India, TB and Its Goal

India, TB and Its Goal

Subject: Science and technology

Section: Health

What is Tuberculosis:

• Tuberculosis (TB) is an infectious airborne bacterial disease caused by Mycobacterium tuberculosis. .
• TB commonly affects the lungs (pulmonary TB) but can also affect other parts (extrapulmonary TB)
• Tuberculosis spreads from person to person through the air, when people who are infected with TB infection cough, sneeze or otherwise transmit respiratory fluids through the air.

What is Multidrug-Resistant TB (MDR-TB):

• In MDR-TB, the bacteria that cause TB develop resistance to antimicrobial drugs used to cure the disease.
• MDR-TB does not respond to at least isoniazid and rifampicin, the 2 most powerful anti-TB drugs.
• Treatment options for MDR-TB are limited and expensive.
• CBNAAT (Cartridges Based Nucleic Acid Amplification Test) is used for early diagnosis of MDR-TB.

What is Extensively Drug-Resistant TB (XDR-TB):

• XDR-TB is a form of multidrug-resistant TB with additional resistance to more anti-TB drugs.
• People who are resistant to isoniazid and rifampicin, plus any fluoroquinolone and at least one of three injectable second-line drugs (amikacin, kanamycin, capreomycin) are said to have XDR-TB

Status of TB Cases in India:

• India continues to have the largest share of the global TB burden.
• The total number of incident TB patients (new and relapse) notified during 2021 in India were 33 lakh as opposed to that of 16.28 lakh in 2020.
• In 2022, 22 lakh cases of TB were registered in the country.
• According to the National TB prevalence survey in India 2019-2021 report, nearly 64% did not get tested for TB. It varied from 46% in the case of Kerala to 88% in Haryana.
• 50% of all people with bacteriologically confirmed tuberculosis have no symptoms and by the time symptoms develop, transmission has probably already occurred.
• There is emerging evidence that TB may not fall under a binary of latent infection (asymptomatic and non-infectious) and active disease (symptomatic and infectious).
• Instead, TB may be a spectrum of disease, including incipient and subclinical stages.
• In 2020, the RNTCP was renamed as the National TB Elimination Program (NTEP) to underscore India’s goal to eliminate TB in the country by 2025, five years ahead of the Sustainable Development Goals.
• The National Strategic Plan for Tuberculosis Elimination(2017-2025) was developed to achieve the goal.
• Though the National Strategic Plan for Tuberculosis Elimination (2017-2025) outlined a paradigm shift in approach and strategy to achieve the ambitious goal, by 2020, it became clear that the NSP will not be able to meet these objectives.
• A new National Strategic Plan for Tuberculosis Elimination (2020-2025) to end TB was launched.

What is National Strategic Plan for TB Elimination:

• It is a framework to guide the activities of all stakeholders whose work is relevant to TB elimination in India.
• It provides goals and strategies for the country’s response to the disease during the period 2017 to 2025.
• It aims to direct the attention of all stakeholders on the most important interventions or activities that the RNTCP believes will bring about significant changes in the incidence, prevalence and mortality of TB.
• It will guide the development of the national project implementation plan (PIP) and state PIPs, as well as district health action plans (DHAP) under the national health mission (NHM).

What is Sputum smear microscopy:

• Sputum smear is a rapid test to detect the presence of acid-fast bacilli (AFB) but a single sputum test lacks sensitivity.
• Even when people finally get tested for TB, sputum smear microscopy with about 50% sensitivity has been used for diagnosis in a majority of the cases in India, thus leading to a huge number of missed TB cases.
• Drawbacks:
  • Besides lower sensitivity, smear microscopy is ill-equipped to diagnose rifampicin resistance.
  • Way back in 2014, the WHO guidelines clearly stated that GeneXpert may be used rather than conventional microscopy and culture as the initial diagnostic test in all adults suspected of having TB.

What is Molecular tests for TB:

• Molecular tests are not only more sensitive than smear microscopy, they also help identify rifampicin resistance at the outset.
• The rapid molecular diagnostic machines have been scaled up from 40 in 2014 to 5,090 in 2022.

