Tuberculosis Elimination Strategy
Assessing India’s Tuberculosis burden
Note4Students
From UPSC perspective, the following things are important :
Mains level: Issues related to health care;
Why in the News?
The Global Tuberculosis Report 2024 presented by WHO indicates that India recorded the highest burden of tuberculosis (TB) in 2023.
Current Scope of Tuberculosis in India
- High Burden: According to the Global Tuberculosis Report 2024, India accounts for 26% of all tuberculosis (TB) cases worldwide, making it the country with the highest TB burden. The report indicates that over 55.9% of global TB cases are concentrated in five countries: India, Indonesia, China, the Philippines, and Pakistan.
- Mortality Rates: Although TB deaths in India have decreased from 580,000 in 2010 to 320,000 in 2023, the country still accounted for 26% of global TB deaths among people with and without HIV in 2023.
- Incidence Trends: The incidence of TB has decreased from 275.7 cases per 100,000 population in 2010 to 194.9 cases in 2023. However, there has been a notable increase in notified TB relapse cases, reaching the highest level since 2010.
- Risk Factors: Individuals with nutritional deficiencies, diabetes, and smoking habits are at the highest risk of contracting TB. The prevalence of TB infection among individuals aged 15 and older is reported at 31.4%, according to the National TB Prevalence Survey conducted from 2019-2021.
- Preventive Treatment Uptake: The number of people receiving preventive treatment has been rising, indicating an increased focus on preventing TB progression among high-risk populations.
Strategies and Programs Implemented by Govt to Reduce TB Incidence
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Challenges India Faces in Eliminating Tuberculosis by 2025
- Funding and Infrastructure Gaps: Despite increases in domestic funding, overall financial resources remain lower than pre-COVID levels, impacting program implementation and outreach efforts.
- Inadequate healthcare infrastructure, particularly in rural areas, hampers access to timely diagnosis and treatment for many patients.
- The COVID-19 pandemic disrupted TB services significantly, leading to a backlog of undiagnosed cases and impacting ongoing treatment programs.
- Stigma and Discrimination: Stigma associated with TB continues to deter individuals from seeking diagnosis and treatment, which can lead to delayed care and increased transmission rates.
- Social determinants such as poverty, malnutrition, and living conditions contribute to higher susceptibility to TB among vulnerable populations.
- Drug Resistance Issues: The rise of drug-resistant strains of TB poses significant challenges for effective treatment and control strategies.
- Multi-sectoral Coordination Challenges: Effective elimination requires collaboration across various sectors (healthcare, education, social services), which can be challenging due to bureaucratic hurdles.
Way forward:
- Strengthening Multi-Sectoral Coordination: There is a need to foster collaboration among healthcare, education, and social services to address the social determinants of TB.
- Enhancing Accessibility and Outreach: Need to improve access to TB diagnosis and treatment in rural areas by investing in healthcare infrastructure, training local health workers, and implementing mobile health units.
Mains PYQ:
Q Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. (2014)
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Tuberculosis Elimination Strategy
Mycobacterium Tuberculosis Bacteria
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Mycobacterium Tuberculosis Bacteria
Why in the News?
- Due to increasing antimicrobial resistance in Mycobacterium tuberculosis (Mtb), many existing antibiotics are becoming less effective.
- As a result, researchers are studying Mtb to identify key proteins and design new drugs to target them.
What is Mycobacterium tuberculosis (Mtb)?
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What do various studies say?
- A 2024 CSIR-CCMB study showed that Mtb uses cysteine synthase enzymes to survive oxidative stress.
- A 2017 Karolinska Institute study identified 71 compounds that inhibit these enzymes, improving the effectiveness of antibiotics like isoniazid.
- Researchers found that Mtb’s ability to evade the immune system is due to its long evolution with humans.
- Other studies focus on Mtb’s phosphate and carbon metabolism, critical for its survival in hostile environments.
- Ways for effective medicine development:
- Target enzymes like CysK2 and CysM to weaken Mtb’s defence mechanisms.
- Study Mtb’s metabolic pathways to identify vulnerabilities for new drug development.
- Explore how Mtb develops antibiotic resistance and find ways to overcome it.
- Investigate how Mtb evades immune responses by manipulating immune cells.
- Combine new inhibitors with existing antibiotics to enhance treatment efficacy.
PYQ:[2014] Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. |
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Tuberculosis Elimination Strategy
Sharpening India’s anti-tuberculosis fight
Note4Students
From UPSC perspective, the following things are important :
Prelims level: About BPaL/M;
Why in the News?
In the present context, in India, there are groundbreaking new treatments available, but we need to rethink and update the program to eliminate TB.
Current status of TB in India:
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What were the problems with previous Extended Treatment Regimen?
- Lengthy and Complex: Traditional TB treatment regimens are long and require patients to take 13 to 14 tablets daily for 9 to 11 months, or 4 to 5 tablets daily for 18 to 24 months.
- Severe Side Effects: These regimens are physically and psychologically draining, causing side effects like loss of hearing and psychosis.
- Economic Impact: Prolonged treatment leads to loss of employment and drives many families into poverty due to the need for frequent clinic visits.
WHO-Recommended Effective Regimen:
- BPaL/M Regimen: WHO has recommended a shorter, safer, and more effective regimen called BPaL/M for drug-resistant TB patients.
- Advantages: This regimen requires only 3 to 4 tablets daily for six months, with fewer side effects and higher success rates (89% compared to 68% for traditional treatments).
- Close to 80 countries have procured the BPaL/M regimen, and 20 high-burden countries are already rolling it out.
Present TB Elimination Policy in India:
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How India can make the best use of new treatments?
- Proactive Screening and Diagnosis: Focus on modernizing health datasets, GIS mapping, and conducting targeted multi-disease screening drives, especially in vulnerable populations (e.g., those with comorbidities, slum dwellers, and prisoners).
- Advanced Diagnostic Tools: Expand the use of portable X-ray machines with AI-driven tools and rapid molecular tests for faster and more accurate detection and drug resistance profiling.
- Early Detection and Treatment: Leveraging new technologies and proactive measures will help improve TB detection rates, reduce delays, and enhance treatment outcomes, ultimately aiding in the elimination of TB in India.
Conclusion: India need to invest in advanced diagnostic tools like AI-driven portable X-ray machines and rapid molecular tests to ensure early and accurate detection of TB, particularly in high-risk and underserved populations, to support timely treatment and reduce TB incidence.
Mains PYQ:
Q Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. (UPSC IAS/2014)
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Tuberculosis Elimination Strategy
India to roll out BPaL Regimen for Drug-Resistant TB
Note4Students
From UPSC perspective, the following things are important :
Prelims level: BPaL Regimen
Why in the News?
India is preparing to introduce the BPaL (bedaquiline, pretomanid, and linezolid) regimen for all patients with multi/extensively drug-resistant tuberculosis (M/XDR-TB).
What is BPaL Regimen?
| Details | |
| Purpose |
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| Components of the regimen | Bedaquiline (Bdq):
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Pretomanid (Pa):
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Linezolid (Lzd):
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Significance of BPaL Regimen
- Studies and trials have shown that the BPaL regimen has higher success rates in treating MDR and XDR TB compared to older regimens.
- It reduces treatment duration for MDR/XDR-TB from the traditional 18-24 months to 6 months approx.
- It is entirely oral with NO injectable, making it easier for patients to adhere to the treatment.
- It reduces number of drugs patients need to take daily from up to 14 to just 3.
PYQ:[2014] Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. |
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Tuberculosis Elimination Strategy
ICMR develops CRISPR Cas-based TB Detection Kit
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TB, CRISPR Cas-based TB Detection Kit
Why in the News?
The Indian Council of Medical Research (ICMR) Regional Medical Research Centre for North East has developed the “world’s cheapest CRISPR Cas-based TB testing system”.
Back2Basics: CRISPR-Cas9 Technology
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About the New TB Detection System
- The system can detect TB bacteria using DNA from a patient’s saliva at a very low cost.
- Specific DNA sequences unique to Mycobacterium tuberculosis (the bacteria causing TB) are identified.
- It can identify the bacteria in preliminary stages and test over 1,500 samples simultaneously within approximately two hours.
- The technology is simple enough to be used in primary health centres in villages.
TB Situation in India:
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National Goals for Elimination of TB:
- Pradhan Mantri TB Mukt Bharat Abhiyan (2022): It is stipulated to meet the goal of ending the TB epidemic by 2025 from the country, five years ahead of the Sustainable Development Goals (SDG) for 2030.
