Marking World Tuberculosis Day Union Health Minister Mansukh Mandaviya has once again reaffirmed the Indian Government’s commitment to making India tuberculosis (TB) free by 2025.
“Tuberculosis is a preventable & treatable disease. On World TB Day, we reaffirm commitment to make India TB-free by 2025 by ensuring access to quality healthcare & advanced treatment. Together we can and we will eliminate TB and work towards a healthy and disease-free [country]” Mandaviya tweeted.
The goal of elimination by 2025 is optimistic, as well as being five years in advance of the global target of 2030. This commitment was reaffirmed last year by Mansukh Mandaviya, as well as the year before by former Health Minister Dr Harsh Vardhan, but is India close to eliminating TB?
Last year India accounted for 27 percent of the global TB burden and 31 percent of mortality due to the disease. According to the India TB Report 2021, in 2019 India recorded 2.640 million cases, amounting to 193 per 100,000 population. The current World Health Organization (WHO) goal for 2035 is a reduction to less than 100 cases per million, given India’s current figure stands at 1,930 per million population this is a very ambitious target for what is now just a three year period.
The goal of elimination was put in place during the Union Health Budget 2017 – at the time offering a slightly more reasonable timeframe to reduce disease figures. However, even then the deadline was heavily criticised, with some noting that at the rate of decline of 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.
Given the impacts on health systems during the COVID-19 pandemic, efforts to eliminate other diseases have often fallen to the sides. As India grappled with incredibly high numbers of COVID-19 cases and the lockdown measures put in place to slow the spread, hospitals were overwhelmed, and many other diseases, TB included, may not have been adequately diagnosed or treated.
In 2020, Health Issues India reported on the effects of the pandemic on efforts to combat TB. One study found that the current gap in care resulting from the COVID-19 pandemic carried the potential to lead to an additional 6.3 million cases and 1.4 million deaths from tuberculosis by 2025. Such a dramatic rise has not yet been observed.
The study, entitled “COVID-19 -Tuberculosis interactions: When dark forces collide” by Zarir Udwadia, a pulmonologist at Mumbai’s P.D. Hinduja Hospital and Medical Research Centre placed a focus on the development of multidrug resistant strains of TB. “Miss a few days of any other treatment and you may not be harmed, but gaps in TB treatment will amplify resistance,” Udwadia said. “Our lack of health infrastructure is the reason we have been floundering amidst the sea of COVID cases. It’s the reason why we have not been able to make progress against traditional and old enemies like malaria, typhoid, dengue.”
Multidrug resistant tuberculosis (MDR-TB) is projected to account for 12.4 percent of cases by 2040 compared to 7.9 percent in 2000. Extensively drug-resistant tuberculosis is anticipated to account for 8.9 percent of cases by 2040, compared to just 0.9 percent in 2000.
Given the disruption to treatment experienced during the COVID-19 pandemic, these projections could be an underestimate. Drug resistance, in TB as well as other diseases, causes significant issues for both healthcare providers and the patients themselves. First line treatments become ineffective, leading to the use of second and third line treatments that are often far less easily available, and considerably more expensive than first line treatments. For some, these more expensive treatments will not be available, either through stock shortages or due to their expense. This allows the more dangerous drug resistant strains to proliferate.
Eventually, current medications become ineffective. This leads to an arms race with the resistant strains, with more research and investments required to create new treatments. Given the time that research, approval and rollout of a medication takes compared to the relative speed in which a pathogen can spread among the population, this could be a losing race.
“Tuberculosis was the top infectious disease killer before COVID & will remain after. This should not be acceptable to any of us. We need to invest in better tools, data, health services, awareness, reduce stigma, provide social support – in other words, multi-sectoral action!” tweeted Soumya Swaminathan, Chief Scientist at the WHO.
Development of drug resistance has presented a race against time to make the most of current medications before they almost inevitably become obsolete. As Soumya Swaminathan has said, elimination of TB will take nothing less than a multi-sectoral approach requiring cooperation from all levels from government to grassroots campaigns. India has shown phenomenal successes in areas such as polio eradication, however, given the ambitious timeline, India may be looking at another failed deadline.