India among high-burden TB nations to register 25-30 pc drops in case notifications: WHO report

Disruptions in services caused by the Covid-19 pandemic have led to further setbacks and according to a new report, there has been a 25 to 30 per cent drop in tuberculosis (TB) case notifications across three high-burden countries – India, Indonesia and the Philippines – between January and June 2020 compared to the same period a year before.

 

The Global TB report, released on Wednesday by the World Health Organisation, has collated data from over 200 countries that has shown significant reductions in TB case notifications. These reductions in case notifications could lead to a dramatic increase in additional TB deaths, according to WHO modelling. Their analysis of the pandemic’s impact on TB mortality indicates that a 50 per cent drop in the detection of TB cases over three months will lead to almost 4,00,000 more people dying from TB.

“The Covid-19 pandemic threatens to reverse recent progress in reducing the global burden of TB disease, if health services are disrupted to the extent that the number of people with TB who are detected and treated falls by 25–50 per cent over a period of three months,” Dr Tereza Kasaeva, director, WHO Global TB Programme, said at a virtual media conference.

In India, the weekly and monthly number of TB case notifications fell by more than 50 per cent between the end of March and late April, following the imposition of a national lockdown. Subsequently, there has been some recovery, but as of the end of June, not to pre-March levels. Compared with the first six months of 2019, monthly notifications in the first six months of 2020 were approximately 25–30 per cent lower in India, Indonesia and the Philippines.

Notifications of new people diagnosed with TB and relapse cases in the country increased from 1.2 million in 2013 to 2.2 million in 2019. This followed the introduction of a national policy of mandatory notification in 2012, and the roll out (also since 2012) of a nationwide web- and case-based reporting system (called ‘Nikshay’), which facilitates reporting of detected cases by care providers in the public and private sectors.

According to the data from the Central TB division, Union Ministry of Health and Family Welfare, as against 12.50 lakh TB cases that were notified to the National TB Elimination Programme from January till June 2019, a total of 9.15 lakh TB cases were notified with officials in the same period this year.

Prof Madhukar Pai, Canada Research chair in epidemiology and global health and Director of McGill International TB Centre, said the Global TB report 2020 confirms what we know that TB services have been seriously disrupted in India. “It is worrisome that the disruptions extend over several months rather than just weeks. The first pressing priority is to catch up on all the missed patients. India alone needs to actively find over half a million persons with TB who were missed during the past six months and offer them TB treatment,” Prof Pai told The Indian Express.

Globally, approximately 1.4 million people died from TB-related illnesses in 2019. Of the estimated 10 million people who developed TB last year, some 3 million were not diagnosed with the disease, or were not officially reported to national authorities. The number of people who fell ill with TB has been declining very slowly in recent years.

Prior to the Covid-19 pandemic, many countries were making steady progress in tackling TB with a 9 per cent reduction in the incidence seen between 2015 and 2019 and a 14 per cent drop in deaths in the same period. High-level political commitments at global and national levels were delivering results. “The Global TB 2020 report is a sobering one and the Covid-19 pandemic has now made it harder to getting back on track,” Peter Sands, Executive Director, Global Fund, said during the media conference.

“Now we will need to tap into some of the innovations that are being used for Covid-19 -like public education via WhatsApp, greater use of masks among people with respiratory symptoms, use of screening apps and contact tracing apps, tele-health consults, novel sample collection closer to homes of patients, rapid molecular testing to check for both Covid-19 and TB e-pharmacies to home deliver medicines and digital adherence technologies to ensure treatment completion.

Global Tuberculosis Report 2019: WHO

  • The World Health Organization (WHO)has recently released its 2019 edition of the Global Tuberculosis (TB) Report.
  • The report provides a comprehensive and up-to-date assessment of the TB epidemic and progress in the response at global, regional and country levels for India.
  • WHO has been publishing global TB report every year since 1997.

Key Findings

  • TB remains the top infectious killer in the world claiming over 4,000 lives a day.

Number of TB Cases:

  • Geographically, most TB cases in 2018 were in the WHO regions of South-East Asia (44%), Africa (24%) and the Western Pacific (18%).

High TB Burden Countries:

  • Eight countries that accounted for two thirds of the global total include India(27%), China (9%) and Indonesia (8%).
  • The above countries are also in WHO’s list of 30 high TB burden countries that accounted for 87% of the world’s cases in 2018.

Multidrug Resistant TB:

  • In 2018, there were about half a million new cases of rifampicin-resistant TB (of which 78% had multidrug resistant TB).
  • The three countries with the largest share of the global burden were India (27%),China (14%) and the Russian Federation (9%).

TB Diagnosis:

  • Globally, 7.0 million new cases of TB were notified in 2018 – an increase from 6.4 million in 2017.
  • Most of the increase in global notifications of TB cases since 2013 is explained by trends in India and Indonesia, the two countries that rank first and third worldwide in terms of estimated incident cases per year.
  • In India, notifications of new cases rose from 1.2 million to 2.0 million between 2013 and 2018 (+60%).

Concerns:

  • Despite increases in TB notifications, there is still a large gap between the number of new cases reported (7.0 million) and the estimated 10.0 million incident cases in 2018.
  • This gap is due to a combination of underreporting of detected cases and under diagnosis (i.e. people with TB do not access health care or are not diagnosed when they do).
  • Ten countries accounted for about 80% of the gap, with India (25%),Nigeria (12%), Indonesia (10%) and the Philippines (8%) accounting for more than half of the total.