- Nikshay Poshan Yojana (2018): Launched in 2018, this scheme provides nutritional support to TB patients. Under this scheme, TB patients receive a direct benefit transfer (DBT) of Rs. 500 per month to purchase food.
PYQ:[2019] What is Cas9 Protein that is often mentioned in news? (a) A molecular scissors used in targeted gene editing (b) A biosensor used in the accurate detection of pathogens in patients (c) A gene that makes plants pest-resistant (d) A herbicidal substance synthesized in genetically modified crops [2014] Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved. |
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Tuberculosis Elimination Strategy
The challenge of Extra-Pulmonary TB
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Diseases in the News;
Mains level: Health and Diseases in India;
Why in the News?
A tuberculosis patient receives treatment from a nurse (instead of a specialist) at a TB hospital in Guwahati.
What is meant by Pulmonary Tuberculosis (TB)?
- Pulmonary tuberculosis (TB) is a serious infection caused by the bacterium Mycobacterium tuberculosis (MTB) that involves the lungs but may spread to other organs where it destroys body tissue. TB is a contagious disease that can infect anyone exposed to MTB.
- It constitutes a significant portion of the TB burden in India, accounting for more than 20% of cases.
Present status of Extra-Pulmonary Tuberculosis (EPTB) in India:According to the World Health Organization (WHO) reports, there are over 10 million new cases of TB every year and India alone accounts for 27% of the global TB burden. However, the burden of EPTB is hard to estimate. EPTB is often stain-negative, which means it is not detectable on regular TB stain tests. |
The twin challenges of the Knowledge Gap:
- Lack of awareness:
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- Among Physicians: Many healthcare providers are unaware that TB can affect organs other than the lungs, such as the eyes and other immune-privileged sites.
- Among Patients: Nearly 1/5th of TB patients have EPTB. Most of them go undiagnosed, and the few who are diagnosed cannot benefit from care unless they visit a few specialist health facilities.
- Lack of Accurate Diagnostic and Treatment Criteria: There is a lack of accurate diagnostic criteria for EPTB, making it challenging to identify the disease correctly. Treatment protocols for EPTB are not well-established or widely known, complicating effective management.
- Although guidelines like INDEX-TB (a set of guidelines by WHO for EPTB management in India) have been formulated, their implementation has remained dormant.
- The current system for collecting EPTB data is fragmented, with specialist departments maintaining diverse data practices.
- National Patient Management Portals, such as Ni-kshay in India, have incomplete and missing data on EPTB patients.
Need to Prioritize Research and Development (R&D) for EPTB:
- Need to understand the infection mechanism deeply: A troubling aspect of EPTB infection is the prolonged presence of disease markers even after the infection is resolved with treatment.
- This phenomenon causes a lot of misery to persons with EPTB and is an active area of research.
- Prioritize Advanced Immunological Tools: Advanced Immunological Tools such as single-cell RNA sequencing, will be able to uncover the immune mechanisms for the disease.
- This will also help physicians to understand the treatment better, instead of going for long-duration anti-TB therapy (sometimes for even two years or more).
Mains PYQ:
Q Can overuse and free availability of antibiotics without a Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved.
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Tuberculosis Elimination Strategy
Clinical Trials for MTBVAC Tuberculosis Vaccine in India
Note4Students
From UPSC perspective, the following things are important :
Prelims level: MTBVAC, TB, DOTS Regimen, Nikshay Poshan Yojana
Mains level: NA
What is the news?
- Bharat Biotech, in collaboration with Spanish biopharmaceutical company Biofabri, has initiated clinical trials for the Mycobacterium Tuberculosis Vaccine (MTBVAC) in India, marking a significant milestone in TB vaccine development.
- The only currently available TB vaccine, the Bacillus Calmette-Guérin vaccine (BCG), was developed 100 years ago and is less effective.
About MTBVAC
- MTBVAC is a unique TB vaccine based on a genetically modified form of Mycobacterium tuberculosis, containing all antigens present in human-infecting strains, unlike the BCG vaccine.
- It is developed in the laboratory of the University of Zaragoza with contributions from Dr. Brigitte Gicquel of the Pasteur Institute, Paris.
- MTBVAC is designed to offer superior and potentially longer-lasting protection compared to the BCG vaccine, particularly for newborns and in preventing TB in adults and adolescents.
Objectives of Clinical Trials in India
- Safety and Immunogenicity: The ongoing trials in India aim to evaluate the safety and immunogenicity of MTBVAC, with plans for a pivotal Phase 3 trial in 2025.
- Population Significance: Studying the vaccine’s efficacy in India, with its high TB burden, is crucial for advancing TB vaccine research and addressing the global TB epidemic.
What is Tuberculosis?
- Tuberculosis is an infection caused by Mycobacterium tuberculosis.
- Robert Koch discovered Mycobacterium tuberculosis which causes TB, and his discovery opened the way towards diagnosing and curing this disease.
- It can practically affect any organ of the body.
- The most common ones are lungs, pleura (lining around the lungs), lymph nodes, intestines, spine, and brain.
Transmission:
It is an airborne infection that spreads through close contact with the infected, especially in densely populated spaces with poor ventilation.
Symptoms:
Common symptoms of active lung TB are cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats.
Treatment Facilities in India:
- DOTS (Directly Observed Treatment, Short-Course) regimen: It is the recommended treatment approach for TB by the WHO. Patients receive a combination of four antibiotics: isoniazid, rifampicin, pyrazinamide, and ethambutol. These drugs are usually administered daily for the first two months of treatment, followed by a continuation phase with isoniazid and rifampicin for an additional four to seven months.
- Nikshay Poshan Yojana (2018): It was launched to support every Tuberculosis (TB) Patient by providing a Direct Benefit Transfer (DBT) of Rs 500 per month for nutritional needs.
Issues in TB Treatment: Drug Resistance
Drug resistance emerges when anti-TB medicines are used inappropriately, through incorrect prescription by health care providers, poor quality drugs, and patients stopping treatment prematurely.
- Multidrug-resistant tuberculosis (MDR-TB): Itis a form of TB caused by bacteria that do not respond to isoniazid and rifampicin, the 2 most powerful, first-line anti-TB drugs. MDR-TB is treatable and curable by using second-line drugs such as
- Extensively drug-resistant TB (XDR-TB): Itis a more serious form of MDR-TB caused by bacteria that do not respond to the most effective second-line anti-TB drugs, often leaving patients without any further treatment options.
PYQ:
2014: Can overuse and free availability of antibiotics without Doctor’s prescription, be contributors to the emergence of drug-resistant diseases in India? What are the available mechanisms for monitoring and control? Critically discuss the various issues involved.
Practice MCQ:
With reference to the Tuberculosis (TB), consider the following statements:
- TB is an infection caused by Mycobacterium tuberculosis.
- It only targets Lungs.
- Nikshay Poshan Yojana aims for TB support is essentially a Direct Benefit Transfer (DBT).
How many of the given statements is/are correct?
- One
- Two
- Three
- None
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Tuberculosis Elimination Strategy
Gendered Challenges in TB Care
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Nikshay Poshan Yojana , Nikshay Mitra
Mains level: Gendered Lens on TB Care
In the news: Case Study
- The intersection of gender norms, economic instability, and homelessness presents unique challenges in accessing tuberculosis (TB) care for women like Reshma.
- Amidst systemic inequities and societal biases, their journey through diagnosis, treatment, and recovery is often fraught with obstacles.
- A recent study sheds light on the nuanced experiences of homeless women grappling with TB, urging a reevaluation of existing healthcare frameworks.
Gendered Lens on TB Care
- Reshma’s Story: Reshma, a homeless woman from Jaipur, embodies the complex narratives surrounding TB care. Her journey, marked by societal abandonment and inadequate healthcare, epitomizes the challenges faced by homeless women battling TB.
- Gender Norms and Diagnosis: Patriarchal norms influence the accuracy and timeliness of TB diagnosis for women, impacting their access to healthcare facilities and adherence to treatment regimens.
- Impact of Economic Precarity: Economic instability exacerbates the vulnerability of homeless women, hindering their ability to navigate TB care pathways effectively.
Data Insights and Inequities
- Study Findings: A recent survey in Jaipur highlighted the prevalence of TB among the homeless population, underscoring the dire conditions that facilitate TB transmission.
- Gender Disparities: Homeless women, like Reshma, bear a disproportionate burden of TB infections, revealing systemic gender inequities within TB care systems.
