The long battle against tuberculosis

Even as tuberculosis continues to claim hundreds of thousands of lives each year, a new report of the World Health Organization shows countries have made significant progress in their battle against the disease in the last 20 years.

Released on Wednesday, the Global Tuberculosis Report, 2015, states that global prevalence of TB in 2015 is 42 percent lower than it was in 1992. It has also set 2035 as the target year for eradicating the disease.

Exactly 20 years ago, in 1995, the WHO established a global reporting system for tuberculosis, which enabled monitoring of the deadly disease. Since then, the apex health body has received reports of 78 million TB cases, of which 66 million have been treated successfully.

The report says that the year 2015 is a watershed moment in the battle against TB since many global TB targets were set for this year in the context of the Millennium Development Goals (MDGs). It is also a year of transitions—from the MDGs to a new era of Sustainable Development Goals (SDGs). The WHO terms the shift from MDG to SDG as moving from the “Stop TB Strategy” to the “End TB Strategy”.

Under the MDGs, around 20 annual rounds of data collection were concluded and almost 205 countries and territories, which account for more than 99 percent of the world’s population, participated.

The report highlights that the MDG target of halting and reversing the incidence of TB by 2015 was achieved globally, in all six WHO regions. The TB incidence rate has fallen at an average rate of 1.5 percent per year since 2000.

Globally, the TB mortality rate in 2015 was 47 per cent lower than in 1990, almost achieving the target of a 50-per cent reduction under the MDGs. Four WHO regions achieved the target (except the African and European regions).

All three targets for 2015 were met in the region of the Americas, the Southeast Asia region and the Western Pacific Region, and in nine High Burden Countries (HBCs) of Brazil, Cambodia, China, Ethiopia, India, Myanmar, the Philippines, Uganda and Vietnam.

However, India, Indonesia and China had the largest number of cases with 23 per cent, 10 per cent and 10 per cent of the global total cases respectively.

The WHO report says the world has experienced a marked increase in global TB notification in 2014 for the first time since 2007. The annual total of new TB cases, which had been about 5.7 million until 2013, rose to slightly more than 6 million in 2014 (an increase of 6 percent).

India saw a 29-per cent increase in notification of cases in 2014, largely due to the introduction of the policy of mandatory notification in May 2012. The country also created a national web-based reporting system in June 2012 and intensified efforts to engage the private health sector. India accounted for 27 percent of global TB notifications in 2014.

Despite progress in TB control, drug resistance is emerging as one of the major challenges in the battle against TB.  India is one of the most vulnerable countries as far as drug resistance is concerned.

The report states that if all the TB cases notified in 2014 had been tested for drug resistance, an estimated 300,000 would have been found to have multi-drug-resistant tuberculosis (MDR-TB), with more than half of them (54 percent) occurring in India, China and the Russian Federation.

Globally, an estimated 3.3 percent of new TB cases and 20 percent of previously treated cases have MDR-TB, a level that has changed little in recent years. In 2014, there were an estimated 480,000 new cases of MDR-TB worldwide, and approximately 190,000 died of MDR-TB, says the report.

By the end of 2014, data on anti-TB drug resistance was available for 153 countries, accounting for more than 95 percent of the world’s population and estimated TB cases. Eighty of these countries have continuous surveillance systems while others rely on epidemiological surveys.

With the eradication of TB becoming a target under the SDGs, the Global Tuberculosis Report has highlighted the ways in which this disease can be defeated by 2035.

It says that government stewardship and accountability, along with monitoring and evaluation, will play a major role in eradicating the disease. The agencies will have to adapt their strategies and targets at the country level with global collaboration. The role of civil society organisations and communities will be important in achieving the target.

It says that the early diagnosis of TB, including universal drug-susceptibility testing, and systematic screening of contacts and high-risk groups, are necessary measures in the process of dealing with the disease. The report recommends collaborative TB/HIV activities, management of co-morbidities and vaccination against TB.

All stakeholders, including communities, civil society organisations, public and private care providers, will have to play a significant role if this target has to be achieved. The report says that rational use of medicines along with measures like regulatory frameworks for case notification and vital registration will have to be taken into account.

The tuberculosis report highlights the impact of e-health intervention in the fight against the disease in India.

It adds that the number of new and relapse cases of the disease notified in India reached 1.61 million in 2014. This means a 29-per cent increase, as compared to 1.24 million in 2013.

The report has credited the increase to better reporting of detected cases to national authorities. Major interventions taken in this area in the recent period include the introduction of a policy of mandatory notification of TB cases in May 2012, launch of a new web-based system (Nikshay) for case-based notification to the Central TB Division (CTD), and setting up of National Informatics Centre, in June 2012. Through the Revised National Tuberculosis Control Programme (RNTCP), Indian authorities have also intensified the efforts to engage with the private sector, the process being facilitated by Nikshay, as per the report.

It further states that it was made mandatory for both public and private sector to notify the cases, in recognition of the fact that private sector plays a major role in treating TB patients. These cases, however, were not reported in government data collection programme (RNTCP). The private sector treats almost 50 per cent of total TB patients. Nikshay was introduced to tackle this challenge and facilitate reporting of all cases whether treated in private or public healthcare facilities. It is accessible via android-based smartphones and a web portal, both of which facilitate the process of notifying cases. Since it rolled out nationwide by the end of 2012, reporting from the private sector has grown and data quality has improved.

 By June 2015, more than 4.6 million TB patients had been reported by over 40,000 public and over 90,000 private health care facilities, with about 5,000 TB cases being added to the system each day, it says. The next phase of Nikshay’s development aims to capture geospatial data to enable spatial surveillance, and to use and record bar codes on medication boxes for drug supply chain and inventory management.

It also talks about linking the benefits given to patients and providers to their Aadhar cards. Three success stories from Mumbai, Patna and Mehsana have been highlighted as good examples of how digital technologies are helping the RNTCP to reach out to providers who are involved in TB care, but have previously been outside the reach of national surveillance.

In these settings, private providers can phone call centres free of charge to ensure free anti-TB medications for their patients. Patients receive “e-vouchers” for standardised medications, which they can redeem for free at private chemists. Call centres also issue reminders to patients for follow-up visits via telephone calls and SMS. This digital system is linked with the RNTCP so that programme staff members receive alerts and can take action as necessary. Incentives for notification are paid to providers electronically, as are payments for laboratory tests.