Two tuberculosis deaths occur in India every three minutes. These can be prevented with proper care and treatment, we are told, but the goal has remained beyond reach for India and the rest of the world. It has often been referred to as a poor person’s disease, and there has been insufficient investment in developing vaccines or drugs. Poverty, malnutrition and lack of access to drugs add to the challenge.
In terms of population coverage, India has the world’s second largest DOTS programme. It is the largest in the world in terms of number of patients initiated on treatment, and its pace of expansion has been quite fast. More than 100,000 patients are placed on treatment every month.
Earlier, the focus was on detection — to encourage people to go for a check-up and sputum testing. But with Multi Drug Resistant TB cases proliferating, the focus is more on completion of the first course — which is the simplest way to defeat resistance.
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India’s TB burden is staggering. Every year, 1.8 million people develop the disease, and about 800,000 of these cases are infectious. Until recently, 370,000 died of it annually. The disease is a major barrier to social and economic development. An estimated 100 million workdays are lost to it, with the country incurring a huge cost – nearly $3 billion. The direct costs are $300 million.
The Revised National Tuberculosis Control Programme based on the DOTS strategy began as a pilot programme in 1993 and was launched in late-1998. Since then, more than 14.2 million patients have been treated and 2.6 million lives saved with DOTS.
The programme has had a success rate of more than 85 per cent in new smear positive patients, and led to the detection of 70 per cent of such cases over the last five years. However, nearly 40 per cent of the population is infected with the bacillus, and this large pool of infected people means TB will continue to be a major problem in the foreseeable future.
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The government’s Strategic Vision for 2012-2017 for TB control aims to achieve universal access, encourage advocacy for administrative and political commitment, and to keep TB control high on the health and development agenda. Communication for demand generation and stigma reduction, targeted behaviour change interventions and community mobilisation will be in focus. Services for the diagnosis and management of drug-resistant TB and TB-HIV co-infected patients are being scaled up for complete geographical coverage by the end of this year.
More than 15,000 suspected patients are being examined for TB, free of charge, each year. Diagnosis and follow-up is done on the basis of examining more than 50,000 laboratory specimens. Each day, about 3,500 patients get started on treatment. More than 6,00,000 health care workers have been trained, and more than 11,500 laboratory microscopy centres upgraded as part of the RNTCP. In rural India, particularly in States such as Bihar, Uttar Pradesh and Rajasthan with low health indicators, at least one trained Community DOT Provider is placed in every village.
However, due to inadequate infrastructure, and the different health-seeking behaviour pattern in urban areas, TB control faces unique challenges. Officials admit that issues of availability and access to preventive, curative and informative TB services in urban areas, especially with migrants and urban poor, need to be addressed. Targeted interventions are being planned to address migrant labourers in peri-urban areas, prison inmates and those in slums. To reach groups such as tribals that are difficult-to-access, target-oriented and issue-based strategies for demand generation are being processed as behavioural change communication interventions.