Barriers to Access and Treatment
- Documentation Challenges: Lack of identity proof and access to banking services impedes homeless women’s eligibility for government-sponsored TB care Initiatives, such as the Nikshay Poshan Yojana and Nikshay Mitra.
- Stigma and Social Dynamics: Societal stigma surrounding TB, coupled with patriarchal control over finances, further marginalizes homeless women, hindering their access to nutritional support and treatment adherence.
Navigating Diagnosis and Care
- Diagnostic Delays: Vague symptoms and logistical barriers contribute to delayed TB diagnosis among homeless women, prolonging their suffering and increasing the risk of disease progression.
- Treatment Adherence: Mobility constraints and medication shortages undermine treatment adherence among homeless women, necessitating tailored interventions to address their unique needs.
Way Forward
- Inclusive Healthcare Policies: Recognizing the intersectionality of homelessness and gender within TB care, policymakers must prioritize the rights and well-being of homeless women in national TB eradication initiatives.
- Investment in Care Ecosystems: A comprehensive approach to TB care for homeless women requires increased investment in counselling, tracking, and support services, acknowledging the heightened challenges they face in accessing and adhering to treatment protocols.
Conclusion
- Addressing the multifaceted challenges faced by homeless women in accessing TB care demands a concerted effort to dismantle gender biases, mitigate economic disparities, and foster inclusive healthcare ecosystems.
- By prioritizing equity and empowerment, policymakers can pave the way for a more just and effective TB care paradigm for all individuals, regardless of their socioeconomic status or gender identity.
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Tuberculosis Elimination Strategy
An ageing India needs age-responsive TB care
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TB and elimination strategy
Mains level: India's TB Prevalence, Challenges and responsibilities and measures,
What’s the news?
- TB, which affects over 25 lakh Indians every year and kills at least 1,000 every day, As India is on the cusp of a demographic shift, with the elderly population set to comprise a substantial portion of society, it is imperative to invest in the health of our elderly population and pay attention to their unique needs.
Central idea
- Advances in healthcare and increased life expectancy are propelling India’s demographic transition, with the elderly projected to constitute 12.5% of the population by 2030, up from 9% in 2011. This underscores the urgent need for age-responsive healthcare systems to address the complexities of TB care among the elderly, aligning opportunity with responsibility.
What is tuberculosis (TB)?
- TB is an infectious disease caused by the bacterium Mycobacterium tuberculosis.
- It primarily affects the lungs but can also affect other parts of the body, such as the kidneys, spine, and brain.
- TB is transmitted through the air when an infected individual coughs, sneezes, or speaks, releasing tiny droplets containing the bacteria. When inhaled by others, these droplets can lead to infection.
The Burden of TB among the Elderly
- Recent findings from India’s National TB Prevalence Survey in 2021 reveal a concerning trend: the prevalence of TB among individuals aged 55 and above stands at 588 per one lakh population, significantly higher than the national average of 316.
- This alarming disparity necessitates a dedicated focus on TB among the elderly and the formulation of age-specific TB guidelines.
Challenges faced by elderly TB patients
- Delayed Diagnosis: TB symptoms, including cough, fatigue, and weight loss, are often misinterpreted as signs of old age or other illnesses. Consequently, TB diagnoses among the elderly are frequently delayed or overlooked.
- Comorbidities: Many elderly TB patients have multiple comorbidities, especially diabetes, which complicates TB management. This leads to a higher pill count and an increased likelihood of side effects, affecting treatment adherence and outcomes.
- Access to Healthcare: Elderly individuals, particularly those in rural and hilly areas, struggle to access healthcare facilities due to mobility challenges. This can lead to delays in seeking medical care.
- Limited Information: Older individuals may have restricted access to reliable health information, as their social networks tend to shrink with age. This lack of information hampers their ability to recognize TB symptoms and seek timely medical attention.
- Economic Dependence: Most individuals over the age of 60 are retired and financially dependent on savings or family. While there are some social welfare schemes for the elderly, they often have limitations and may not provide adequate financial support.
- Stigma and Mental Health: TB-related stigma is a concern among the elderly, contributing to social isolation. Many elderly TB patients experience loneliness, anxiety, and a sense of purposelessness, negatively impacting their mental health.
Strategies to address these challenges and provide elder-friendly TB care
- Holistic Care Models: Transition from disease-specific care to holistic models that reduce the need for elderly patients to interact with multiple healthcare providers and facilities.
- Health Professional Training: Build the capacity of healthcare professionals at all levels to better understand TB in the elderly and manage multiple comorbidities effectively.
- Improved Case-Finding: Enhance case-finding mechanisms through effective sputum collection and transportation systems, mobile diagnostic vans, and active case-finding at geriatric OPDs and residential homes.
- Technical Protocols: Develop technical and operational protocols that guide the diagnosis and treatment of TB in the elderly, including sample extraction, comorbidity assessment, and drug dosage adjustments.
- Socio-Economic Support: Design and implement support protocols in consultation with elderly TB patients, including community care models, doorstep medicine delivery, peer support, counseling, and assistance with accessing social support schemes.
- Data Collection and Analysis: Ensure rigorous gender and age-disaggregated data collection and analysis to identify TB trends among the elderly, with a dedicated age category in all TB reports.
- Strengthen Collaboration: Foster collaboration within the healthcare system to build elderly-friendly care systems effectively.
- Research Agenda: Promote research focused on TB in the elderly, exploring state-specific trends, substance use, drug resistance, co-morbidity patterns, TB preventive therapy uptake, and intersectionality with other equity aspects.
Conclusion
- On this International Day of Older Persons, India must reaffirm its commitment to the well-being of its elderly citizens. By implementing age-responsive TB care models, strengthening healthcare systems, and conducting focused research, we can pave the way for a healthier, more inclusive future for our aging population.
Also read:
India’s diabetes epidemic is making its widespread TB problem worse
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Tuberculosis Elimination Strategy
Lancet TB study: Food for cure
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Tb eradication goal and initiatives
Mains level: India's TB burden, initiatives, challenges and way forward
What’s the news?
- A recent study published in the medical journal Lancet reveals a significant link between nutrition and tuberculosis (TB) survival.
Central idea
- Undernutrition has, for a long time, been recognized as the leading risk factor for tuberculosis. In India, modeling studies have suggested that addressing undernutrition could reduce cases by over 70 percent in vulnerable states. A study in the Lancet shows that a good diet not only reduces the incidence of the disease among vulnerable people living with infected people, but it also reduces mortality in TB patients.
A Jharkhand Case Study
- A study observed a striking 60% reduction in mortality risk among TB patients who gained weight early in the disease.
- Early weight gain is directly linked to improved survival rates.
- The data underscores the immediate positive impact of proper nutrition on TB outcomes.
- Early weight gain correlates with lower mortality rates, highlighting the significance of a well-balanced diet.
- The study’s results carry crucial implications for policymakers and healthcare practitioners.
- A study addresses a vital knowledge gap by emphasizing the direct influence of nutrition on TB patients.
Impact of TB on Nutrition
- Diminished Appetite and Caloric Intake:
- 75% of TB patients experience significant appetite reduction during treatment.
- Reduced food intake leads to an inadequate caloric supply, worsening nutritional deficiencies for those already combating TB.
- Fever-Driven Caloric Expenditure:
- Fever amplifies caloric expenditure by 10–15% in TB patients.
- Increased calorie loss due to fever exacerbates the nutritional imbalance in individuals with TB.
- Wasting and Weight-for-Height Ratio:
- Over 40% of severe TB cases result in wasting, causing low weight-for-height ratios.
- Wasting intensifies nutritional strain, necessitating comprehensive strategies to address this challenge.
- Nutritional Recovery and Relapse Risk:
- Patients with poor diets during recovery face nearly 30% higher relapse rates.
- Inadequate nutritional recovery raises the risk of TB relapse, highlighting the importance of post-TB dietary care.
Government Initiatives to Eliminate Tuberculosis
- Nikshay Poshan Yojana: A government scheme providing financial aid to TB patients Aims to alleviate nutritional challenges during treatment and recovery.
- Policy Guidelines on Nutrition: The National Tuberculosis Elimination Programme (NTEP) recommends a daily caloric intake of 2,800 calories for TB patients. It enhances patients’ nutritional status, which is vital for effective recovery.
- Challenges in Implementation: The 2020 study highlights healthcare providers’ difficulties in executing nutritional support. It Sheds light on potential hindrances to ensuring effective aid distribution.