Can improved nutrition help prevent TB:

• According to recent reports in Lancet and The Lancet Global Health nutritional support has helped prevent both tuberculosis (TB) among household contacts and mortality among TB patients in a trial in Jharkhand.
• In 2017, the World Health Organization had estimated that undernutrition is responsible for twice the number of TB cases than HIV globally

What was the outcome of the trial:

• The RATIONS (Reducing Activation of Tuberculosis by Improvement of Nutritional Status) trial enrolled 2,800 people with pulmonary TB disease and 10,345 household contacts of TB patients.
• While all the TB patients received nutritional support, household contacts were randomly assigned to receive either nutritional support or usual diet alone. There were 5,621 household contacts in the intervention arm and 4,724 contacts in the control group.
• While there were 108 (4%) deaths among TB patients across all body weights, mortality among those under 35 kg body weight (severely underweight) was 7%
• In comparison, in a study carried out by the Chennai Based NIRT in Tiruvallur district, Tamil Nadu, which did not provide any nutrition support to the TB patients, mortality was 14% in those weighing under 35 kg; mortality dropped to 4% among those weighing over 35 kg.
• Incidence of TB deaths reduced by 12% with a one­unit increase in BMI and by 23% for a two­unit increase in BMI.
• With nutritional support, at six months, the proportion of those with normal BMI increased from 16.5% to 43.5%.
• In general, extreme undernutrition — BMI less than 13 in men and BMI less than 11 in women — can often be fatal.
• However, in the current trial, more than 85% of such TB patients survived with nutritional support. Over 80% of TB patients had a BMI less than 18.5 and nearly 49% had a BMI less than 16 (severely underweight).
• There was 5% weight gain in the first two months which was associated with 60% lower risk of TB mortality.
• As per a 2022 study undertaken in India, the absence of weight gain during treatment in patients with severe undernutrition was associated with a five fold higher death rate. Among the household contacts, nutritional support led to a 39%­-48% reduction in TB disease in the intervention group compared with the control arm.
• In the study that lasted for six months, 122 people in the control group developed TB whereas the intervention arm had only 96 TB cases. There was a 39% reduction in TB incidence — pulmonary and extrapulmonary — while there was 48% reduction in pulmonary TB.
• The 39%-­48% reduction in TB disease in the household contact intervention arm was after adjusting for confounding factors such as TB preventive treatment to children below five

What effect does undernutrition have:

• According to WHO Global TB report 2022 many new cases of TB are attributable to five risk factors — undernourishment, HIV infection, alcohol use disorders, smoking (especially among men) and diabetes.
• In TB­endemic countries such as India, undernutrition is the most widely prevalent risk factor, accounting for the “highest population attributable risk for TB in India”
• As per a 2016 paper by NIRT researchers, undernutrition is an important risk factor for progression of latent TB infection to TB disease. It increases the risk of drug toxicity, TB relapse and mortality.
• For each unit reduction in BMI, the risk of TB increases by about 14%.
• Undernourished patients also tend to have poor bioavailability of drugs such as rifampicin, leading to treatment failure and development of multidrug resistance.

How do schemes like Nikshay Poshan Yojan and Ni­kshay Mitra help:

• Nikshay Poshan Yojana is a direct benefit transfer (DBT) scheme for nutritional support to TB patients. It was launched in 2018.
• All notified TB cases are provided with a financial incentive of ₹500 per month. 
• According to the 2022 India TB report, seven million TB patients have benefited between 2018 and 2022, and ₹2,089 crore has been disbursed during this period.
• Also, as of March 9, 2023, 55 lakh consented TB patients across India adopted by Ni­kshay Mitras will receive nutritional support

What are some other government measures:

• The National Tuberculosis Elimination Programme(NTEP) – Aims to strategically reduce TB burden in India by It was previously known as Revised National Tuberculosis Control Programme (RNTCP).
• The National Strategic Plan for TB Elimination – It was launched to achieve the target of ending TB by 2025 in a mission mode.It is a multi-pronged approach which aims to detect all TB patients with an emphasis on reaching TB patients seeking care from private providers and undiagnosed TB in high-risk populations
• Ni-kshay Poshan Yojana(Nutritional Support to TB) –  It helps to meet the nutritional requirements of TB patients, especially the underserved
• Patient Provider Support Agencies (PPSA) – To engage the private sector, Patient Provider Support Agencies (PPSA) have been rolled out across 250 districts through the domestic setup and JEET initiative
• Universal Drug Susceptibility Testing (UDST) – To ensure every diagnosed TB patient is tested to rule out drug resistance before or at the time of treatment initiation itself.
• Pradhan Mantri TB Mukt Bharat Abhiyaan – To bring together all community stakeholders to support those on TB treatment and accelerate the country’s progress towards TB elimination.
• Ayushman Bharat – Health and Wellness Centres – To decentralize comprehensive primary healthcare including TB care services at the grassroots level.
• Bedaquiline and Delamanid -Newer drugs like Bedaquiline and Delamanid have also been made available for management of DR-TB.