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How does India fare on the roadmap to elimination?

India has a prolonged history of setting ambitious elimination deadlines for a host of diseases, only to miss the deadline and simply re-announce another year. 

Many diseases, such as leprosy, are simply neglected with most individuals affected belonging to lower castes and viewed as outcasts from society — a view proliferative through thousands of years. The case for other diseases, such as tuberculosis, is far more dire. Many of these diseases are seeing growing tides of drug-resistant cases. This situation threatens to spiral out of control, eventually giving rise to strains of diseases that are all but untreatable.

There have been some success stories in recent years, though these are often few and far between. India’s capacity to control and even entirely eradicate diseases is not in doubt. India’s polio campaign was groundbreaking. Deemed to be one of the more difficult countries to eradicate polio due to population size and geographic diversity, India’s campaign was hailed the world over as a gargantuan success story. This was made possible through political will, grassroots efforts and international cooperation. This success can be replicated, though great effort will be needed.


Neonatal tetanus and yaws: the success stories

yaws elimination
Secondary yaws ulcerative lesions
Source: (September 2015). “Yaws.”. International journal of STD & AIDS 26 (10): 696-703. DOI:10.1177/0956462414549036. PMID 25193248

At the beginning of 2017, India was the first country included in the World Health Organization (WHO) Neglected tropical diseases roadmap to be free of both yaws (endemic treponematoses) and neonatal tetanus.

Yaws is a childhood infectious disease caused by the Treponema pallidum subspecies pertenue. The effects of the disease, if left untreated, can be severe, potentially causing chronic disfigurement and debilitation. The disease affects the skin, bones and cartilage and is found primarily in those under the age of fifteen, predominantly in ages six to ten. 

It can be transmitted person to person and is found more often in rural communities with impaired access to healthcare. The disease is easily and affordably treatable with a single oral dose of azithromycin, an antibiotic. However, before the eradication efforts, the disease had often proliferated throughout the country due to lack of diagnosis – commonly occurring in rural regions.

Neonatal tetanus, meanwhile, is a form of tetanus occurring in newborn babies. The condition is typically due to non-sterile conditions present during the birth and due to the weak immune system of the child is commonly fatal. Tetanus is caused by the spores of the bacterium Clostridium tetani releasing a neurotoxin. This neurotoxin is produced during the growth of the bacteria in dead tissue. In the case of neonatal tetanus, this may be the umbilicus following a non-sterile birth.

While India has shown some success in eradicating these conditions, the deadlines for many other diseases have already passed.


Measles: a former elimination goal of 2020

vaccine Copyright: keeratipreechanugoon / 123RF Stock Photo
Immunisation coverage is vital in the fight to eliminate measles and rubella. Image credit: keeratipreechanugoon / 123RF

Among the many promises of the Union Health Budget 2017 was the elimination of measles in India by 2020 — a deadline that has come and gone with measles still far above the elimination threshold.

While the deadline seemed overly optimistic, it did ride on the back of years of success stories in regards to reducing measles cases. Vaccine rollout had been increased consistently, with rural populations also being reached by campaigns. However, as seen with the global polio eradication effort, the last few cases present a far more difficult hurdle to cross than the initial stages of the campaign against the disease.

Data from the WHO shows that vaccination campaigns over the period from 2000 to 2015 reduced the number of deaths associated with measles by 79 percent globally. India’s performance has gradually increased, though it is not yet close to elimination.

Measles is one of the leading causes of child mortality in India. In 2015, the virus killed 49,200 Indian children, mostly under the age of five. That year, measles killed 134,200 children worldwide. India thus accounts for 36.6 percent of the world’s child mortality caused by measles, significantly higher than expected based on its share of the world’s population.

Following the Union Health Budget 2017, the WHO noted the underperformance of India’s vaccination campaign, stating “of the estimated 19.2 million infants not vaccinated with at least one dose of measles vaccine through routine immunization in 2018, about 6.1 million were in three countries: India, Nigeria and Pakistan.”

At 2.3 million, India has the second highest number of children who are not vaccinated against measles, a report published in Morbidity and Mortality Weekly Report (MMWR) noted. Only Nigeria at 2.4 million placed higher than India. However, this figure – taken in 2018 – does show clear progress. In 2017, India had 2.9 million unvaccinated children, showing a reduction of 600,000 in just a single year. Should this momentum be sustained, India could indeed eliminate measles within the country. 

The deadline of 2020, nonetheless, has come and gone. While measles vaccination has increased, much hinges on the current climate throughout the COVID-19 pandemic. Routine immunisation has been disrupted during this time, which will likely impact the measles figures over the coming years. 