- Nutritional Education Integration: The government introduces awareness campaigns on the importance of proper nutrition during and after TB treatment. Empowers patients to make informed dietary choices, aiding recovery and reducing relapse risks.
- Path to Elimination: The government‘s aim is to eliminate TB by 2025. The government seeks to reduce the disease burden, including its nutritional implications for the affected population.
Challenges in Addressing TB’s Nutritional Impact
- Awareness and Education Gap: Limited awareness among TB patients and healthcare providers regarding the importance of proper nutrition during treatment. This hinders the adoption of adequate dietary practices that can positively influence recovery.
- Nutritional Support Integration: Difficulty in seamlessly integrating nutritional support within the broader TB treatment framework. Patients may not receive the required dietary assistance, potentially hampering their overall health outcomes.
- Resource Constraints: Limited resources to provide consistent and effective nutritional aid to all TB patients Inadequate support might lead to unequal access to nutritional assistance, affecting recovery rates.
- Complexity of Implementation: The implementation of nutritional programs, such as Nikshay Poshan Yojana, might be hampered by administrative complexities. Delays in aid distribution could compromise timely nutritional support for TB patients.
- Socio-Economic Factors: Socio-economic disparities affect patients’ ability to access nutritious foods. Underprivileged individuals might face difficulties maintaining a balanced diet, negatively influencing their recovery.
- Fragmented Approach: Lack of coordination among different government departments and stakeholders involved in TB care and nutritional support Fragmented efforts could lead to inefficiencies and gaps in providing holistic care to TB patients.
- Cultural and Dietary Diversity: Designing nutritional interventions that accommodate the diverse dietary preferences and cultural practices of TB patients, One-size-fits-all approaches might not be effective across various cultural contexts.
Way forward
- Enhanced Nutritional Counseling: Strengthen healthcare providers’ training to offer comprehensive nutritional counseling to TB patients. Empowered patients make informed dietary choices, aiding recovery and reducing relapse risks.
- Holistic Nutritional Assessment: Integrate nutritional assessments as a standard procedure in TB patient care. Customized dietary plans can counteract malnutrition, promoting faster recovery.
- Collaboration with NGOs: Partner with non-governmental organizations to extend nutritional aid and support. A wider reach ensures that nutritional assistance reaches vulnerable populations effectively.
- Strengthening Nikshay Poshan Yojana: Evaluate and refine the scheme based on challenges highlighted in the 2020 study. An optimized scheme ensures the efficient distribution of financial support for nutritional needs.
- Leveraging Digital Platforms: Utilize technology for nutritional awareness campaigns and real-time monitoring of patients’ dietary adherence. Technology enhances outreach and aids in tracking patients’ progress.
Conclusion
- For India, a nation grappling with a high TB burden, the Lancet study emphasizes the urgency of integrating robust nutritional strategies into TB elimination programs. By addressing implementation challenges and promoting patient awareness, India can navigate closer to its ambitious TB eradication goal by 2025.
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Tuberculosis Elimination Strategy
BPaL Trial yields 85% TB Cure Rate
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Bedaquiline, Pretomanid, and Linezolid (BPaL) Treatment
Mains level: Elimination of TB from India
Central Idea
- The interim results of a randomized phase-3/4 trial conducted in India to evaluate the safety and effectiveness of BPaL Regimen, an all-oral, short-course treatment are promising.
- BPaL is administered for individuals with pre-XDR TB or treatment-intolerant/non-responsive MDR pulmonary TB
What is BPaL?
- The trial uses only three drugs—Bedaquiline, Pretomanid, and Linezolid (BPaL).
- The treatment duration is only 26 weeks, contrasting with the conventional 18-month treatment involving eight to nine tablets per day.
Trial Outcomes
- It offered a significantly reduced number of tablets per day, resulting in better treatment adherence and improved outcomes.
- Approximately 70% of the trial participants have completed the 26-week treatment, with a cure rate exceeding 85%.
- In comparison, the cure rate for conventional treatment for DR-TB is 60-65% even with strict adherence.
Treatment Superiority
- Advanced TB Cases: The trial participants had advanced TB affecting both lungs, yet the cure rate was above 85%, demonstrating the superiority of the BPaL short-course therapy.
- Importance of Early Diagnosis: Early diagnosis and initiation of treatment with the three-drug regimen can lead to even better outcomes for patients with pre-XDR TB.
Issues with the treatment
- Three to four trial participants experienced serious adverse effects, but these were either managed or occurred too late in the disease’s progression to be helped.
- Some cases of mild adverse effects caused by linezolid included a drop in haemoglobin and platelet counts, as well as neuropathy (tingling sensation and numbness in the legs).
TB Menace in India
- Total TB Cases: In 2021, there were approximately 21.3 lakh (2.13 million) reported TB cases in India.
- Incidence Rate: The incidence rate of TB in India in 2021 was 210 cases per lakh population.
- Drug-Resistant TB: The number of drug-resistant TB cases in India declined from around 1.49 lakh in 2015 to 1.19 lakh in 2021.
- Government Initiatives: To combat TB, India has set the target of eliminating the disease by 2025, and various initiatives have been implemented, including active case finding, screening, and improved access to diagnostic tests and treatment.
Back2Basics:
XDR TB (Extensively Drug-Resistant TB) |
Treatment-Intolerant/Non-Responsive MDR Pulmonary TB |
| Resistant to most effective first-line and some second-line TB drugs. | Patient cannot tolerate prescribed medications or infection does not respond to treatment. |
| More dangerous and difficult to treat than MDR TB. | Requires exploration of alternative treatment regimens. |
| Limited treatment options, higher mortality, and increased transmission risk. | Adjustments in drug combinations or dosages may be needed. |
| Spreads rapidly, posing a serious public health threat. | Crucial to prevent development of extensively drug-resistant strains. |
| Requires preventive measures and early diagnosis. | Identifying reasons for treatment intolerance and providing support. |
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Tuberculosis Elimination Strategy
Tuberculosis (TB) Should No Longer Exists in the 21st Century: India can lead the way
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TB, disease, vaccines and other developments
Mains level: TB elimination strategy
Central Idea
- At the One World TB Summit in Varanasi, Uttar Pradesh on March 24, 2023, Prime Minister Narendra Modi called for a fresh approach to the global tuberculosis (TB) elimination response, with innovation and research being central drivers of change. This is a critical step as India and the world look to redefine their TB elimination response. India’s recent progress in TB control efforts and COVID-19 response provides a good reflection point, which offers lessons to address the challenges faced in the fight against TB.
India’s Progress in TB Control Efforts
- Expanded reach and improved detection measures: India’s National TB Elimination Programme has introduced several measures to find, notify, and treat TB cases, resulting in expanded reach and improved detection measures. As a result, the number of TB case notifications has significantly increased, rising from 15.6 lakh in 2014 to over 24 lakh in 2022.
- Innovative approaches: India has adopted innovative approaches to TB management, including engagement with the private sector, launch of social support provisions, and introduction of diagnostic tools and new drug regimens. These measures have improved TB management in the country.
- Increased investment in health research and development: India has recognized the importance of investing in health research and development, especially in recent years. The Mission COVID Suraksha programme to develop vaccines was a good example of a public-private partnership, with clear goals and outcomes. The country has also established centres of excellence, which will facilitate collaboration between Indian Council of Medical Research laboratories and the private sector.
- Expansion of diagnostic tools: India has been working on expanding access to diagnostic tools for TB. Innovations such as nasal and tongue swab-based tests for TB can be a game changer by reducing diagnostic delays, and handheld digital x-ray machines with artificial intelligence-based software can now be taken to villages and urban settlements to screen large numbers of high-risk individuals.
- Introduction of new therapeutic molecules: India has been investing in the development and introduction of new therapeutic molecules for TB treatment. Shorter, safer, and more effective regimens, such as the 1HP regimen for latent TB infections, the four-month regimen (HPZM) for drug-susceptible TB, and the six-month regimen (BPaL/M) for drug-resistant TB, have been developed.
Why there is a Need for Disruptive Approaches and New Tools in TB elimination response?
- Lack of widespread awareness: Despite the progress made by India’s National TB Elimination Programme, there is still a lack of widespread awareness about the disease, which has led to delayed diagnosis and treatment.
- Access to quality care: Many people with TB in India and other developing countries do not have access to quality care, which has led to high rates of morbidity and mortality.
- Limited diagnostic tools: There is a need to expand access to diagnostic tools for TB, especially in rural and remote areas.
