Will Himalayan Indian state eliminate tuberculosis by 2023?

Bobby Ramakant *

Two years before the pandemic had struck us, the hilly state of Himachal Pradesh in India had declared that it will eliminate tuberculosis (TB) by 2023 - two years before the national #endTB target (2025), and seven years before the global #endTB target (2030). State Chief Minister’s dedicated initiative had further galvanized the efforts towards containing the ancient disease. But are we on track?

We must remember that an infectious disease anywhere is an infectious disease everywhere. TB anywhere is TB everywhere. If we are to eliminate TB from our home and communities, it also must be eliminated from all other home and communities around the world. The same holds true for COVID-19.

TB care failed to reach over one-third of TB patients in India in 2020

As per the latest Global TB Report of the World Health Organization (WHO), only 63% of the estimated total number of people with active TB disease were diagnosed and put on treatment in 2020. Over half a million people died of TB in the same year.

Even before the pandemic had struck the world, most parts of the world were not on track to end TB by 2030. India was no different, with appallingly low TB decline rate - year after year - than the required decline necessary to eliminate the disease.

TB services too were adversely affected when COVID-19 lockdown was clamped in March 2020. After an initial couple of months of hiccups, Kangra's dynamic District TB Officer Dr RK Sood led from the front in mobilising his team to rise up to the challenge. Home delivery of TB medicines was an important activity of Dr Sood’s team to help people with TB stay on treatment. Uninterrupted treatment is essential to prevent emergence of any further anti-TB drug resistance, as well as for better treatment outcomes. Dr Sood has been instrumental in strengthening TB, HIV and related health responses in this part of the state since decades.

Kangra's District Strategic Plan to end TB provides an important roadmap. More importantly, Kangra is among those districts that are aspiring to achieve sub-national TB-free certification from authorities (including WHO). Despite mountainous terrain and extreme climate, the state has significantly contributed towards making healthcare accessible to its people. But no less mountainous challenges remain if the state is to keep the promise of eliminating TB in next 21 months.

Dr Sood shared that notification of new TB cases had significantly declined in the state when COVID-19 lockdown was imposed. So, his team tried to find new ways of making TB programme work even in the time of COVID-19 crisis.

By mid-2020, Sood’s team dedicated their Sundays in actively testing people for TB at people’s doorsteps. People were more likely to be home on Sundays. This house to house screening every Sunday also helped build and/or regain institutional trust of people in public health services. New TB case notifications went up, but they still remained way below the numbers diagnosed in 2019. Dr RK Sood said that “We do not know the reason. It could be the effect of mask or COVID-19 restrictions but we do not know.”

COVID-19 adds to the risk of progressing from latent TB infection to active TB disease

One-third of the world's population is estimated to be infected with latent TB. Latent TB is where bacteria are in the human body but do not cause the disease and it cannot spread to others. However, latent TB in some people may progress towards active TB disease. So, every case of active disease comes from this pool of people with latent TB. The good news is that there are effective treatments available (TB preventive therapy) for those with latent TB so that their risk of converting into active disease is decimated.

The risk factors that make latent TB progress into active TB disease include COVID-19. Tobacco smoking, diabetes, HIV, malnutrition, are some of the other major risk factors that cause the latent TB infection to progress to active disease.

With a large part of the population estimated to be exposed to COVID-19, Dr Sood is right in alerting that it could lead to more people with latent TB presenting with active TB disease.

Himachal Pradesh has begun rollout of TB preventive therapy. In Kangra, TB preventive therapy rollout began in end of 2021. With support from the International Union Against Tuberculosis and Lung Disease (The Union), latent TB test and treat model is guiding these efforts. Household contacts of TB patients are being tested for latent TB and, when eligible, are provided with TB preventive therapy, said Dr Sood.

Alarm bells on increase in TB deaths in last two years

Dr Sood is concerned on the unsatisfactory treatment success rate, as well as increase in TB deaths since last two years. If a rapid risk assessment is done at the time of TB treatment initiation, then it can help identify factors that are associated with unfavourable treatment outcomes, including risk of death. TB programmes could intensify care and support to these patients, in order to optimise treatment outcomes among them. “We are trying to address this through differentiated care. We have started to sensitize our teams on differentiated care and will rollout this approach in three months. We are also doing mortality analysis”, said Sood.

Major changes warranted if we are to #endTB

When a person visits a healthcare facility to get a TB test, it is important to use the best diagnostics, like rapid tests, so that we can diagnose TB quickly and accurately and also know which drugs will work on that person (that is, if there is any drug resistance). This is also essential for ensuring that the person (if positive for TB) is put on the most effective treatment without any delay.

As per the latest WHO report, only 18% of the patients were tested with rapid molecular diagnostics at the time of diagnosis in India in 2020.

In Kangra district of Himachal Pradesh, Dr Sood said that there are 16 rapid molecular diagnostic test machines (Cartridge-based Nucleic Acid Amplification Test or CB-NAAT). Half a dozen more such machines are soon to come. Moreover, CB-NAAT machines deployed for testing COVID-19 will also be used for TB testing. “We will soon have at least one CB-NAAT machine in every block of Kangra and come closer to the dream of replacing sputum microscopy by CB-NAAT by end of this year or the following year,” he said.

Dr Sood hopes that new shorter TB treatment regimens will soon reach the patients in near future. “This is also important for treatment adherence as well as for improving quality of care for our patients,” he said.

“99-DOTS (Directly Observed Treatment Shortcourse – standard therapy for drug-sensitive TB) usage is around 90% and adherence rate is around 85-90%. So now it is very important to focus our energies on 10-15% of those people who need support for better adherence” rightly said Dr Sood.

Digital pillbox

Another recent major stride in Kangra is the use of a special digital pillbox called MERM (Medication Event Reminder Monitor). This will help improve treatment monitoring and adherence to the therapy for those people with drug-resistant TB.

Motivated healthcare workers are essential if we are to #endTB

"Biggest challenge is that our human resource is highly demotivated or demoralized. We need to have incentives for the healthcare workers," said Dr Sood.

"Right now, we are having a huge human resource crisis in our laboratory services. Many of our Designated Microscopy Centres (DMCs) are non-functional or running on purely ad hoc basis by using the laboratory technicians of the National AIDS Control Programme to run the CB-NAAT machines. Recruitment is going on since last six months," shared Dr Sood.

"Gains in public health are very fragile. Today everything is okay and next day there could be an outbreak (or other setbacks) and things go out of control" rightly warned Dr Sood. "Our team needs to be very motivated. Only then can we make a dent. Otherwise we will only have small oases of excellence."