TB Treatment Outcomes:

  • The latest treatment outcome data for new cases of TB show a global treatment success rate of 85%in 2017, an increase from 81% in 2016. The improvement was mainly due to progress in India.

Financing for TB Prevention:

  • Funding for the provision of TB prevention, diagnostic and treatment services has doubled since 2006.
  • In India, domestic funding quadrupled between 2016 and 2019.

Suggestions:

  • Annual financing for TB prevention and care and for TB research needs to approximately double.
  • Access to TB care and preventive treatment needs to be expanded.
  • Substantial costs faced by TB patients and their households should be mitigated.
  • Multi sectoral action on the broader determinants of the TB epidemic needs to be intensified.
  • Intensified research and development is required to meet the Sustainable Development Goals (SDGs) and End TB Strategy targets set for 2030.
  • The End TB Strategy milestones for 2020 and 2025 can only be achieved if TB diagnosis, treatment and prevention services are provided within the context of progress towards Universal Health Coverage (UHC).
    UHC means that everyone can obtain the health services they need without suffering financial hardship.
  • SDG Target 3.8 is to achieve UHC by 2030.

WHO End TB Strategy

  • The strategy aims to end the global TB epidemic, with targets to reduce TB deaths by 95% and to cut new cases by 90% between 2015 and 2035, and to ensure that no family is burdened with catastrophic expenses due to TB.
  • It sets interim milestones for 2020, 2025, and 2030.

India TB Report 2020

  • Recently, the Ministry of Health and Family Welfare has launched the annual Tuberculosis (TB) Report 2020.
  • Eliminating TB by 2025:India is committed to eliminating tuberculosis from the country by 2025, five years ahead of the global target by the World Health Organisation (WHO).
  • National Tuberculosis Elimination Programme:To align with the ambitious goal, the programme has been renamed from the Revised National Tuberculosis Control Programme (RNTCP) to National Tuberculosis Elimination Programme (NTEP).

Key Points

  • State TB Index: On the basis of the score in State TB Index, Gujarat, Andhra Pradesh and Himachal Pradesh were the top three best-performing states for tuberculosis control under the category of states with 50 lakh population.
    Tripura and Nagaland were best-performing in the category of states having less than 50 lakh population.
  • Dadra and Nagar Haveli, and Daman and Diu were selected as the best performing Union Territories.
  • Rising Tobacco Consumption: It also revealed that Tobacco consumption is rising among Indian TB patients.
  • 8% of TB cases can be attributable to tobacco usage.
  • HIV Patients and TB:People living with HIV are the most vulnerable among all those TB patient groups which have other comorbidities (rate of death). Hence, the World Health Organization lays social emphasis (through awareness programmes) on them.
  • HIV-associated TB: India accounts for 9% of all HIV-associated TB deaths in the world, the second-highest number
  • A total of 92,000 HIV-associated TB patients were recorded on an annual basis.
  • Awareness among TB patients about their HIV status has gone up to 81% from 67%.
  • Diabetes Associated TB: The other such group is patients suffering from diabetes. According to the report, 20% of all TB cases in India also suffer from diabetes.
  • In 2019, among the notified TB patients under the Revised National TB Control Programme, 64 % were screened for Diabetes.
  • Missing Patients: The report highlighted that the notification of TB is a major hurdle in surveillance of the disease in India.
  • Nearly 54 million TB casesare still missing across India.
  • Lower Reporting than WHO: According to the report, India notified the highest number of04 lakh tuberculosis cases last year (2018) as against an estimated 26.9 lakh cases by WHO, indicating that around three lakh patients missed out from the national TB programme.
  • Low Fatality:It stated that 79,144 deaths due to tuberculosis were reported in 2019, which is much lower than the WHO estimate of 4.4 lakh fatalities.
  • Treatment Success Rate:It is around 70-73% in the last two years. From 2014-2016, it was between 76 and 77%.

Initiatives by India

  • The Nikshay Ecosystem: It is the National TB information system which is a one-stop solution to manage information of patients and monitor program activity and performance throughout the country.
  • Nikshay Poshan Yojana (NPY):This scheme is aimed at providing financial support to TB patients for their nutrition.
  • TB Harega Desh Jeetega Campaign: Launched In September 2019 it is showcasing the highest level of commitment for the elimination of TB.
  • The Saksham Project:It is a project of the Tata Institute of Social Sciences (TISS) that has been providing psycho-social counselling to DR-TB patients.

Tuberculosis

  • TB is caused by bacteria (Mycobacterium tuberculosis)that most often affect the lungs.
  • Transmission: TB is spread from person to person through the air. When people with TB cough, sneeze or spit, they propel the TB germs into the air.
  • Symptoms: Cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats.
  • Treatment: TB is a treatable and curable disease. It is treated with a standard 6-month course of 4 antimicrobial drugs that are provided with information, supervision and support to the patient by a health worker or trained volunteer.
  • Anti-TB medicineshave been used for decades and strains that are resistant to 1 or more of the medicines have been documented in every country surveyed.
    Multidrug-resistant tuberculosis (MDR-TB) is a form of TB caused by bacteria that do not respond to isoniazid and rifampicin, the 2 most powerful, first-line anti-TB drugs. MDR-TB is treatable and curable by using second-line drugs.
  • Extensively drug-resistant TB (XDR-TB)is a more serious form of MDR-TB caused by bacteria that do not respond to the most effective second-line anti-TB drugs, often leaving patients without any further treatment options.