- Drug-resistant TB: The emergence of drug-resistant TB has made treatment more difficult, requiring the development of new therapeutic molecules and regimens.
- Need for innovative approaches: Innovative approaches are needed to change the way TB is prevented, diagnosed, and treated.
- Rapidly evolving technology: Advances in technology, such as point-of-care tests, artificial intelligence-based software, and handheld digital x-ray machines, have made it possible to develop new tools to combat TB.
- For example: Innovative technologies such as handheld digital x-ray machines with artificial intelligence-based software and nasal and tongue swab-based tests for TB can reduce diagnostic delays and provide rapid, low-cost diagnostics. Similarly, newer and more effective regimens and repurposed existing drugs for TB can play a crucial role in the long run.
Importance of Prioritizing TB Vaccine Trials
- Vaccines are key to ending the TB epidemic: Vaccines are one of the most effective ways to prevent infectious diseases. For TB, a vaccine would be a critical tool for ending the epidemic, especially for those who are at the highest risk of developing and spreading TB.
- BCG vaccine is not effective for all: The current TB vaccine, Bacille Calmette-Guérin (BCG), is not effective for everyone, especially adolescents and adults who are at the highest risk of developing and spreading TB. Therefore, new and effective vaccines are needed to provide adequate protection.
- Multiple TB vaccine candidates in the pipeline: There are currently over 15 TB vaccine candidates in the pipeline, which have shown promise in pre-clinical and clinical trials. Prioritizing these clinical trials will help identify the most effective vaccine candidates for various community settings and different target groups.
- Cost-effectiveness: Vaccines are a cost-effective way to prevent diseases, and a TB vaccine would be no different. Investing in TB vaccine trials and development would save resources in the long run by reducing the burden of TB on health systems and economies.
- Global impact: TB is a global public health issue, affecting millions of people worldwide. The development of a new TB vaccine would have a significant impact not only in India but also in other high-burden countries.
Facts for prelims: Types of vaccine technologies
|
Vaccine Technology |
Explanation |
Examples |
| Inactivated or killed vaccines | Use viruses or bacteria that have been inactivated or killed so that they can no longer cause disease | Inactivated polio vaccine, hepatitis A vaccine |
| Live attenuated vaccines | Use viruses or bacteria that have been weakened so that they can’t cause disease in healthy people | Measles, mumps, and rubella (MMR) vaccine, yellow fever vaccine |
| Protein subunit vaccines | Use pieces of the virus or bacteria, such as proteins or sugar molecules, to stimulate an immune response | Human papillomavirus (HPV) vaccine, pertussis (whooping cough) vaccine |
| Nucleic acid vaccines | Use genetic material from the virus or bacteria, such as DNA or RNA, to stimulate the immune system | COVID-19 mRNA vaccines from Pfizer-BioNTech and Moderna |
| Viral vector vaccines | Use harmless viruses, such as adenoviruses, to deliver genetic material from the target virus or bacteria into the body to stimulate an immune response | Johnson & Johnson COVID-19 vaccine, Ebola vaccine developed by Merck |
How Testing and Diagnosis of TB can be improved?
- Increased access to diagnostic tools: There is a need to increase access to diagnostic tools for TB, especially in rural and remote areas. Innovative approaches such as point-of-care tests (POCTs), including home-based tests, can provide decentralized, rapid, and low-cost diagnostics to provide results within minutes.
- Introduction of new diagnostic tools: New innovations such as nasal and tongue swab-based tests for TB can be a game changer by reducing diagnostic delays. Further, handheld digital x-ray machines (with artificial intelligence-based software) can now be taken to villages and urban settlements to screen large numbers of high-risk individuals, safely and conveniently.
- Strengthening the laboratory network: It is essential to strengthen the laboratory network in India to ensure quality diagnostics, especially in the private sector. Accreditation of private laboratories for TB diagnosis and linking them with the public sector is essential.
- Integration with other healthcare services: TB testing and diagnosis need to be integrated with other healthcare services to improve access and reduce stigma. For example, TB screening can be done in conjunction with diabetes or HIV screening.
- Empowering patients: Empowering patients with knowledge about TB symptoms and diagnostic tests can help increase awareness and improve early diagnosis. TB awareness campaigns can also help reduce stigma associated with the disease.
- Collaboration between public and private sectors: Collaboration between the public and private sectors can improve access to diagnostic tools and reduce the time required for TB testing and diagnosis. The private sector can be leveraged to provide affordable and quality TB diagnostics and treatment.
Need for Appropriate Policy Frameworks
- Smoothening the rollout of proven tools: Creating regulatory and policy frameworks can smoothen the rollout of proven tools to reach people with as little delay as possible. This requires greater collaboration between policymakers, scientists, product developers, and clinical researchers across the country and even across regions.
- Harmonization of standards and regulatory processes: Harmonization of standards and regulatory processes between countries can enable mutual recognition of evidence-based standards and licenses and save critical time towards rollout.
- Addressing the regulatory challenges: Appropriate policy frameworks can address the regulatory challenges of introducing new tools and approaches. This can help reduce the time and cost of clinical trials and shorten the time to market for new tools and products.
- Encouraging innovation: Policy frameworks that incentivize innovation can encourage the private sector to invest in TB research and development. This can lead to the development of new and effective tools for TB prevention, diagnosis, and treatment.
- Supporting public-private partnerships: Appropriate policy frameworks can support public-private partnerships that can bring together the strengths of both sectors to develop and scale up innovative solutions for TB control.
Conclusion
- India’s scientific ingenuity during the COVID-19 pandemic has cemented its position as pioneers in innovation in the life sciences. India must use its G-20 presidency to build a global health architecture that creates equitable access for all. India must use this opportunity to call for the collaborative development of transformational tools and approaches that cater to not only India’s needs but also those of the under-represented but disproportionately affected developing world. TB should no longer be the leading infectious disease killer globally in the 21st century, and India can lead the way.
Mains Question
Q. At the One World TB Summit held at in Varanasi recently, Prime Minister Narendra Modi called for a fresh approach to the global tuberculosis (TB) elimination response. In this light discuss India’s Progress in TB Control Efforts and the need for disruptive approaches and new tools in TB elimination response.
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Tuberculosis Elimination Strategy
Strengthening the Fight Against Tuberculosis (TB)
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TB
Mains level: TB Burden, Challenges and solutions
Central Idea
- The fight against tuberculosis (TB) has been going on for over 30 years since it was declared a global health emergency, yet the goal of ending TB by 2030 is still uncertain. The fight against TB needs a renewed focus on three key areas i.e., vaccine development, newer therapeutic agents, and improved diagnostics to meet the goal of ending TB by 2030.
Background
- In 1993, the World Health Organization declared TB a global health emergency and the 1993 World Development Report stated that TB treatment for adults was the best buy among all developmental interventions.
- Since then, the global response to TB has been slow and lacks urgency.
Global Fund
- The Global Fund to Fight AIDS, TB, and Malaria was created in response to the call for action against TB at the G7 summit in Okinawa, Japan, in 2001.
- The Global Fund has become the single largest channel of additional funding for global TB control.
- However, it faces constraints due to zero-sum games from donor constituents and competition between the three diseases it finances.
StopTB Partnership
- The StopTB Partnership was constituted to mobilize and marshal a disparate set of actors towards the goal of ending TB.
- It has been adapting to changes, such as using molecular diagnostic tools developed to respond to bioterrorism to diagnose TB and using social safety programs to address the poverty drivers of the TB epidemic.
Facts for prelims: Basics of TB
- Tuberculosis is an infectious disease caused by bacteria called Mycobacterium tuberculosis.
- It mainly affects the lungs, but can also affect other parts of the body such as the kidneys, spine, and brain.
- TB spreads through the air when a person with active TB disease in the lungs or throat coughs, sneezes, or speaks.
- Symptoms of TB include coughing that lasts for three or more weeks, chest pain, coughing up blood, fatigue, fever, and weight loss.
- TB can be treated with antibiotics, but drug-resistant forms of TB are a growing concern.
Three key areas that need attention
- Vaccine development:
- The development of an adult TB vaccine is the first area that needs urgent attention.
- The current vaccine is 100 years old, and the development and wide use of an adult TB vaccine are essential to ending TB.
- COVID-19 vaccine development process provides insights into accelerating the process.
- India’s capabilities can play a significant role in vaccine development and equitable distribution.
- Newer therapeutic agents for TB:
- A few new anti-TB drugs are available but face cost and production constraints.
