for the scheme, but over 40% have still not received a single financial benefit, and their payment is still pending.
Unfortunately, most states are well below the national average when it comes to paying a mere Rs 500 at least once.
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In Delhi, only 30% of beneficiaries (patients) received the money, even though they only received it for one month. The remaining 70% of patients have never had it once.
Table number 2 indicates the percentage of recipients who received at least one NPY benefit band out of the total number of notified patients.
FORGOTTEN RULES FOR BASIC TESTS
A test to check a person’s biological resistance to rifampin, a primary drug for tuberculosis, is an invaluable indicator of whether there is resistance to first-line drugs in the patient.
The universal drug susceptibility test (UDST) is an essential element in the early stages of the TB care cascade.
Only after the physician has ruled out such drug resistance, the patient can be put on conventional drug therapy and treatment can continue as normal until the point of recovery.
However, any resistance to Rifampicin (due to late diagnosis, incorrect previous prescriptions, non-completion of previous treatment, etc.) requires modulating the treatment. If this is not done, the disease could progress to multi-drug resistant forms which are fatal.
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The National Tuberculosis Program rolled out the UDST in 2018, whereby rifampicin resistance testing is mandatory for all notified TB patients.
Unfortunately, here too, the number of people – in the private and public sectors – who have received the UDST is not as high as it should be!
Together, the other data show the high prevalence of people diagnosed with MDR-TB.
For example: In Rajasthan, only 38% of patients in public and private hospitals were tested for rifampicin resistance. Similarly, in Madhya Pradesh, 34% of patients were tested for Rifampicin resistance.
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The trend was the same in Chattisgarh, Delhi, Bihar, UP and several other states.
In fact, one of the most disturbing data from the national TB prevalence survey shows that 64% of symptomatic TB patients did not even seek treatment. This shows how deep-rooted India’s problem of TB management is, where both the government and the private sector need to ensure that all programs and initiatives are on track.
Despite the government’s intention to eradicate tuberculosis in India, it seems that “Dilli abhi door hai…”
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