India on the right path to ending TB

India is the one of the world’s frontrunners in finding innovative solutions to combat tuberculosis (TB).

India accounts for a little more than a quarter of the global burden of TB and has the largest number of multidrug-resistant TB (MDR-TB) cases worldwide. The upward revision of the TB burden to an estimated 2.8 million in 2015 reflects the Indian government’s increased ability to identify the true burden of TB and gain a more robust understanding of the TB epidemic across the country.

“Today we can say that India is on the right path to ending TB,” said Dr Henk Bekedam, WHO Representative in India. “It has state-of-the art tools and strong political leadership to tackle the challenge of TB and MDR-TB. We now need to ramp up the response to increase detection and ensure that all those who are in need of treatment can access it.”

India certainly is on the right track. There is political commitment at the highest level and Prime Minister Narendra Modi is actively involved in the country’s TB control activities.

Prime Minister Modi addressed TB in his monthly radio programme ‘Man Ki Baat’ in May this year and also discussed the country’s TB control strategy with all the Chief Secretaries of the states in his monthly progress review meeting ‘Pragati’.

Speaking on World TB Day this year, India’s Minister of Health and Family Welfare, Mr Jagat Prakash Nadda said, “The Government of India stands committed to accelerating its efforts to combat tuberculosis in the country.”

India’s national TB strategic plan for the next four years is aligned with WHO’s End TB Strategy. It calls for the use of digital technologies to improve TB reporting and care, the engagement of the private sector, the roll-out of rapid molecular tests to diagnose TB and drug resistance, new anti-TB drugs, and a shorter MDR regimen to combat drug-resistant TB. Achieving universal access to TB care is also a key component of India’s campaign for a TB Free India.

“As in India, TB remains a serious problem across the South-East Asia Region and requires the fullest attention of Member States, donors and civil society leaders. To achieve the 2030 target of ending TB, countries must build on key interventions made in recent years. With increased resources, the vision of achieving a region free of TB with zero deaths, disease and suffering can become a reality,” said Dr Poonam Khetrapal, Regional Director of WHO South-East Asia Regional Office.

In India, for decades, the majority of patients diagnosed and treated by private health care providers were not reported to the country’s national TB programme, resulting in underreporting of TB cases.

To address this, the Indian government implemented a policy of mandatory TB notification in 2012 and created a national web-based reporting system called Nikshay. This facilitated the reporting of TB cases, including those detected in the private sector. As a result, reporting from the private sector grew considerably. In 2015, the number of notified TB cases was 34% higher than in 2013 thanks to Nikshay.

Innovative models for private sector engagement have been introduced in three districts – Mehsana in Gujarat, Mumbai in Maharashtra and Patna in Bihar, and later expanded to one more district - Nagpur also in Maharashtra. These include the introduction of vouchers for free diagnosis and free drugs for patients in private clinics through links with private laboratories and pharmacies in the neighbourhoods, and tiered referrals to access these services. These models have produced impressive results.

“When I visited the largest slum in Mumbai with over one million people, I saw a model of care that seems to work whereby private practitioners are empowered to detect and report TB cases through the support of an NGO and patients are mobilized to access TB services through the incentive of vouchers,” said Dr Mario Raviglione, Director of WHO’s Global TB Programme.

India’s TB programme has shown its resolve in fighting drug resistance by rolling out drug-resistant TB services across the entire country. New drugs to treat MDR-TB have been introduced as well as the new shorter MDR-TB regimen, which cuts the duration of treatment in half - from two years to less than one year. The rapid TB test, Xpert MTB/RIF®, continues to be rolled out across the country, bringing the total number of sites offering Xpert testing to 628.

Despite substantial progress, India still has its work cut out in tracking the missing one million TB cases, particularly in the private sector, and ensuring that those in need of care and treatment are able to access it.

India is expected to complete its national drug-resistant survey by the end of 2016 and its national TB prevalence survey should begin in 2017. This underscores the country’s commitment to improving surveillance and ensuring that all TB patients, including those with MDR/XDR-TB, are properly diagnosed and treated.

TB research is also a top priority for the country. The newly formed TB research consortium reflects India’s commitment to develop new diagnostics, drugs and vaccines, which are urgently needed to end the epidemic.