- Shorter, injection-free regimens are needed to improve compliance and reduce patient fatigue.
- A continuous pipeline of new drugs is essential to combat drug resistance.
- Improved diagnostics:
- AI-assisted handheld radiology and passive surveillance of cough sounds can revolutionize TB diagnostics.
- Incentivize biotech startups to disrupt the complexity and price barriers of molecular testing.
Conclusion
- India’s leadership role in the G20 and the upcoming StopTB Partnership board meeting in Varanasi provide the perfect opportunity for India to lead the way in ending TB. With the collective will and action of leaders, it is possible to end TB sooner rather than later.
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Tuberculosis Elimination Strategy
Tamil Nadu’s TN-KET initiative results in reduced TB deaths
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TB
Mains level: Elimination of TB from India
Tamil Nadu has pioneered an initiative across the State to reduce the mortality rate among people with tuberculosis named: TN-KET (Tamil Nadu Kasanoi Erappila Thittam) meaning TB death-free project.
What is TN-KET?
- TN-KET aims to reduce the mortality rate among people with tuberculosis.
- This initiative, which began in April 2022, has already achieved significant reduction in the number of early TB deaths.
Unique features
- Differentiated TB Care: This is at the heart of the initiative, which aims at assessing whether people with TB need ambulatory care or admission in a health facility to manage severe illness at the time of diagnosis.
- Radiological assessment: The guidelines require comprehensive assessment of 16 clinical, laboratory and radiological parameters.
- Triage of assessment: The preliminary assessment of patients based on just three conditions — very severe undernutrition, respiratory insufficiency, and inability to stand without support — was found to be feasible for quick identification at diagnosis.
Outcome: Significant reduction in early TB deaths
- Above features vastly cut down the delay and increasing the chances of saving lives.
- The initiative has achieved the initial target of 80% triaging of patients, 80% referral, comprehensive assessment and confirmation of severe illness, and 80% admission among confirmed.
- The State’s target is to achieve 90%-90%-90% at each district.
Key challenges
- The challenge is to increase the duration of admission, especially for people with very severe undernutrition, which comprises 50% of the admitted patients.
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Tuberculosis Elimination Strategy
TB mukt India
Note4Students
From UPSC perspective, the following things are important :
Prelims level: multi drug resistant TB
Mains level: TB control
Context
- People’s participation in the ‘TB-Mukt India’ campaign can help eliminate the disease by 2025.
What is TB?
- A potentially serious infectious bacterial disease that mainly affects the lungs.
How TB is caused?
- Tuberculosis (TB) is caused by a type of bacterium called Mycobacterium tuberculosis. It’s spread when a person with active TB disease in their lungs coughs or sneezes and someone else inhales the expelled droplets, which contain TB bacteria.
What does TB do to humans?
- It mainly affects the lungs, but it can affect any part of the body, including the tummy (abdomen), glands, bones and nervous system.
How long has the TB infected us?
- TB is as old as humanity itself, infecting us for at least 5,000 years. The infecting agent, a bacterium, was identified way back in 1882, by Robert Koch, signalling one of the landmark discoveries which laid the foundation of modern medicine
Is TB painful?
- If TB affects your joints, you may develop pain that feels like arthritis. If TB affects your bladder, it may hurt to go to the bathroom and there may be blood in your urine. TB of the spine can cause back pain and leg paralysis. TB of the brain can cause headaches and nausea.
Can we get TB if vaccinated?
- BCG is a vaccine for TB. This vaccine is not widely used in the United States, but it is often given to infants and small children in other countries where TB is common. The BCG vaccine is not very good at protecting adults against TB. We can still get TB infection or TB disease even if you were vaccinated with BCG.
When do TB symptoms start?
- TB disease usually develops slowly, and it may take several weeks before you notice you’re unwell. Your symptoms might not begin until months or even years after you were initially infected. Sometimes the infection does not cause any symptoms. This is known as latent TB.
Is TB curable permanently?
- TB can usually be completely cured by the person with TB taking a combination of TB drugs. The only time that TB may not be curable is when the person has drug resistant TB.
What are drug-resistant tuberculosis?
- Drug-resistant tuberculosis (DR-TB) is a form of antimicrobial resistance that is difficult and costly to treat. It is caused by TB bacteria that are resistant to at least one of the first-line existing TB medications, resulting in fewer treatment options and increasing mortality rates.
Risk factors for TB include
- Poverty
- HIV infection.
- Being in jail or prison (where close contact can spread infection)
- Substance abuse.
- Taking medication that weakens the immune system.
- Kidney disease and diabetes.
TB statistic for mains
We are home to 1 in 4 of the world’s TB patients.
Over 2.5 million Indians are infected.
Government initiatives
- Nikshay Poshan Yojana: in which TB patients receive Rs 500 every month while on treatment was launched. Nikshay Poshan Yojana ensure that the patients have economic support and nutrition during the required period.
- TB Harega Desh Jeetega Campaign: was launched to accelerate the efforts to end TB by 2025. The campaign aims to initiate preventive and promotive health approaches.
- Community-led approach: By applying “multi-sectoral and community-led” approach, the government is building a national movement to end TB by 2025.
- Ni-kshay Mitra: Any individual or organisation can register as Ni-kshay Mitra on the Ni-kshay 2.0 portal to support people affected by the disease. The initiative intends to provide essential nutritional and social support to people with TB and root out stigma and discrimination against them.
Some positive suggestions to eliminate TB
- Sincere efforts need to be made to make our health systems more accessible and reliable.
- It also required to ensure that those seeking care trust the healthcare system and get the appropriate care for completing treatment.
- There is a need to create more labs, point of care tests, an assured drug pipeline, access to new drugs.
- The government should also ensure counselling and support for those affected.
- Every patient who is diagnosed late and does not receive timely treatment continues to infect others.
- To break this cycle, government machinery at the field level should work with communities and provide free diagnosis and treatment to every affected individual.
Conclusion
- We have ignored TB for too long. It’s time we acknowledge the magnitude of the disease, and work harder at offering individuals equitable healthcare access and resources that the disease warrants.
Mains question
Q. Do you think we can eliminate TB by 2025? Discuss the roadmap and give some affirmative actions to be taken by government.
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Tuberculosis Elimination Strategy
Nutrition status and TB risk
Note4Students
From UPSC perspective, the following things are important :
Prelims level: MDR TB
Mains level: Paper 2- TB challenge
Context
Historical importance of good nutrition was ignored by the modern therapist who tried to control TB initially with streptomycin injection, isoniazid and para-aminosalisylic acid. In the ecstasy of finding antibiotics killing the germs, the social determinants of disease were ignored.
Lack of patient-centric TB treatment
- With more drug arsenals such as rifampicin, ethambutol, pyrazinamide, the fight against TB bacteria continued, which became multidrug resistant.
- The regimes and the mode of delivery of drugs were changed to plug the loopholes of non-compliance of patients.
- Blister packs of a multi-drug regime were provided at the doorstep, and the directly observed treatment/therapy (DOT) mechanism set up.
- Many of the poor discontinued blister-packaged free drugs thinking that these were “hot and strong” drugs not suited for the hunger pains they experienced every night.
Role of nutrition in dealing with TB
- India has around 2.8 million active cases. It is a disease of the poor.
- And the poor are three times less likely to go for treatment and four times less likely to complete their treatment for TB, according to WHO, in 2002.
- The fact is that 90% of Indians exposed to TB remain dormant if their nutritional status and thereby the immune system, is good.
- When the infected person is immunocompromised, TB as a disease manifests itself in 10% of the infected.
- The 2019 Global TB report identified malnutrition as the single-most associated risk factor for the development of TB, accounting for more cases than four other risks, i.e., smoking, the harmful use of alcohol, diabetes and HIV.
- The work and the findings of a team at the Jan Swasthya Sahayog hospital at Ganiyari, Bilaspur in Chhattisgarh established the association of poor nutritional status with a higher risk of TB.
Way forward
- Chhattisgarh initiated the supply of groundnut, moong dhal and soya oil, and from April 2018, under the Nikshay Poshan Yojana of the National Health Mission.
- All States began extending cash support of ₹500 per month to TB patients to buy food. This amount needs to be raised.
- Nutrition education and counselling support: Without simultaneous nutrition education and counselling support, this cash transfer will not have the desired outcome.
Conclusion
Food is a guaranteed right for life under the Constitution for all citizens, more so for TB patients. Thus, the goals of reducing the incidence of TB in India and of reducing TB mortality cannot be reached without addressing undernutrition.
