What India needs to do if it's serious about going TB-free by 2025

There is a distinct possibility of life existing beyond our planet, if NASA's recent revelations are to be believed. We might not be alone.

But we knew that already, at least the biologists among us. We share our most personal space - our body - with trillions of bacteria. And if you are Indian, a few thousand of these trillion-odd guests could be Tuberculosis (TB) bacteria, lying latent. True for at least 40 per cent of the population - their upper arms scarred by the BCG jab or not.

That the effectiveness of BCG vaccine is a modest 27 per cent for babies born in India has long been known. That its effect peters down within a decade of immunization is also strongly established. With nearly zero protection thereafter, the sleeping devils that are the TB bugs could wake up at any point in time to strike as many as 10 per cent of us with full-blown tuberculosis.

The risk is the highest for the 6.2 crore diabetics, the 20 lakh HIV sufferers, and all those (in excess of 2.3 crore) of our fellow citizens who live and work in precariously wretched conditions, irrespective of the pigeon-hole the economists sort them into by carefully calculated poverty line(s), livable or not.

For the remaining 60 per cent population, who may not harbour latent TB bacteria, the likelihood of acquiring infection from one's surroundings remains. TB is air-borne. Tending to the sick or simply sharing breathing space with them puts one at risk of acquiring active tuberculosis in lungs, spine, brain or any other site.

Aptly expressed by Charles Dickens in the pre-antibiotics era (Nicholas Nickleby, published 1838) as "a disease that wealth never warded off, or poverty could boast exemption from; which sometimes moves in giant strides, and sometimes at a tardy sluggish pace, but, slow or quick, is ever sure and certain" - this description for TB is as timeless as Dickens himself.

TB's tale is as old as time. It finds mention in Vedic and Greek texts, and a laboratory proof in Tutankhamen's embalmed mummy.

Achtung TB

The only effective protection against TB is to eliminate it from our surroundings - by treating all those who have it. TB is fully treatable, provided it is diagnosed, and the causal bacteria is not of the TB superbug variety that requires a cocktail of antibiotics and buckets of luck to be eliminated.

India's TB Control Programme (called, RNTCP) offers free treatment, using the WHO-recommended Directly Observed Treatment, Short-Course (DOTS) strategy. In the last fifteen years, RNTCP has made significant progress in TB control, with a treatment success rate of 85 per cent for those diagnosed and enrolled. Unfortunately, far too many are not.

Earlier this month, in his 2017-18 Budget speech, finance minister Arun Jaitley advanced India's resolve to eliminate TB by 10 years, the new deadline being 2025. A welcome announcement, but one that cannot unfortunately be taken at its face value.

In the last five years, TB control budget has been consistently slashed year after year by as much as 40 per cent - a telling signal of the half-hearted accountability and commitment to the cause that deserves to be declared as a health emergency.

To honour the announcement, RNTCP would need an immediate shot in the arm. At the current decline rate of 0.9 per cent a year in new TB cases - that's an audacious goal against an ultra-audacious adversary. Not to forget a no-holds barred budget to clear the fog and the friction en route. Here are the issues to accost to reach there.

The fog

India doesn't have a clear measure of the expanse and degree of the challenge that we have set out to tackle. The estimated number of new TB patients added to the population in 2015 ranges from a worrying 2.2 million (Ministry of Health and Family Welfare, 2016) to an alarming 2.8 million (WHO, 2016) to a frightful 3.8 million (The Lancet, 2016) - baffling - for a nation that churns out a similar number of analytical minds as STEM graduates per year.

TB elimination warrants action with a "search and treat" approach with a precision no less than that of the taxman. With that aim, Nikshay - an aptly-named, e-initiative to register and monitor every TB patient in India - was launched in 2012. A brilliant thought, now wryly scraping its way through shoddy infrastructure, thereby producing foggy results. It registered 1.7 million new patients in 2015 (40 per cent of the WHO estimate above), mostly from public health facilities.

Submissions from private practitioners were merely 11 per cent of the total, whereas 50-70 per cent TB patients are managed in the private health sector, just like any other ailment.

Nikshay's performance has been pale, but unsurprising. 70 per cent of India's Gram Panchayats do not have network connectivity, let alone primary healthcare centres in villages. Its success will remain jaded until BharatNet's optical fibre network reaches all villages, which will take until 2023. That's woefully close to the year 2025.

This year, Nikshaya is planned to introduce patient registration via a call centre - a smart, interim step to improve patient notifications in the absence of internet. With this enhancement, it also hopes to ease the inertia of India's private practitioners to engage with RNTCP. Again, the health ministry has taken an aggressive commitment of achieving 100 per cent participation by the private sector within 2017 - a lofty aim.

Currently, a sixth of private practitioners have been sensitized to the DOTS strategy, much fewer among them have been imparted training on its practice protocol.

The friction

In urban India, 8 out of 10 allopathy physicians work in the private sector. As a patient visiting a private practitioner in a city, say Delhi, there is a 40 per cent chance that one's doctor may not hold a medical degree.

The odds of meeting a degree-less, allopathic-doctor-by-experience is up to 70-80 per cent in the states of Uttarakhand, Punjab, Haryana, UP, Bihar, Jharkhand. This worrying reality,and the fact that a very tiny fraction is trained to prescribe the standard of care treatment for TB, found a recorded proof in an eye-opening study led by Dr Zarir Udwadia in Mumbai.

In a survey with 106 general practitioners in the Dharavi area, just 6 prescribed an appropriate drug regimen; 4 of these 6 were allopaths.