India aimed to eliminate lymphatic filariasis by the end of 2017


Image credit: Kateryna Kon / 123rf
Wuchereria bancrofti, a roundworm nematode, one of the causative agents of lymphatic filariasis, 3D illustration showing presence of sheath around the worm and tail nuclei non-extending to tip. Image credit: Kateryna Kon / 123rf

The Union Health Budget 2017 set out an aim to eliminate lymphatic filariasis (LF) by the end of that year. This deadline has been revised several times. India, as a signatory to the World Health Assembly resolution for elimination, had initially set the target for elimination of filariasis by the year 2015, later aligning with the global target of 2020. This target has again been failed, with a revision again taking place though not yet set.

Health Issues India wrote at the time of the 2017 budget that “a time frame of ten months is quite possibly an attempt at political point scoring, rather than a potential prospect. Medical experts have implied that the goal is not possible, as simply mobilising campaigns and medical supplies to affected areas may in itself take more than the intended time frame.”

Indeed, such optimistic targets seem to be ignoring the technical capacities of the elimination efforts. Repeated imposition of deadlines, followed by failure to meet said targets, does little to improve the public’s perception of the healthcare sector. The failures to meet overly optimistic targets could even result in lesser performance down the line due to a lack of public faith in government health policies.

LF in particular is a difficult disease to actually declare to be eliminated. The symptoms of filariasis vary depending on the level of tissue infiltration of the roundworms, as well as the species of roundworm causing the infection. In the most extreme cases, infection can result in elephantiasis. This is caused by an infiltration into the lymphatic system, causing oedema and thickening of the skin resulting in large scale deformities, primarily in the lower extremities. While elephantiasis is an unignorable symptom, many who harbour the parasitic roundworms subcutaneously show no symptoms at all. Some infected patients display rashes. Many have mild to no symptoms at all.

In addition, the spread via a mosquito vector allows for unexpected resurgences. Long incubation times before severe symptoms arice can allow individuals to act as reservoirs for the disease, transmitting it to others while remaining unaware.


Visceral leishmaniasis: closest to eradication?

Copyright: drmicrobe / 123RF Stock Photo
Cutaneous leishmaniasis ulcer and close-up view of leishmania promastigotes

Of all the conditions with elimination deadlines, visceral leishmaniasis (VL) — also known as Kala-azar — may be the closest to being achieved. Cases are currently geographically isolated, a factor which may have a significant positive impact in controlling the disease. Bihar currently houses ninety percent of all VL patients, with three other states – Jharkhand, West Bengal and Uttar Pradesh – also known to have VL cases.

As Health Issues India reported at the time of the Union Health Budget 2017, “despite being the most likely to be eliminated, this target has been set and was not attained in previous announcements by the Indian government. In 2014…Health Minister Harsh Vardhan claimed the disease would be eliminated by 2015. Previous deadlines had been set for 2010.”

This, however, is not to say that progress is not being made. In fact, the overwhelming majority of areas affected by VL already fall within the elimination criteria. According to a recent report by the WHO, 94 percent of affected districts fall below the elimination threshold of one case per 10,000 population.

“There are around 130 million people at risk of Kala-azar in the 54 districts of four endemic States” said Dr Neeraj Dhingra, director, ofthe National Vector Borne Disease Control Programme, Ministry of Health and Family Welfare, in the WHO report. “We have made substantial progress in reducing the endemicity of kala-azar by ensuring house to house search, treatment and follow up of cases. We are determined to eliminate the disease soon and counter the challenges of continued transmission in the country.”

The disease has shown to be easily treated, with clinical trials of amphotericin B showing an efficacy of around 99 percent. This accounts for what the WHO states is a ninety percent reduction in the overall number of cases since concerted efforts began to curb the disease in 2005. However, where India is failing is in detection.

Health disparities are common in India, between the rich and the poor, and the urban and the rural. In rural settings the chances of an individual being diagnosed with a condition are far lower simply through lack of healthcare infrastructure. Adding to this a common lack of knowledge among the local population regarding health matters and a situation is created where many disease instances slip under the radar.

“What we find today is almost six percent of blocks are still above the elimination threshold and have high case fatality” said Dr Jorge Alvar, head of the mission who, in the past, led the global leishmaniasis elimination programme at WHO. “Compounded to this we’ve had weak reporting of relapsed cases, increased cases of post Kala-azar dermal leishmaniasis and inadequate tools for vector surveillance. All these need to be addressed along with a reinforcement of the national task force to harmonise efforts by stakeholders and the ministry of health.”

Progress has undeniably been made regarding VL. However, to truly declare the disease to be eliminated, and proceed to move to attempt to eradicate the condition, efforts must be made to improve surveillance among underperforming districts. 


Leprosy: an ongoing struggle


leprosy elimination Image ID: 81042848 (L)
Leprosy can result in infections that may require amputation

The 2017 budget gave yet another overly optimistic aim of eradicating leprosy in India by 2018. Once again this deadline has come and gone and leprosy remains an issue within the country. 