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Tuberculosis Elimination Strategy
Fighting TB with lessons learnt during Covid pandemic
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Not much
Mains level: Paper 2- Covid lessons for TB
Context
On World TB day, we need to ask how best we can leverage the lessons learnt from Covid-19 to help gain a new momentum in TB control.
Comparing the impact of Covid-19 and TB
- In the first year of the Covid-19 pandemic, 1.8 million people were reported to have succumbed to the virus.
- In the decade between 2010-20, 1.5-2 million individuals died every year because of tuberculosis.
- The difference in responses to the two pandemics can only be explained by the differences in the profiles of those who get infected.
- TB disproportionately affects people in low-income nations, the poor and the vulnerable.
- The increased burden on healthcare to manage Covid has led to a serious setback in TB control.
Using lessons from Covid-19 for TB control
- To leverage the lessons learnt from Covid-19 to control TB, we need to focus on the epidemiological triad: Agent, host and the environment.
- Test, treat and track has been a strategy successfully employed for Covid.
- Scaling up testing: We need to aggressively scale up testing with innovative strategies such as active surveillance, bidirectional screening for respiratory tract infections using the most sensitive molecular diagnostics, and contact tracing.
- Vaccine: The biggest victory against Covid has been the speed with which vaccines were developed, scaled up and deployed.
- We need to replicate the same for tuberculosis, lobbying for funding from governments and industry to develop a successful vaccine for TB.
- Social security programs for the prevention of risk: Malnutrition, poverty and immuno-compromising conditions such as diabetes are some of the factors strongly associated with TB.
- Social security programmes that work towards prevention of modifiable risk factors would possibly pay richer dividends than an exclusive focus on “medicalising” the disease.
- Environmental factors: Environmental factors which have been neglected include ventilation of indoor spaces, educating individuals to avoid crowds when possible, and to encourage voluntary masking, especially in ill-ventilated and closed spaces.
- Investment and actions: Covid has been a stellar example of how investments and actions can be swift, and public education can transform behaviour.
- Similar aspirations for TB can help turn this crisis into an opportunity to re-imagine our overburdened and underfunded systems.
- Involvement of private sector: We need to actively engage the private sector, build bridges and partnerships as we did in the case of Covid.
Way forward
- The country needs to invest in state-of-the-art technologies, build capacity, expand its health workforce and strengthen its primary care facilities.
- It also needs to consider telemedicine and remote support as important aspects of health services.
- We need to build an open and collaborative forum where all stakeholders, especially affected communities and independent experts, take a lead role.
Conclusion
We have ignored TB for too long. It’s time we acknowledge the magnitude of the disease, and work harder at offering individuals equitable healthcare access and resources that the disease warrants.
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Tuberculosis Elimination Strategy
TB’s steep socio-economic cost to women
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Nikshay Poshan Yojana
Mains level: Paper 2- TB's impact on women
Context
As India steadily steers its way through the pandemic to safer shores, we must foreground a disease which has been impacting our country for years, and disproportionately affecting women – tuberculosis.
Toll of TB
- In India, the TB case fatality ratio increased from 17 per cent in 2019 to 20 per cent in 2020.
- According to a joint report (2010-13) of the Registrar General of India and the Centre for Global Health Research, TB was the fifth-leading cause of death among women in the country, accounting for nearly 5 per cent of fatalities in women aged 30–69.
How TB affects women more than men
- Much steeper socio-economic price: While both men and women suffer the consequences of this debilitating disease, women patients pay a much steeper socio-economic price.
- Beyond clinical metrics: From social ostracisation and lack of family support to the negative impact on marital prospects, women absorb the repercussions of TB beyond the clinical metrics.
- Stigma also acts as a strong deterrent when it comes to health-seeking behaviour.
- Fewer women, therefore, get included in the available cascade of care for TB.
Measures by government
- In 2019, the Health Ministry-Central TB Division developed a national framework for a gender-responsive approach to TB in India.
- The document takes cognisance of the challenges faced by women in accessing treatment and offers actionable solutions.
- Gender-responsive policy interventions: In December 2021, a parliamentary conference on ‘Women Winning Against TB’ was organised by the Ministry of Women and Child Development where gender-responsive policy interventions were discussed.
- The Vice-President of India urged states to take proactive steps such as ensuring nutritional support to women and children and the doorstep delivery of TB services, especially for women from socio-economically weaker backgrounds.
Suggestions
1] Highlight the issue at the relevant forum
- One, as elected representatives, we need to come together more to highlight the issue at all relevant forums and spaces.
- These meetings see increased participation of women leaders from all walks of life in the community going forward.
2] Strengthen counselling network
- We need to strengthen counselling networks for women patients and their families.
- Irrespective of where the patient seeks care – public or private sector – build the capacity of healthcare workers to educate the patient’s family about the importance of providing her a supportive environment during the course of her treatment.
3] Nutritional needs
- We need to ensure that the nutritional needs of women are being met.
- Undernutrition is a serious risk factor for TB and research indicates such risks are higher for women.
- It is commendable that the government, through Nikshay Poshan Yojana, has effectively provided a monthly benefit of Rs 500 to enable a nutritious diet for TB patients in the last few years.
- For the 2020 cohort, the total amount paid under NPY via DBT has been over Rs 200 crore.
- Additionally, we can look to further strengthen inter-departmental coordination, wherein the Public Distribution System can explore appropriate linkages with relevant departments of the MoHFW and even include a protein-rich diet for TB patients.
4] Amplify accurate TB messaging
- At a community level, we must amplify accurate TB messaging and showcase how gender plays a role in determining the course of action on the ground.
Conclusion
These are universal problems that must transcend gender binaries. Only when equitable solutions are offered to vulnerable sections of society will we be able to realise the dream of TB-Mukt Bharat.
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Tuberculosis Elimination Strategy
BCG vaccine: 100 years and counting
Note4Students
From UPSC perspective, the following things are important :
Prelims level: BCG, TB and other respiratory diseases
Mains level: Not Much
The first use of BCG (Bacillus Calmette-Guerin), the vaccine against tuberculosis (TB) in humans have been completed for 100 years.
What is TB?
- TB is a very ancient disease and has been documented to have existed in Egypt as early as 3000 BC.
- It is caused by a bacterium called Mycobacterium tuberculosis, belonging to the Mycobacteriaceae family consisting of about 200 members.
- Some of these cause diseases like TB and leprosy in humans and others infect a wide range of animals. Mycobacteria are also widely dispersed in the environment.
- In humans, TB most commonly affects the lungs (pulmonary TB), but it can also affect other organs (extra-pulmonary TB).
Yet not eliminated
- Other historically dreaded diseases like smallpox, leprosy, plague, and cholera have been either eradicated or controlled to a large extent due to advances in science and technology.
- However, TB continues to be a major public health problem in the world.
- According to the WHO’s Global TB Report, 10 million people developed TB in 2019 with 1.4 million deaths. India accounts for 27% of these cases.
BCG Vaccine for TB
- BCG was developed by two Frenchmen, Albert Calmette and Camille Guerin, by modifying a strain of Mycobacterium Bovis (that causes TB in cattle) till it lost its capacity to cause disease while retaining its property to stimulate the immune system.
- It was first used in humans in 1921.
- Currently, BCG is the only licensed vaccine available for the prevention of TB.
- It is the world’s most widely used vaccine with about 120 million doses every year and has an excellent safety record.
BCG in India
- In India, BCG was first introduced on a limited scale in 1948 and became a part of the National TB Control Programme in 1962.
- India is committed to eliminating TB as a public health problem by 2025.
Effectiveness of BCG
- One intriguing fact about BCG is that it works well in some geographic locations and not so well in others.
- Generally, the farther a country is from the equator, the higher is the efficacy.
- In children, BCG provides strong protection against severe forms of TB.
- This protective effect appears to wane with age and is far more variable in adolescents and adults, ranging from 0–80%.
- In addition to its primary use as a vaccine against TB, BCG also protects against respiratory and bacterial infections of newborns and other mycobacterial diseases like leprosy and Buruli’s ulcer.
- It is also used as an immunotherapy agent in cancer of the urinary bladder and malignant melanoma.
Try answering this PYQ:
What is the importance of using pneumococcal conjugate vaccines in India? (CSP 2020)
- These vaccines are effective against pneumonia as well as meningitis and sepsis.
- Dependence on antibiotics that are not effective against drug-resistant bacteria can be reduced.
