‘Smoking, alcoholism biggest TB risks in India’

Undernutrition, alcohol abuse and smoking are the biggest risk factors for tuberculosis (TB) in India, where the infection sickened an estimated 2.69 million people and killed 449,000 in 2018, according to World Health Organisation Global TB Report 2019 released this week.

While the poor with little or no access to treatment are at highest risk of disease and death, the airborne infection – it spreads through droplets from coughing — is common in urban centres where people are in close contact with each other in workplaces, public transport and living spaces.

On the upside, more people were tested and put on treatment in India in 2018 than ever before, which lead to TB cases in the country declining from 2.74 million in 2017, and incidence rate falling to 199 from 204 per 100,000 population in 2017.

Tracking of drug resistant cases also improved. TB patients tested for rifampicin resistance (RR) increased from 32% in 2017 to 46% in 2018, with the treatment success rate going up from 69% to 81% for new and relapsed drug-sensitive cases within a year in 2017, the last year for which data is available.

But India is nowhere close to meeting its target of eliminating TB by reducing incidence from the current 199 to less than 10 cases per 100,000 population by 2025, which is five years ahead of the global elimination target.

“The notification of TB cases in India has gone up from 1.9 million in 2017 to close to 2.2 million in 2018. While treatment success has improved, the high number of 46,000 RR/ multidrug resistant (MDR) TB cases in the country, up from 36,000 in the previous year, remain a concern,” said Dr Poonam Khetrapal Singh, WHO Regional Director for South-east Asia.

TB is caused by Mycobacterium tuberculosis and spreads through air through droplets from persistent coughing, which is among the symptoms that include fatigue, weight loss, shortness of breath, night sweats and chest pain.

The disease is treated free under the Revised National Tuberculosis Control Programme, which is the world’s largest and fastest expanding TB control programme, but the disease is continuing to devastate lives because of the government’s inability to regulate an exploitive private health sector that is continuing to prescribe incomplete and wrong medications, and to ensure continual supply of live-saving medicines at all times.

Gaps in medication and not completing the treatment cause drug resistant TB, which is longer, toxic and more expensive to treat.

India has increased outlay for TB control to improve results. “India’s domestic TB funding has quadrupled between 2016 and 2019, which will show results with improved outreach of services using new diagnostics and drugs, decentralised peoplecentred and community-led initiatives, intensified case finding, and increase coverage of preventive treatment for those at risk of developing TB,” said Dr Khetrapal Singh.

TB sickened about 10 million people worldwide and killed 1.5 million in 2018, a 6% decline from the 1.6 million deaths 2017, according to the Global TB Report 2019. “India has the highest TB burden in the world, with one in four of all global cases reported in the country. The number of people with TB in India is falling, but progress is still too slow to meet the targets. And if we don’t end TB in India we can’t hope to end TB globally,” said Dr Paula I Fujiwara, scientific director of the International Union Against Tuberculosis and Lung Disease (The Union).

Eight countries accounted for 66% of the new cases: India, China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa.

Every TB high-burden country except Indonesia remains behind the pace needed to meet the global elimination target by 2030, according to the WHO report.

TB is preventable, treatable and curable, with prevention being the most effective way to stop disease. “For a realistic chance of eliminating TB, we need to begin preventing the disease wherever we are treating it,” said Fujiwara.

The WHO TB- elimination strategy involves screening for active and latent TB infections in high-risk groups such as among family and other close contacts of patients, funding high-quality health services, and investing in new drugs, vaccines and diagnostic tests to ensure TB is diagnosed and treated at the onset, which lowers the chances of it turning resistant to drugs.

The areas of concern are slow decline of 2-3% in incidence because of missing cases, increasing gap between detected RR/MDR-TB patients specifically for India and Indonesia, and preventive treatment coverage remaining low ranging from 8.5% to 43% in children and 10% to 17% in people living with HIV.

“The way forward is strengthening case finding through private sector and community engagement, enhance preventive treatment coverage, rapid expansion of universal drug-susceptibility testing and commensurate increase in treatment facilities to reduce initial loss of patients, and bringing social protection and patient-support mechanisms to all TB patients will lead to a decline in cases, loss of health and income from illness,” said Dr Khetrapal Singh.