Context

• Tuberculosis (TB), a disease long considered curable, remains one of the deadliest infectious diseases worldwide.
• Despite India’s ambitious pledge in 2018 to achieve the "End TB" targets by 2025, five years ahead of the global timeline, the challenges are profound.
• While ambitious policies and initiatives are rolled out from the national level, the ground reality in India needs to be better understood to translate them into effective interventions.

The Current Situation of TB in India, the Vulnerabilities of High-Risk Groups and Breakdowns in Treatment and Supply Chains

• The Current Situation of TB in India
  • In 2024, TB reclaimed its position as the leading infectious disease killer globally, with India contributing 26% of the global TB burden, including drug-resistant TB (DR-TB) cases and TB-related deaths.
  • The COVID-19 pandemic, logistical issues, and gaps in healthcare infrastructure have further complicated efforts to combat the disease effectively.
  • Addressing the vulnerabilities of affected populations, improving diagnosis and treatment, and ensuring better program implementation are crucial to overcoming these hurdles.
• The Vulnerabilities of High-Risk Groups
  • India’s National Tuberculosis Elimination Programme (NTEP) identifies high-risk groups prone to TB, including individuals exposed to factors like silicosis, undernutrition, overcrowding, and uncontrolled co-morbidities such as diabetes.
  • Migrant workers are particularly vulnerable due to poor access to healthcare.
  • Many, like those in mining and stone-carving communities, face severe lung damage caused by inhaling fine dust.
  • Migrant workers often return to their native villages when ill, disrupting their treatment and making it difficult for healthcare systems to track their progress.
• Breakdowns in Treatment and Supply Chains
  • India has made notable progress in initiating treatment for over 95% of notified TB cases, aided by an exclusive procurement and supply chain system.
  • However, the system experienced a major setback in 2023 due to drug shortages.
  • Many critical medicines remain unavailable in the open market, forcing families to bear catastrophic healthcare expenses.

Challenges in Diagnosing Extrapulmonary Tuberculosis

• Diagnostic Delays and Misdiagnosis
  • The first major challenge lies in the presentation of EP-TB.
  • Symptoms vary widely depending on the affected organ, making it difficult for healthcare providers to suspect TB as the underlying cause.
  • For instance, TB of the spine may initially present as back pain, while TB of the brain (tuberculous meningitis) could manifest as persistent headaches or confusion.
  • Such symptoms are easily mistaken for other common conditions, resulting in delayed diagnosis and advanced disease stages by the time treatment is initiated.
• Limited Access to Diagnostics
  • The diagnostic infrastructure for EP-TB in India remains underdeveloped, especially in rural and underserved areas.
  • Advanced molecular tests like Cartridge-Based Nucleic Acid Amplification Testing (CBNAAT) and Truenat, which are crucial for diagnosing EP-TB, are often only available at district-level healthcare facilities.
  • Accessing these tests requires patients to travel long distances, which is both time-consuming and expensive.
• Underprepared Healthcare Providers
  • A significant number of healthcare providers, particularly in the private sector, are ill-equipped to diagnose EP-TB.
  • Studies, such as those conducted by Daniels and colleagues in Mumbai, reveal that only 35% of private practitioners can correctly diagnose TB based on classical symptoms.
  • Many private doctors, driven by patient convenience or lack of knowledge, prescribe broad-spectrum antibiotics without conducting proper diagnostic tests.
  • This reluctance to notify TB cases as required by national guidelines not only delays appropriate treatment but also contributes to underreporting and the perpetuation of the disease burden.

Necessary Measures to Address the Challenges

• Strengthening Diagnostic Infrastructure
  • Expanding the availability of molecular diagnostic tools like CBNAAT and Truenat to primary and community health centres is essential.
  • Ensuring a consistent supply of cartridges and reagents, coupled with the deployment of trained technicians, can reduce delays in diagnosis.
• Training Healthcare Providers
  • Regular training programs for general practitioners, nurses, and frontline workers can enhance their ability to suspect and diagnose EP-TB early.
  • Emphasising simple diagnostic techniques and clinical history-taking can help bridge the gap where advanced tools are unavailable.
• Integrating EP-TB into Screening Algorithms
  • Incorporating EP-TB into routine TB screening protocols, particularly in high-burden areas, can ensure that cases are identified early.
  • Training frontline workers to recognise the diverse presentations of EP-TB can improve detection rates.
• Community Awareness Campaigns
  • Raising awareness among the general public about EP-TB symptoms can encourage early healthcare-seeking behaviour.
  • Community outreach programs should focus on dispelling myths about TB and highlighting the availability of free diagnostic and treatment services under the NTEP.
• Public-Private Collaboration
  • Engaging private practitioners through training, incentives, and monitoring mechanisms can improve notification rates and ensure that cases are appropriately diagnosed and managed.
  • Public-private partnerships can also help in scaling up access to diagnostic tools and resources.
• Ownership and Community Participation
  • Effective TB elimination requires ownership and collaboration at all levels.
  • A successful example comes from Idukki district in Kerala, where partnerships with Kudumbashree, a women’s self-help group, enabled widespread community participation.
  • Advocacy by political leaders and cross-learning from best practices proved instrumental in achieving and sustaining TB control efforts.
  • Program implementers must go beyond routine responsibilities to adapt to local challenges.
  • Drawing inspiration from Vietnam, which successfully used active case-finding for TB among high-risk groups, India must explore innovative approaches to improve case detection and treatment outcomes.

Signs of Progress and the Road Ahead

• Despite the challenges, there are reasons for cautious optimism.
• India’s TB case notifications reached an all-time high, and TB deaths declined by 24% compared to 2015—exceeding the global average.
• The administrative structure of the NTEP is designed to address diverse contextual challenges, offering hope for progress.
• However, achieving the "End TB" targets by 2025 requires substantial restructuring of conventional frameworks.
• Investments in diagnostic infrastructure, multisectoral interventions addressing social determinants, and robust program management are essential.
• Community engagement and cross-learning from international successes can provide valuable insights to combat TB effectively. 

Conclusion

• Tuberculosis remains a formidable public health challenge in India, exacerbated by socio-economic vulnerabilities, healthcare system inefficiencies, and logistical barriers.
• While ambitious policies have been implemented, bridging the gap between policy and practice is critical.
• Through sustained political will, innovative strategies, and community involvement, India can make significant strides toward eliminating this deadly disease.
• Although the 2025 target appears ambitious, consistent efforts can lay the foundation for a TB-free future.