- These vaccines have no side effects and cause no allergic reactions
Select the correct answer using the given code below:
(a) 1 only
(b) 1 and 2 only
(c) 3 only
(d) 1, 2 and 3
Post your answers here.
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Tuberculosis Elimination Strategy
A tale of two bugs
Note4Students
From UPSC perspective, the following things are important :
Mains level: Paper2- India has shown that it has political will, technical capacity and financial resource to control the infectious diseases it need to marshal these resou.rce to eradicate TB
Context
India needs to take TB at the same level of seriousness at which it is dealing with the Covid-19.
Contrast and between the response
- Tuberculosis in India: Indians will still have to contend with other deadly respiratory tract infections which spread via airborne transmission. We will still have to contend with one particular bug which kills millions of us and which has been around for millennia. Tuberculosis.
- But all comparisons between COVID-19 and TB end with the superficial observation that they are both deadly respiratory tract infections.
- Speedy tackling of COVID-19: COVID-19 began its march through humankind barely half a year ago and, in record time, scientists have identified the virus and hundreds of millions of dollars have been allocated to controlling its spread, developing vaccines (at last count, more than a dozen candidates) and testing medication regimens for those infected.
- Waning of the epidemic: While the virus has spread to over 100 countries, the epidemic already shows signs of waning in the Asian countries where it hit first and hardest.
Response to the TB
- How long has the TB infected us? On the other hand, TB is as old as humanity itself, infecting us for at least 5,000 years.
- The infecting agent, a bacterium, was identified way back in 1882, by Robert Koch, signalling one of the landmark discoveries which laid the foundation of modern medicine.
- How was the response to TB? The subsequent response to this disease, which was infamously called the White Plague and was a leading cause of death globally at the start of the 20th century, is similar to what we see today for COVID-19, but played out over decades rather than months.
- Measures taken: TB was made a notifiable disease, campaigns were launched to prohibit spitting and containment policies, including sequestering infected persons, were implemented.
- The first vaccine was produced over a hundred years ago, and the first curative treatments available by the 1950s.
- Divide between rich and poor in TB infections: TB was largely beaten in the rich world, not only because of these medical miracles but also thanks to the dramatic reduction in poverty and improvement in living standards.
- There is compelling evidence that addressing these social determinants was even more impactful than medical interventions in the war against TB.
- The disease of squalor: TB has always been, and this is even more true now than ever before, a disease of poverty and squalor. And no country is more affected than India.
- Every TB statistic is grim:
- We are home to 1 in 4 of the world’s TB patients.
- Over 2.5 million Indians are infected.
- In 2018, over 4,00,000 Indians died of the disease.
- To put this in stark perspective, more people died of TB in India last week than the entire global death toll of COVID-19 to date.
- Contrast with the response to COVID-19: Given our urgent, energetic and multifaceted response to the latter Covid-19, one is left wondering why we have failed so miserably for another bug, particularly one which has been around for so long, which has been exquisitely studied and characterised, which is preventable and treatable, and which most of the world has conquered.
Why TB has not been given such attention?
- It is because those who suffer from TB are not likely to be boarding international flights or passing through swanky airports to attend conferences.
- It is because TB infects people in slower tides, slow enough for industries to replace the sick with healthier recruits without endangering the bottom line.
- It is because TB does not threaten the turbines that keep the global economy throbbing.
- It is because TB no longer poses a threat to rich and powerful countries.
- It is because those who have TB live on the margins and have little political influence.
- It is because TB control requires society to address the squalid environments, which shroud the daily lives of hundreds of millions of Indians.
- It is because TB is a medieval scourge that reminds us of our shameful failure to realise a just, humane and dignified life for all our people.
Conclusion
If there is one lesson from COVID-19, it is that India, and the global community, has the political will, technical capacity and financial resources to act in a committed and concerted way to control infectious diseases. It needs to marshal these assets to eradicate TB, the most pernicious and pervasive infection of all, both through addressing its social determinants and scaling up effective biomedical interventions. But, for this to happen, we will have to be as concerned about the health needs of those who travel by foot and bicycle as we do for those who board cruise ships and international flights.
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Tuberculosis Elimination Strategy
TrueNat
Note4Students
From UPSC perspective, the following things are important :
Prelims level: TrueNat
Mains level: Menace of TB and its elimination measures
The WHO has endorsed TrueNat, an Indian indigenous molecular diagnostic tool for tuberculosis (TB) diagnosis.
TrueNat
- The TrueNat TB test is a new molecular test that can diagnosis TB in one hour as well as testing for resistance to the drug rifampicin.
- The TrueNat MTB and MTB Plus assays also show comparable accuracy to the TB-LAMP assay as replacement tests for sputum smear microscopy.
- The data for TrueNat MTB-Rif shows similar accuracy to WHO-approved commercial line probe assays.
- It is developed by the Goa-based Molbio Diagnostics.
- The company was provided with technical assistance and resources by the Foundation for Innovative New Diagnostics (FIND) to help commercialise Truenat.
- ICMR had assessed and validated the diagnostic tool. It has high diagnostic accuracy as initial test to diagnose TB.
- It will be used as an initial test thus replacing sputum smear microscopy.
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Tuberculosis Elimination Strategy
[op-ed snap]Eradication of TB by 2025
Note4Students
From UPSC perspective, the following things are important :
Prelims level: Not much.
Mains level: Paper 2-Issues relating to development and management of social sector/ services relating to health, education, human resources.
At the End TB summit, 2018 the prime minister of India made a bold commitment to end tuberculosis by 2025-five years ahead of the global target. Which is possible to achieve if the efforts are put at the level it was done in case of polio.
The toll taken by TB
- Despite the disease being fully curable, people still die from it.
- TB usually affects people in their most productive years and drives families into debt.
- It has a direct link to human suffering, discrimination and also poverty.
- Due to its infectious spread, it directly affects our economic growth as well.
- With resilience, sufficient investment, innovative approaches and strategies and the participation of all stakeholders, TB can be defeated.
First Step- Awareness
- The first step is the creation of awareness and empowering of communities.
- TB affects millions, yet very few know enough about it.
- Multilingual, multi-stakeholder awareness effort to ensure that all Indians knows about the challenges of TB and where to seek treatment is required.
- With the expansion of the media and evolving technology, it is possible to reach everyone with the right information.
Second Step- Access to diagnosis and treatment
- Ensuring that every Indian get access to correct diagnosis and treatment for TB, regardless of their ability to pay for it is the second step.
- To do so, working with the private sector is necessary as was done in the case of polio.
- There are numerous innovative private-sector programmes and partnership schemes for TB.
Role of Private sector
- Recently launched programmes for doctors and labs offer the private sector various incentives.
- Even today, about half a million TB cases go unnotified, especially those seeking care in the private sector.
- Those cases need to be tracked and ensured that everyone in the need of treatment and care gets it.
- Organisations like Indian Medical Association and Indian Academy of Paediatrics are working with the private sector to ensure patient-centric care as per “Standards of TB Care in India” (STCI).
Drug-resistant TB
- A key challenge is building a forward-looking plan to address and control drug resistance.
- Drug-resistant TB is a man-made menace that is a major roadblock in a fight against TB.
- Every TB patient must be tested for drug resistance at the first point of care, whether in the public or private sector, to rule out any drug resistance.
Efforts by the government
- Nikshay Poshan Yojana -in which TB patients receive Rs 500 every month while on treatment was launched.
- Nikshay Poshan Yojana ensure that the patients have economic support and nutrition during the required period.
- ‘TB Harega Desh Jeetega Campaign’ was launched to accelerate the efforts to end TB by 2025.
- The campaign aims to initiate preventive and promotive health approaches.
- By applying “multi-sectoral and community-led” approach, the government is building a national movement to end TB by 2025.
- Resource allocation towards the TB Elimination Programme has been increased by four-fold.
- Sincere efforts need to be made to make our health systems more accessible and reliable.
- It also required to ensure that those seeking care trust the healthcare system and get the appropriate care for completing treatment.
- There is a need to create more labs, point of care tests, an assured drug pipeline, access to new drugs.
- The government should also ensure counselling and support for those affected.
- Every patient who is diagnosed late and does not receive timely treatment continues to infect others.
- To break this cycle, government machinery at the field level should work with communities and provide free diagnosis and treatment to every affected individual.
Conclusion
With all the efforts, planning and resource put in place to eradicate the menace of TB from India, it is possible to achieve the goal by 2025.
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