New Delhi: Despite some progress, a new global report on tuberculosis has warned, India is faltering in treating patients, especially those with drug-resistant versions of the disease and under-funding its eradication efforts.

The result is that India--with 17.7% of the planet’s population and 27% of its TB patients, more than any other country--is unlikely to meet its target of eliminating tuberculosis by 2025.

There has been a 1.7% reduction in tuberculosis cases--short of the 10% required to meet the 2025 TB-elimination target--and 3% reduction in deaths in 2017 compared to the previous year, noted the Global Tuberculosis Report 2018 by the World Health Organization (WHO) released on September 18, 2018.

India’s TB cases have declined from 2.79 million in 2016 to 2.74 million in 2017, a reduction of 1.7%--a little slower than the 2% annual reduction across the world, which now has 10 million cases. TB deaths have dropped from 423,000 in 2016 to 410,000 in 2017.

There was also a reduction in rifampicin--first-line TB drug--resistant tuberculosis (RR TB) and multidrug-resistant tuberculosis (MDR-TB) from 147,000 cases to 130,000 cases in 2017, a reduction of 8%.

RR TB and MDR-TB cases are difficult and more expensive to treat with a 46% success rate. India has 24% of the world’s drug-resistant TB burden.

Further, India is still a long way from its TB elimination goal and has challenges in getting patients on treatment, treating drug-resistant TB patients and meeting funding requirements.

Elimination far ahead

The decline in TB cases and deaths, as we said, is not enough to meet the elimination target.

India had announced a plan to eliminate TB by 2025, five years before the global target of 2030.

Since 2016, India’s TB incidence dropped 1.7% annually, compared to a 4-8% decline in Southern African countries, such as Eswatini (formerly Swaziland), Lesotho, Namibia, South Africa, Zambia and Zimbabwe.

India needs a 10% annual drop in TB cases to eliminate the disease by 2025, Soumya Swaminathan, former director general of Indian Council of Medical Research and now a deputy director general at WHO, told IndiaSpend in November 2017.

“Eliminating” TB would mean less than 10 cases per 100,000 population per year. In 2017, India’s TB incidence was 204 per 100,000 population.

To achieve its goal of eliminating the TB epidemic in 10 years, by 2025, India would have to reduce new TB cases by 95% over the next decade, FactChecker reported in March 2017.

Currently no more than 65% of TB patients in India are treated, which means more than a quarter of the burden may not be adequately addressed and may even transmit the disease further, according to the report.

Better notification but still a long way to go

Globally, 32% cases were not notified--the process of reporting the disease to the government surveillance system--with India accounting for 26% of what is in officialese called the “notification gap”, the highest in the world.

Underreporting of cases, under-diagnosis--people do not go to a doctor or they do not get diagnosed when they do--and overestimation of new cases could be the reasons for the gap between estimating and reported cases, said the report.

India improved the reporting of TB cases by engaging with private doctors, simplifying the national electronic notification system--Nikshay--and mandatory notification, said the report.

In 2015, the estimates of TB cases in India increased from 2.2 million in 2014 to 2.8 million due to cases notified from private sector. There was also a doubling of deaths reported, from 220,000 in 2014 to 480,000 the same year.

About 384,000 cases were notified from the private sector in 2016, according to India TB report 2018, while the private sector treated about 2.2 million cases a year, according to a 2016 study published in the Lancet, based on data from the sale of drugs containing rifampicin.

“India has a GeneXpert [Rapid TB diagnosis device] in every district but it still needs to scale up its usage because it significantly improves detection of primary [pulmonary] TB and even drug-resistant TB cases,” said Stobdan Kahlon, medical coordinator at Médecins Sans Frontières, India.

India still widely uses sputum microscopy to detect TB, a process where a sputum sample is examined under the microscope to look for TB bacteria. It is inexpensive and easy to conduct but not the most accurate test available for the disease because it is less effective in detecting cases of extrapulmonary TB--that affects organs other than lungs--and of TB in children and HIV positive patients.

India is not implemented six of 16 key WHO recommendations on TB care, IndiaSpend reported in July 2017.

Drug-resistant TB treatment falters

India has estimated 135,000 cases of RR/MDR-TB cases but has only put 26,966 patients on second-line drugs; this means it has missed diagnosing and treating 80% of such cases.

While the global success rate of drug-resistant TB treatment was 55%, India had a success rate of 46%, according to the report. There are many other countries with a high TB burden but high success rates--Bangladesh, Ethiopia, Kazakhstan, Myanmar, Vietnam had treatment success rates of over 70%.

“Closing gaps in treatment and detection requires much higher coverage of drug susceptibility testing among people diagnosed with TB, reducing underdiagnosis of TB, models of care that make it easier to access and continue treatment and new diagnostics and new medicines and treatment regimens with higher efficacy and better treatment outcomes,” said the report.

“We have known for some time now that there is gap in MDR-TB diagnosis and treatment,” said Chapal Mehra, convenor of Survivors Against Tuberculosis, a TB patients network. “If we want to contain our MDR-TB numbers, we need to diagnose cases early and treat them right in the first instance. We need drug-susceptibility test-guided treatment but also need access to new and more effective regimens. This needs to happen faster than it is happening right now.”

Bedaquiline, a new drug for drug-resistant TB, that has received recommendation by the WHO, is currently available to Indian patients under conditional access programme, and should be made available more widely because it is safer and has better mortality results, IndiaSpend reported in August 2018.

Finding TB in HIV positive patients

HIV increases the risk of TB and morbidity and mortality. HIV-positive patients with latent TB are 26 times more likely to get active TB. In 2017, 11,000 HIV-positive patients in India died due to TB.

However, it is not easy to detect TB in HIV patients: In 50% of cases, HIV-TB patients are smear negative--their sputum samples do not show signs of TB bacteria.

In 2017, India’s national TB body, the Revised National Tuberculosis Control Programme, and the National AIDS Control Organisation captured data on the number of HIV patients visiting the government’s anti-retroviral centres being tested for TB and found 59% of patients did not get TB care.

The reasons for missing care included poor access to services, weaknesses in service delivery, gaps in recording and reporting and poor engagement with the private sector.

The government has rolled out TB delivery system in all HIV clinics in December 2016; 6% of HIV patients were found to have TB symptoms, of which 14% were diagnosed with TB.

India’s TB funding needs to increase 1.4 times

The BRICS nations--Brazil, Russia, India, China and South Africa--accounted for 54% of global TB funding, with 94% from domestic funds.

Between 2016 and 2018, domestic funding for India’s national TB quadrupled, from $110 million (Rs 79 crore) in 2016 to $458 million (Rs 3,320 crore) in 2018, the report said, accounting for 79% of India’s national TB budget.

India has set aside $580 million (Rs 4,400 crore) for TB care in 2018 but will need $1,386 million (Rs 10,080 crore), said the report, which puts the shortfall at about 60%.

(Yadavar is a principal correspondent with IndiaSpend.)

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