Far from approaching eradication — which would require zero new cases within the country — leprosy cases may even be increasing. As reported by Health Issues India at the time, the prevalence rate as of 2014 was 0.68 per 10,000 (86,000 cases), with India at the time home to 57 percent of the world’s leprosy patients.

A spike in the number of new infections has furthered alarm that the disease may be showing signs of a resurgence in India. 90,709 cases of leprosy were recorded in the 2017-18 period, statistics suggested.

Figures appear to vary depending on the source, with some suggesting the current numbers are actually an underestimate. The Central Leprosy Division of the Union Health Ministry reported the detection of 135,485 new leprosy cases in India in 2017. As noted by Health Issues India previously

“Given the current population of India, cited in 2017 as being 1.36 billion, these additional 135,485 cases would establish a rate of one person per 10,045 individuals who have contracted leprosy. While this figure falls within the accepted rate for elimination, it is worth reminding that this figure is just the new cases detected within 2017. This potentially entails that the overall figure for leprosy in India is now above the accepted limit for elimination criteria.”

Far from eradicating the disease by 2018, leprosy appears to be resurging. While the rising figures may also be an indication that diagnosis rates have improved, India is a long way from achieving the far more difficult aim of eradication.


Tuberculosis: an ever more difficult struggle for elimination

TB tuberculosis elimination Photo credit: Prof Madhukar Pai, MD, PhD Canada Research Chair in Epidemiology & Global Health Director, McGill Global Health Programs Associate Director, McGill International TB Centre
X-rays of a tuberculosis patient in India

At the time of the Union Health Budget 2017 the deadline set for the elimination of tuberculosis (TB) was far more reasonable in terms of timeframe. The deadline put in place was 2025. In contrast to the other deadlines that expected what would amount to major campaigns to be planned, underway and completed all within the same year, this deadline allowed some breathing space.

However, as noted at the time, at the rate of decline of tuberculosis (TB) prevalence in India over the past 24 years (0.91 percent per year), it would take India 183 years for the disease to be considered eliminated.

Tuberculosis may be among the more difficult diseases on the list to finally gain control over. Drug resistance is one of the key reasons the fight against TB must be prioritised. Failure to do so could see the goal become all but impossible in the years to come.

Globally, of the 500,000+ people who develop drug-resistant tuberculosis (DR-TB) each year, India contributes to over 25 percent of cases. On an annual basis, there are over 100,000 new cases of DR-TB in India. Notably, the cost of second and third-line treatments against drug resistant TB are far more expensive than the more commonly available first-line counterparts. As drug resistant strains are spread, the cost of fighting TB rises considerably.

Development of drug resistance has presented a race against time to make the most of current medications before they almost inevitably become obsolete. Many therapies are also being made less effective by the appearance of so-called “extensively drug-resistant TB” (XDR-TB).

Despite the grim outlook, Vardhan has reiterated the Government’s commitment for tuberculosis elimination by 2025. Grassroots campaigns are essential to this, according to Prime Minister Narendra Modi. He uses the term “TB-free village, panchayat, district and state.” 


A grim situation the world over

While the situation in India appears grim, it is not uncommon. Globally, disease elimination targets set by both countries and the WHO have been met with disappointment consistently. This situation rings true of both NTDS, often falling aside in terms of national priorities, and major killers such as HIV and malaria.

The situation appears to contradict itself. Diseases such as leprosy, among others flagged as NTDs, are by their very namesake, neglected. They occur predominantly in low- to middle-income nations and despite typically being treatable, continue to spread due to lack of healthcare infrastructure and low diagnostic capacity. 

By contrast, high-profile diseases such as HIV and TB often suffer from previous success in their campaigns. Vast amounts of progress have been made in reducing disease figures. Due to this, many countries have fallen into complacency and figures have often flatlined, with progress against the diseases now stalling. Reliance on outside donations has also left many health systems unable to accommodate their country’s disease burdens should this outside funding dry up.

Bruno Gryseels, director of the Institute of Tropical Medicine in Antwerp, in comments to The Financial Times, noted that the world will not always fund such prevention and control programmes, and suggests implementing the control programmes into national health services.

The situation is complex, with some sceptical of bulk donations by international non-government organisations (NGOs) or pharmaceutical companies as being simply a short-term remedy for a long-term problem. 

Sustainable solutions are necessary that do not rely on donations that will not last indefinitely. Healthcare infrastructure must also be improved. A stockpile of medication donated in bulk is worth nothing if it is not being administered where needed; neither is it of any use if the affected individuals are never diagnosed at all. India’s repeated failure in hitting deadlines is disappointing, though it is not alone in missing these targets. India was capable, through much effort, of eradicating polio. It can do so for other diseases if it has the capacity, the resources and the will.


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