Ministry of Health report disagrees with minister’s claim that India will end TB by 2025

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New Delhi: On March 25, Union Health Minister Mansukh Mandaviya released a “National Tuberculosis Prevalence Survey” and the country’s “Annual Tuberculosis Report” at a ceremony in Vigyan Bhawan in New Delhi.

These documents are important for a country’s assessment of the status of its tuberculosis (TB) elimination programs. In 2020 alone, India spent Rs 3,300 crore on its TB control programs.

The first, the prevalence survey, is actually a new effort and offers a previously unavailable means of assessing India’s progress and what course correction might be needed, if any.

However, it seems to be riddled with issues – at least eight are listed below. They include biases in favor of certain states, missing data, surveillance of disease patterns and reporting discrepancies, and data that appears to be at odds with government confidence.

Together they undermine confidence in the survey and raise concerns about whether the national government has a clear picture of what it needs to do to eliminate TB in India by 2025. Let’s start there.

1. Missing target – Union Health Minister Mansukh Mandaviya said on March 24 that India was on track to eliminate tuberculosis (TB) by 2025, and attributed this to the “leadership” of Prime Minister Narendra Modi. While the WHO had set 2030 as the target to achieve this extraordinary feat, Mandaviya added, Modi had achieved it five years earlier.

In 2017, three years after Modi took over as prime minister, India created a “national strategic plan” to eliminate TB by 2025. It aimed to reduce the prevalence of TB in India to 142 per 100,000 population by 2020, from a baseline of 217 in 2015. However, the TB prevalence survey indicated that the prevalence of TB among Indian adults was 312 per 100 000 in 2019-2021.

He also reported that the prevalence to notification ratio was 2.84 for the whole country. This means that for every 2.84 people with TB, only one was registered in the national surveillance system. The other 1.84 were “missed”.

The main challenge in the fight against tuberculosis is the missing cases. And 1.84 is a big number.

“This high ratio is… [a] a clear indicator that India is not on track to achieve elimination in the next three years,” said a TB expert who advises the Union government on condition of anonymity.

2. Missing data – The report says little about the efforts of individual states to eliminate TB, according to experts to whom Thread Science has spoken. Data from a few states were included, but their sheer number makes the rest of the missing data more significant.

Specifically, Delhi had the highest prevalence (747) in 2019-2021 while Gujarat had the lowest (137).

“When there is such variation, I would say we need subnational data,” said Yogesh Jain, a doctor in Chhattisgarh. The science of yarn. Jain has written several articles on the subject of eliminating TB.

He added: “For example, the tribal population is now known to be more prone to disease. What should a state with a large tribal population infer from the report? »

According to Jain, even the reasons for the prevalence of TB can differ. “There is a lot of tuberculosis in Kerala because of diabetes. It’s almost in epidemic proportions there. In Delhi, among migrants, or in Chhattisgarh, undernutrition could be the underlying cause.

According to him, no report could help in the development of tuberculosis control policies if it did not address the various causes of tuberculosis.

Shibu Vijayan, global technical director for TB at health nonprofit PATH, echoed Jain when he said India needed to take a more granular approach.

3. Performance mismatch – The report placed the prevalences of Kerala (149) and Gujarat (137) next to each other. However, the states have very different prevalence to notification ratios: 1:0.91 for Gujarat versus 3.33:1 for Kerala. This difference upset Vijayan’s mind.

“We know that TB is directly linked to the quality of a state’s socio-economic indicators,” he said, meaning the ratios in the report do not match what we know about well-being. relative of the two states.

For example, in the NITI Aayog Sustainable Development Goals assessment, Kerala scored 88 and 83 for eradicating hunger and poverty, while Gujarat scored 46 and 66 respectively (out of 100). Overall, Kerala ranked 1 on the index and Gujarat 11. This performance, however, is at odds with the new TB report.

“We really need to look beyond this report to understand what’s happening in these states, which are close to each other in terms of prevalence but differ so much otherwise,” Vijayan said.

4. Private facilities under the bus? – According to the report, healthcare seeking behavior towards choosing a government over a private facility for treatment was equipotent in Gujarat. In Madhya Pradesh, Himachal Pradesh and Uttarakhand, on the other hand, more people preferred private facilities.

At first glance, it appears that private sector institutions play just as important a role as government institutions.

Notification numbers tell a different story.

According to a government platform, the number of TB patients notified in government facilities in Gujarat from 1 January 2021 to 31 December 2021 was almost double those notified in private facilities. This was also the case in Madhya Pradesh. In Himachal Pradesh, 10 times as many TB patients were notified in public facilities.

One way to explain the discrepancy between the new TB report and the government portal notification data is that, although private facilities charge patients and treat them for TB, they do not register their patients in the national surveillance file.

In 2018, the Union Ministry of Health made TB notification mandatory in public and private facilities. Doctors who fail to do so are subject to punishment under Sections 269 and 270 of the Indian Penal Code. (The latter includes a jail term of up to two years.)

5. Single TB – Leena Menghaney, public health lawyer at Médecins Sans Frontières, said the report was completely silent on co-infections, meaning people who have both TB and HIV/AIDS or both tuberculosis and diabetes. She said these people are “a very large cohort”.

Menghaney also said the report contained almost no information on extra-pulmonary tuberculosis, that is, tuberculosis infections of the brain, bones, intestines and other parts of the body.

“The [report] The methodology said she was looking for patients who had lung damage or who had only had sputum tests.

Jain, in Chhattisgarh, also said the report was unclear as to whether the people who compiled checked the prevalence of these ‘other’ forms of TB. By conservative estimates, he added, extrapulmonary TB accounts for 30% of all people with TB in India.

6. Too Many Deaths – According to the annual TB report, 4.5 lakh people died in 2021 due to TB.

“We know that TB is a curable disease. Therefore, this high estimate, after so many years of a dedicated TB programme, is shocking and embarrassing,” said the TB expert at the Union Health Ministry.

The person also said that a major obstacle to reducing the number of deaths from tuberculosis was that the country’s doctors were following a not-so-standard treatment protocol, even though the ministry had published one.

7. An underutilized solution – Vijayan of PATH said we will need to “revamp” existing tools to eliminate TB for the foreseeable future.

“X-ray is an excellent tool that is underused for TB detection, although it is part of the diagnostic algorithm. If there is a case in a family, why do we have to wait for the other members cough and then propose [them] a laboratory test, which may not even be available in a village? ” He asked. “But an x-ray is available. It can detect lesions in the lungs.

These lesions can indicate TB – which can then be confirmed by a laboratory test.

This point is also mentioned in the TB prevalence survey, but nothing more. The investigation report reads as follows:

“We observed that 4475 (1.8%) participants had a chest radiographic abnormality suggestive of tuberculosis of at least two [experts], which was not microbiologically confirmed tuberculosis and therefore classified as clinically diagnosed tuberculosis. This is a higher percentage of chest radiographic abnormalities, indicating the importance of using chest radiographic examination in TB case finding activities. »

8. Neglecting food safety – If a person is well nourished and exposed to the bacteria that cause TB, the infection may not develop into disease.

“This has been proven in several studies. But any government that thinks it can eradicate TB without providing food for everyone is clearly not thinking about it,” Jain said.

Vijayan also said that it is high time India stopped confining TB elimination to the country’s health services.

“We have been providing TB drugs and diagnostics for ages now. We have made progress but we are not where we wanted to be. All social sector departments must present themselves as [part of] next generation TB strategy, for any tangible achievements. »

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