Within this group of 106, the study landed with 63 different types of drug prescriptions, revealing the inconsistency in the approach to treatment, and a strong tendency to over-treat. This was in 2010; the situation may have only marginally improved in the last six years.

The ad hoc-ism trickles down to TB diagnostics, the most important cog in the machine. Unlike the Victorian times, incessant cough and spitting blood is neither a telltale signal of TB, nor a mark of one's creative genius (of the likes of Pascal, Chopin, Kafka, Orwell, Munshi Premchand, in a long list of those who were consumed by the dreaded TB).

In common practice, symptomatic diagnosis prevails over laboratory techniques for doctors to establish TB. The meandering quest for a confirmed diagnosis adds to the bill; the delay in initiation of correct treatment adds to the danger.

Put together, the accentuated agony of suffering lasts for as long as 8 weeks, with a change of 3 doctors before being put on confirmed treatment for TB, as shown by Dr Madhukar Pai's team via meta-analysis of study results from several states in India.

RNTCP has an expansive lab network, enough to cover three-fourths of the population - a great achievement. 64 labs across India are the nodal centres that specialise in culture techniques to detect and categorise TB.

Village and district level coverage comes from 13,309 centers across the country, equipped to diagnose active TB by the age-old technique of blood smear microscopy - effective in low-resource settings, with a chance of missing 36-44 per cent positive cases though.

There is still a long way to go in increasing patient accessibility to a modern, more accurate and rapid test of TB, by GeneXpert machines. This WHO-recommended test can also detect the more debilitating, drug-resistant forms of TB within 2 hours. Currently, India has 600 installations, of which 131 are in the private sector.

All this, if put to full use, and without delay, will alleviate the pain and the strain on the pockets of active and latent TB patients. For that, private practitioners have to be convinced, incentivised and trained to join-in as whole-hearted allies much before 2025. Without them, it is a war lost already.

The damage

TB has long been marked with the "ancient disease" label. It is no longer valid. The millennial generations of TB bacteria have emerged, sharing traits with their namesakes. They multi-task - against many drugs that made old TB treatable.

They aren't wary of change - the impatient ones have changed forms from being multi-drug resistant (MDR) to becoming extensively drug resistant (XDR), and now totally drug resistant (TDR) species.

They are the TB superbugs - first reported in India by Dr Udwadia in 2011 - brought on by erratic over-prescriptions, untreated reinfections, aborted treatment or delayed diagnosis.

The economically poor, who are mostly subjected to one or more of the above circumstances, are the ones at maximum risk of contracting the resistant forms of TB. 3-4 per cent of the total new patients are estimated to contract drug-resistant TB of the lungs, and it is on a rise.

The treatment cost of drug-resistant forms of TB is 80-100 times higher than that of the non-resistant type. With medical expense running into Rs 2.8-4.2 lakh over two years for private care - equal to or less than the average annual income of 206 million Indian households - drug-resistant TB is catastrophic not just for the individual grappling with it, but for the entire household.

In such circumstances, any instance of delay or stock-outs of drugs crashes the only hope of survival.

What will it take?

1. All rural and urban private doctors to join the front, allopathy or AYUSH doctors, qualified or not. Include as many allied health workers, volunteers and pharmacists to support.

Task size: Training for the remaining 7 lakh private doctors, who aren't yet sensitized.

So far, 1.27 lakh have been sensitised; as few as 41,000 have been trained.

2. Search, and notify all active TB patients

Task size:Call-centre operations and door-to-door field officers staff to double to register patients manually or over phone until Nikshaya is fully-powered up in its reach and usage.

Increase incentive amount for private practitioners to mandatorily register and treat all TB patients following RNTCP guidelines. The amount of Rs 1,500 per case (instituted in 2014) didn't bring the desired results. It may also need an upward revision up to a multiple of two or three.

3. Flag all those patients with MDR, TDR and XDR -TB, and facilitate availability of drugs to them in time

Task size: Facilitate/ Incentivize GenXpert installation in the 300 accredited private labs who don't have it yet. Cut the nepotism to access Bedaquiline - the only hope of "therapeutically destitute" patients of drug-resistant TB.

No one should undergo the agony such as that of Mr. Tripathi - counting days of grappling with a possibility of death of his teen-aged daughter, while the red-taped file of request slowly exchanged hands between bureaucracy and courts to finally get access to the drug.

4. Run cross-country surveillance of all high-risk groups to detect latent TB; nip TB in the bud

Task size: Advocacy and promotion programmes targeted up to the village level to maximise participation.

Pulse Polio advocacy programme is a great example to emulate for desired results sample collection/assay drives along the same route for notification and disease management in high-risk groups of HIV patients, slum dwellers, health workers, rural migrant populations, prisoners, and orphanage residents, and many more.

5. Increase essential drug stocks in the country (public and private channels) to manage the influx of new patients and preventive disease management

Task size: Be ready to increase stock such that it is ready to cater to the missing patients that should come in the know by the revved-up efforts on tracking and notifying missing patients

6. Health insurance and financial support scheme for economically vulnerable patients with TB, especially sufferers of the drug-resistant or extra-pulmonary types

Task size:56 per cent of our population makes a living at less than Rs 1.5 lakh ($2,500) a year - they are also at the highest risk. If TB doesn't kill many of them, the economic burden of managing the disease might.

Going by the consistent demand of the RNTCP (over the last three years) of Rs 1,100 crore per year, the 2025 TB elimination deadline will need in excess of Rs 9,000 crore until then to expedite the current efforts, starting now.

Has the government pledged to fulfil that?

That firm commitment is the only thing that lies between the TB-inflicted India of now and a TB-free India of 2025.