Sound the alarm: India is failing the 'End-TB' strategy on all counts

The World Health Organisation considers India as the most vulnerable country to tuberculosis, according to its Global Tuberculosis Report 2016 released on October 12.

The report has revised estimates of new tuberculosis cases in India to 2.8 million in 2015 compared with 2.2 million in 2014. The severity of the challenge is also seen in the staggering number of deaths – 4,80,000 – from this disease in the country last year, which is about a quarter of the 1.8 million TB deaths globally.

The new report is a wake-up call for India to break the status quo on how tuberculosis and its drug-resistant forms are being diagnosed and treated.

India is also among six countries including Indonesia, China, Nigeria, Pakistan and South Africa that account for 60% of new TB cases. Most worrying is the low rate of decline in TB incidence, which has remained static at 1.5% between 2014 and 2015. This low decline rate needs to be scaled up to the level of 4% to 5% annually by 2020 if India is to reach the first milestones of the “End TB” strategy, which aims to end the global TB epidemic.

The new report strongly highlights the lacunae in testing for TB and reporting new cases. Only 6.1 million of the estimated 10.4 million new cases every year have been detected and officially notified, leaving a huge gap of 4.3 million undetected cases. This problem is due to under-reporting of TB cases, particularly in countries like India, where high numbers of unregulated private healthcare providers do not report TB cases. Moreover, there are many instances of under-diagnosis simply because of inaccessible healthcare.

Drug-resistant TB

About 4,80,000 people in the world had multi-drug resistant TB in 2015, of which India, China and Russia accounted for more than 50%. Unfortunately, only one out of five people have got access to second line treatment (which is used to treat the disease that is resistant to first line therapy), and overall global cure rates for multi-drug resistant TB continue to remain low at about 52%.

Ten countries account for 77% of the total estimated gaps between incidence and notifications. India, Indonesia and Nigeria alone account for more than 60% of the gaps between enrolment for multi-drug resistant TB treatment in 2015 and the estimated number of incident multi-drug resistant or rifampin-resistant TB cases in 2015. Rifampin is the most commonly used drug to treat TB.

Globally, 7,234 patients with extreme drug-resistant TB were enrolled for treatment – that is more than twice the number in 2014. Most of these cases in 2015 were notified in India, Ukraine, Russia and South Africa.

The treatment success rate of multi-drug resistant TB cases was less than 50% in countries with the largest number of patients – India, Philippines, Russian Federation, South Africa and Ukraine. This can be attributed mainly due to a large number of deaths in India, South Africa and Ukraine, high treatment failures in Russia and Ukraine, and high rates of loss to follow-up or missing data in India, the Philippines and South Africa. Among six countries that had more than 100 extreme drug resistant patients, mortality was highest (40%) in India and South Africa.

Given that the TB problem does not seem to be going away any time soon, the World Health Organisation seems keen to change its advocacy strategy too. The report notes that ministers of health in tuberculosis-ridden countries may not be the right officials to approach. Instead, efforts should be directed to approach finance ministers and heads of state – in India’s case, the Prime Minister.

The report comes as a severe warning for India to tackle this TB epidemic. India has to show a strong political commitment to check this disease and allocate more funding towards efforts to stem the deaths of thousands of poor, undiagnosed and untreated victims.

Sachi Satapathy works with the International Union Against Tuberculosis and Lung Disease. The views expressed here are personal.