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Indian government outlines plan to try to eliminate tuberculosis by 2020

BMJ 2014; 349 doi: https://doi.org/10.1136/bmj.g6604 (Published 03 November 2014) Cite this as: BMJ 2014;349:g6604

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Tuberculosis, an ancient disease, has become one of the most pressing problems of our times. Tuberculosis is a highly contagious, air-borne disease caused by Mycobacterium tuberculi which mostly affects the lungs but can affect other organs as well.

Since its declaration as global emergency by World Health Organization almost 21 years ago, not much has changed despite the burgeoning progress in medical science (1). Tuberculosis is the second leading cause of deaths in the world (2). According to the world tuberculosis report 2014, it is estimated that 9 million cases of TB were registered and 1.5 million lives were lost due to TB (2). Among the 9 million TB cases reported, co-infection with HIV was observed in more than a million cases causing a double whammy (2). As TB is both a preventable and curable disease, even a life lost due to TB is a life too many.

Tuberculosis, the much dreaded disease, remains a major public health challenge across the world which causes enormous socio-economic losses in terms of funds for surveys, diagnosis, research, quality-adjusted life-years (QALYs) or disability-adjusted life-years (DALYs) and cost of prevention and treatment. Tuberculosis ranks seventh in the global disability adjusted life years (DALYS) lost. The problem is further compounded by emergence of multidrug resistant (MDR), extensive drug resistant (XDR), and total drug resistant (TDR) strains. Co-infection with human immunodeficiency virus (HIV), a cause of concern for researchers as well as public health workers and administrators, is also wreaking havoc particularly in low-income countries. Often, the lack of political will, stability and financial constraints mar the public health programmes. Despite sincere efforts from various agencies and public –private partnerships, there is still a huge gap in funds required and received to combat tuberculosis. Although huge strides in genomics, proteomics, high throughput genomic screening have led to considerable progress, there is a huge need to stock up our armamentarium with novel drugs for combating tuberculosis(3). Success of global TB control partly depends on its success in India and China as these two countries constitute more than half of global Tuberculosis burden.

Tuberculosis is one of the leading causes of mortality in India. TB costs more than thousand lives every day in India. India is the highest TB burdened country accounting to 24% of total tuberculosis cases in the world (2). India also ranks second in occurrence of multi-drug resistant (MDR)-TB cases. India bears an annual economic loss of $ 23.7 billion due to tuberculosis (4). This grim situation calls for the need of scaling up our efforts in fight against tuberculosis by adopting new methods for developing effective vaccine and drugs.

Revised National Tuberculosis Control Program (RNTCP) was introduced in India in 1997 to reduce and control the menace of tuberculosis. To control MDR-TB, RNTCP is employing directly observed treatment, short-course (DOTS) facility as plan of action for past 7 years where a patient takes dose of medication under direct observation. Though the TB cases are declining slowly and steadily, India is still far away from achieving Millennium Development Goal 6 by next year deadline.

In this regard, the time for announcement of “TB Mission 2020” by Union Health Minister is apt. The resolution of providing free diagnosis and treatment to all patients irrespective of public or private setting will ensure coverage of those who cannot afford the treatment and are often missed. As tuberculosis is viciously linked with poverty and malnutrition, the step of providing nutritional support will result in better treatment outcomes by strengthening the weakened immune system(5). This will also ensure adherence to treatment plan and thus, may serve a key factor in preventing the progression of latent infection into the active case. It is imperative to redress socio-economic determinants of the disease to control TB. Being an air-borne disease, chances of TB transmission are high in over-crowded, badly ventilated places. This warrants the need of targeting the slum areas with impoverished population for providing free diagnosis, access to treatment and care and support. A number of factors like work schedule, timings, lack of awareness and undesirable side effects can dissuade the patient to visit DOTS centers. The target ““Reaching the unreached” of National Strategic Plan(NSP2012-2017) under RNTCP be met only if we adopt out of box thinking and innovative solutions that can bridge the gap between public health workers, administrators and patients. In this regard, digitalization of the whole process of surveillance and monitoring will help in keeping track of the cases and reviewing the progress. One such effort in this direction is NIKSHAY, a web based solution by National Informatics Centre, for monitoring of TB patients which not only keep records but also alerts patients through SMS services on daily basis(6). Another worth-mentioning effort, Operation ASHA, launched in 2005 by an NGO, introduced an e-compliance system based on biometric monitoring that records the fingerprint of the patient at time of receiving dose, thus eliminating chance of error or false data(7). Such models can be replicated and adopted at large scale for monitoring TB cases effectively.

We need to focus on more than just connecting the “DOTS” to have a tuberculosis free world.

REFERENCE:
1. WHO. TB–a global emergency. WHO Press Release: WHO/31. Geneva: World Health Organization, 1993
2. WHO Global Tuberculosis Report 2014(http://www.who.int/tb/publications/factsheet_global.pdf )Accessed on 20.11.2014)
3. Arora N, Banerjee AK. Targeting tuberculosis: A glimpse of promising drug targets. Mini Rev Med Chem. 2012 Mar; 12(3):187-201.
4. Engaging workplaces in TB care and control. (http://www.who.int/tb/careproviders/ppm/EngagingworkplacesYesudian.pdf) Accessed on 20.11.2014
5. Krishna Bihari Gupta, Rajesh Gupta, Atulya Atreja, Manish Verma, and Suman Vishvkarma. Tuberculosis and nutrition. Lung India. 2009; 26(1): 9–16.
6. Revised National tuberculosis Control Programme ( http://nikshay.gov.in/User/Login.aspx) Accessed on 20.11.2014
7. http://www.opasha.org/wp-content/uploads/2012/04/OpASHA_eCompliance-Pres... Accessed on 20.11.2014

Competing interests: No competing interests

21 November 2014
Neelima Arora
Researcher
Amit Kumar Banerjee, Mangamoori Lakshmi Narasu
JawaharLal Nehru technological University