While the onset of COVID-19 in March 2020 did impact tuberculosis elimination efforts and services across the country, several campaigns were put in place to offset the impact, according to Dr. Raghuram Rao, Assistant Director General, Central TB Division, Ministry of Health & Family Welfare. He told Frontline that eliminating TB is a big challenge for the government because it requires holistic efforts from several different departments. Edited excerpts from an interview:
How did COVID-19 impact tuberculosis programmes in India?
TB notifications declined by 24 per cent in 2020 and by 10 per cent in 2021 as compared to pre-pandemic 2019 levels. The National Tuberculosis Elimination Programme (NTEP) responded with timely and immediate mitigation measures like TB and COVID-19 bi-directional screening, diagnostic and treatment capacity upgradation, and standard operating procedures (SOPs) for testing for TB, the introduction of an all-oral shorter regimen for MDR-TB, and testing for COVID-19 among notified TB patients.
Large-scale active TB case-finding campaigns were undertaken with massive screening and testing in communities; outreach workers and volunteers facilitated surveillance for symptoms within households, doorstep collection of samples, and delivery of monthly medicine stocks to help patients adhere to treatment regimens. They also had teleconsultations with patients. Molecular diagnostic capacities for testing TB and Drug Resistant TB (DR-TB) were rapidly expanded.
As a result of these measures NTEP is poised to achieve notifications above the pre-pandemic levels, with a total of 18,36,561 patients notified between January and September 2022. The overall treatment success rate has remained at 84 per cent in 2022 (January-September 2021 cohort) despite the pandemic.
What are the main challenges the government faces today in eradicating TB?
The elimination of TB requires a response not just by the Health Ministry but also by several line departments to address social determinants such as undernutrition, housing, poverty alleviation, and livelihood. The Ministry is closely working with these departments.
Health-seeking behaviour of the community is also a challenge that needs to be constantly addressed with timely and effective communication strategies. The non-availability of an efficacious vaccine certainly leaves a big vacuum in prevention efforts. Unlike in COVID-19, where we could develop a vaccine within a short duration, TB research and development needs a big push.
What is being done to counter DR-TB, which is on a rise?
The increase in reporting of DR-TB cases under the programme is not synonymous with an increase in DR-TB burden. In fact, the programme has scaled up its reach and coverage with a host of targeted interventions by which we are able to identify early DR-TB cases and initiate appropriate treatment.
Some key initiatives include free diagnostic and treatment services for DR-TB at all districts including identified private health facilities; the introduction and expansion of newer anti-TB drugs (like bedaquiline and delamanid); provision of Rs.500 per month for nutritional support; and pan-India scale-up of shorter oral MDR/RR-TB regimen from April 2022, making the treatment injection-free for the majority of patients.
Some other initiatives include decentralisation of rapid molecular testing facilities to sub-district levels. Currently, 4,760 NAAT (nucleic acid amplification test) laboratories and 96 liquid culture laboratories are available across the country, covering all districts. We are also introducing a comprehensive package for differentiated care of TB patients to identify patients requiring referral or hospitalisation to reduce mortality.
We are focused on active TB cases, but is anything also being done for latent TB, which according to reports is present in most Indians?
Prevention is one of the four critical pillars (detect-treat-prevent-build) of the plan to eliminate TB by 2025. It focuses on preventing the emergence of TB in vulnerable populations. This programme has offered TB preventive therapy (TPT) for more than a decade, albeit in a limited manner, to children below the age of six and to people living with HIV/AIDS. In 2021, NTEP expanded the policy to all household contacts of index pulmonary TB patients.
Is India any closer to developing a vaccine for tuberculosis?
The Department of Health Research/Indian Council for Medical Research (ICMR) is working towards a TB vaccine in India. The India TB Research Consortium under ICMR has been constituted with the specific purpose of testing and validating new/novel drugs/diagnostics/vaccines. The pipeline for vaccines is being closely pursued for fast-tracking and early introduction of potential vaccine candidates.