TAKING ON TB

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THE CONTEXT: India faces significant challenges in eliminating Tuberculosis (TB), including the under-reporting of cases, the rise of multi-drug resistant TB, and the need for better diagnostics and treatment adherence. Recent progress has been made, including narrowing the gap between estimated and actual TB cases and increasing the diagnosis of drug-resistant TB.

ABOUT TUBERCULOSIS:

Tuberculosis (TB) is an infectious disease primarily affecting the lungs, but it can also target other parts of the body. It is caused by the bacterium Mycobacterium tuberculosis. TB is typically spread through the air when a person with active pulmonary TB coughs, sneezes, or speaks, releasing respiratory droplets that can be inhaled by others.

TYPES OF TUBERCULOSIS:

Pulmonary TB

Pulmonary TB is the most common form of the disease, where the bacteria infect the lungs. Symptoms may include Persistent cough lasting three weeks or longer, Coughing up blood or phlegm, Chest pain, and Shortness of breath.

Extrapulmonary TB

Extrapulmonary TB occurs when TB affects organs other than the lungs, such as the lymph nodes, abdomen, bones, and joints, or the central nervous system. It accounts for about 15% of all TB cases.

Latent TB

Latent TB infection is when the bacteria are present in the body but inactive, causing no symptoms and not being contagious. However, latent TB can become active, especially if the immune system is weakened.

Active TB

Active TB, also known as TB disease, is the contagious form of TB that causes symptoms. It can be life-threatening if not properly treated.

Specific Types of Extrapulmonary TB

TB Lymphadenitis: Affects the lymph nodes, often presenting as painless lumps on the head and neck.

Skeletal TB: Affects the bones and joints.

Miliary TB: A rare form of TB that can affect multiple organs, including the blood, bones, lymphatic system, and central nervous system.

Gastrointestinal TB: Affects the gastrointestinal tract, with symptoms like other gastrointestinal conditions.

TB Meningitis: Affects the meninges, and the membranes surrounding the brain and spinal cord, and can cause severe headaches, sensitivity to light, and neck stiffness.

TB Peritonitis: Causes inflammation of the peritoneum, leading to abdominal swelling and tenderness.

TB Pericarditis: Affects the pericardium, and the tissue surrounding the heart, and can cause chest pain and shortness of breath.

Cutaneous TB: Affects the skin and is very rare.

National TB Elimination Program (NTEP) in India: The National TB Elimination Program (NTEP), formerly known as the Revised National Tuberculosis Control Program (RNTCP), is India’s state-led initiative to combat tuberculosis (TB). The program aims to eliminate TB in India by 2025, five years ahead of the global Sustainable Development Goals (SDG) target.

EVOLUTION OF NATIONAL TB ELIMINATION PROGRAM IN INDIA

1962: The Government of India launched the National TB Program and established District TB Centers.

1993: The World Health Organization (WHO) declared TB a global emergency, prompting more focused efforts.

1997: The National TB Program was revised to RNTCP, introducing the Directly Observed Treatment Short-course (DOTS) strategy.

2005-2011: The second phase of RNTCP expanded coverage across India and improved the quality and scale of services.

2012-2017: The National Strategic Plan (NSP) for this period included mandatory notification of TB cases, rapid molecular testing, and integration with the National Health Mission.

2017-2025: The current NSP focuses on patient-centric care for TB elimination, with strategies such as active case finding and treatment, and integration of advanced diagnostic and treatment technologies.

2020: The RNTCP was revised to the National TB Elimination Program (NTEP), reflecting the shift in focus from control to elimination.

