TB challenges in India

According to the recent WHO Global TB report, India, annually, is hit by approximately 2 million new TB cases. Almost 50% of them are infectious TB (sputum smear positive Pulmonary TB) and if remains undiagnosed and untreated, each of those infectious TB cases has the capacity to infect 10-15 persons per year. So TB has tremendous potential to spread fast in a densely populous country. And India is one of such brightest examples in the globe.

Many TB cases receive treatment at the private sector. Those cases are not reported to anywhere so we have no idea about their numbers/estimates. The public-private mix (PPM) schemes have been initiated to imrprove involvment of the private doctors in the National TB Program (RNTCP) of India.

HIV is a very powerful enhancer of TB epidemic that has been already experienced in Sub-Saharan Africa where as high as 40% of the country's population is infected by HIV. High load of HIV can easily trigger TB in a country with equally high TB burden.

Fortunately, for India, HIV is not that strong driving force of TB epidemic with the low prevalence rate (0.3%). Approximately 5% of the TB affected population is co-infected by HIV. The key challenge of TB/HIV collaboration is to reach the HIV infected population with adequate and appropriate TB services in politically and geographically difficult places like North-Eastern states, and in highly vulnerable states like UP, Bihar, Orissa, WB etc where public health systems are comparatively weaker as a result of inadequacies in infrastructure and political committment.

On the other hand, TB is a bigger threat in a country where more than 40% of the total population (1.2 billion) is estimated to be infected by TB. The key driving forces of TB in India are poverty, malnutrition, unhealthy living, smoking, migration and increasing trend of diabetes. Though the country has achieved the targets of 70% case detection rate and 85% cure rate, there are a number of districts consistently showing poor performances in terms of low case detection and cure rates. Besides, there are greater number of high risk population groups who have still extremely poor access to TB services and information. That include poor homeless people in urban set ups, slum dwellers, tribal groups, sex workers, drug users, prisoners, migrants, refugees, internally displaced people etc. The support of NGOs is a must to help those underprivileged and underserved population groups utilize the TB services from the National Program. RNTCP has already started schemes that can be adopted by the NGOs to provide meaningful contribution to the National TB care and control initiatives. But the responses of the NGOs, so far, are not encouraging like the HIV program.

Engaging the private doctors in the TB program is one of key strategies to achieve the goal of universal access. The PPM strategy has mainly 2 objectives: 1) improve TB case reporting from the private sector, 2) encourage private sector to follow the RNTCP drug regimes and the DOTS strategy. It targets both the qualified and unqualified private doctors. So far the experience of PPM is mixed but remains always challenging.

RNTCP will be going into its third phase from 2011 with the target of 100% TB case detection that will make the task of TB care and control steeply challenging in the coming days.

Sugata Mukhopadhyay

Universal Health