THE ISSUES:

• Under-reporting of TB Cases: Historically, a significant challenge for India’s anti-TB program has been the under-reporting of cases. This not only affects the individuals who go undiagnosed and untreated but also poses a risk of infection to others they encounter.
• Closing the Case Gap: The India TB Report 2024 indicates progress, showing that the gap between estimated and actual TB cases is narrowing, with the 2023 target of initiating treatment in 95% of diagnosed patients being met.
• Ambitious Elimination Target: Despite recent successes, India’s goal to eliminate TB by 2025 appears challenging, especially given the epidemic proportions of multi-drug resistant (MDR) TB.
• MDR-TB Diagnostics and Treatment: There has been significant progress in identifying MDR-TB, with an increase in the percentage of diagnosed patients being offered tests for drug resistance. However, molecular testing, which is more effective for detecting MDR cases, is not yet the predominant method. Treatment regimens for MDR-TB are complex, and less than 60% of patients complete the full course of second-line treatments.
• Mental Health in TB Treatment: Mental healthcare is increasingly recognized as an essential component of TB treatment. However, in India, support for patients undergoing the demanding treatment process is rare.
• Vulnerable Populations: TB disproportionately affects the poor, slum dwellers, and HIV/AIDS patients. There is a need for targeted interventions that combine advanced technology and compassionate care to address the needs of these high-risk groups.

THE WAY FORWARD:

• Engagement with the Private Sector: The private sector accounts for a significant portion of healthcare services in India, including TB care. To address under-reporting and improve the quality of TB care, there is a need for meaningful engagement with private healthcare providers. This includes implementing successful private sector engagement models, such as the Patient-Provider Support Agency (PPSA) model, which has been shown to increase TB case notifications and improve treatment outcomes.
• Investment in Health: Increasing governmental expenditure on health and specifically on the RNTCP is necessary to scale up efforts to meet the ambitious target of TB elimination by 2025. This includes addressing key determinants of TB such as poverty, undernutrition, and tobacco smoking through intersectoral collaboration.
• Modernizing TB Care: Modernizing the TB standard of care and control system is essential. This involves scaling up rapid molecular diagnostics, making drug-susceptibility testing more widely accessible, switching to daily drug regimens, and implementing tools for adherence support.
• Research and Surveillance: Investing in research for the development and validation of new tools, including diagnostics, drugs, and vaccines, is critical. Surveillance efforts should include periodic prevalence surveys, nationwide TB drug-resistance surveillance, and implementation science to identify and treat missing TB patients.
• Addressing Drug-Resistant TB: There is a need to focus on the management of drug-resistant TB, including the provision of second-line drugs and the transition to shorter-duration drugs like bedaquiline, especially after the patent decision that could enable the production of cheaper generic versions.
• Integrating Mental Health: Mental health support should be embedded in the TB treatment program to improve adherence and patient outcomes. This includes counseling and psychosocial support.
• Applying New Technology: Leveraging technology for real-time treatment monitoring systems, such as ’99 DOTS’, and exploring digital payment systems like e-RUPI for smart payments can enhance the efficiency of TB care and support.

THE CONCLUSION:

To overcome the hurdles in TB elimination, India must enhance engagement with private healthcare providers, invest in health infrastructure, and adopt modern diagnostics and treatment regimens. Emphasizing mental health support and targeting interventions for vulnerable populations are also crucial. With concerted efforts, India can move closer to its goal of eliminating TB by 2025.

UPSC PAST YEAR QUESTIONS:

Q.1) The public health system has limitations in providing universal health coverage. Do you think that the private sector could help in bridging the gap? What other viable alternatives would you suggest? 2015

Q.2) Appropriate local community-level healthcare intervention is a prerequisite to achieving ‘Health for All ‘in India. Explain. 2018

Q.3) What do you understand by fixed-dose drug combinations (FDCs)? Discuss their merits and demerits. 2013

Q.4) Can overuse and the availability of antibiotics without doctor’s prescription, the contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. 2014

MAINS PRACTICE QUESTION:

Q.1) Evaluate the effectiveness of India’s current strategies towards TB elimination. Discuss the challenges posed by drug-resistant TB and suggest integrated approaches to address these challenges within the framework of sustainable development goals (SDGs).

SOURCE:

https://indianexpress.com/article/editorials/express-view-taking-on-tb-9240926/