In India, eradicating TB is a multi-dimensional challenge

Internationally, tuberculosis (TB) kills 2.5 persons every three minutes. India has one of the highest rates of TB and drug-resistant TB in the world. This is a long-standing problem, but the Covid-19 pandemic made it worse. The WHO reported 18 % more TB cases in India in 2021 than in 2020.

The country needs a multi-pronged approach for tackling TB because its disease burden is so high, and drug resistances are quite prevalent. Apart from treatment itself, this approach must encompass preventive measures such as vaccination, improved nutrition and comprehensive testing.

Pharmaceutical treatment

Even treating a standard tuberculosis infection is difficult. Patients must endure a course of heavy antibiotics for several months. Drug-resistant tuberculosis is even more difficult to treat and sometimes nearly impossible. When bacteria do not respond to the standard medication, patients require a ­second-line treatment, which typically involves expensive and rather toxic drugs. In some cases, the bacteria do not even respond to those drugs, so only very few treatment options remain.

In August 2024, the Indian government announced a new set of rules for treating patients with drug-resistant tuberculosis. This regimen is called BPaL and is expected to make a significant difference. So far, the success rate for the treatment of multi-drug resistant TB was 56 % and only 48 % for extremely drug resistant TB. The new BPaL programme will make second-line treatment more generally affordable and help to shorten treatment periods.

Since the new regimen is yet to be rolled out, there is no guarantee that these drugs will achieve a success rate of 100 %. And even if it does, there is no assurance that all infected individuals will be diagnosed and treated in a timely manner. The prevention of TB infections thus remains indispensable.

TB prevention programmes

India already has several TB prevention strategies in place. The TB Mukt Panchayat Abhiyan (Campaign to End TB at the Village Level) is a worthy example. It empowers local communities to assume ownership of national control programmes at the grassroots level. The idea is that local officials and healthcare workers raise awareness, test and trace suspected cases and then provide first-line treatment to patients. A strong point of the initiative is that it fosters healthy competition among villages, motivating people to eliminate TB in their respective areas.

Vaccines are another crucial preventive tool in India. The Bacillus Calmette-Guérin (BCG) vaccine is the primary vaccine to protect children. It has been part of India’s Universal Immunization Programme (UIP) since 1985. According to recent figures, the coverage rate is now 91 %. Unfortunately, however, the BCG vaccine has limited efficacy. It effectively prevents severe forms of TB in children but offers only limited protection against common manifestations of TB in adults.

In recent years, Indian scientists have been testing two new vaccines. Both may prove more effective. However, clinical trials are still going on, so it will not be possible to administer either of them to the masses anytime soon.

Socio-economic and environmental dimensions

Even if vaccine effectiveness improves, other challenges must be considered. TB is a complex disease. It is particularly dangerous in environmental and socio-economic settings in which the bacteria thrive. Accordingly, TB tends to affect poor communities in particular.

In India, the prevalence of self-reported TB is six times higher among the 20 % of the poorest people than among the 20 % of the wealthiest. This disparity is linked to the strong connection between economic status and various risk factors for TB. Cramped neighbourhoods and heavily polluted environments are particularly dangerous. According to the WHO, both air pollution and smoking are major risk factors for TB. Additionally, living in overcrowded spaces with poor ventilation allows the infection to spread rapidly in poorer neighbourhoods.

The implication is that urban planning and sanitation matter very much. Indeed, many Indians live in informal settlements without adequate sanitation. Insufficient waste management and lack of access to clean water contribute to poor health. The affected communities are more vulnerable to infections like TB. Only better urban planning will lead to better housing conditions with better sanitation. Socio-economic factors are important when it comes to reducing TB transmission.

People’s nutritional status matters too. Experts reckon that as many as 61 % of female TB patients and 57 % of their male counterparts in India suffer undernutrition. For obvious reasons, a low body-mass-index is among the major TB risk factors. Undernutrition weakens a person’s immune system, making infections more likely and allowing diseases to progress faster. Contact with the bacteria is more likely to cause infection, and since the body’s ability to fight severe disease is diminished, patients’ recovery can prove difficult even if they get the right treatment.

To eliminate TB in India, undernutrition must therefore be tackled too. The government is running relevant programmes such as the National Nutrition Mission. These programmes must continue in parallel with India’s National TB Elimination Programme.

Conclusion

Recent steps taken by the Indian government are commendable. However, TB remains fundamentally a social disease, closely linked to factors such as hunger, poverty and lack of sanitation. To tackle the complex issues, India must address all risk factors. In other words, it needs a holistic approach to achieve the government’s ambitious goal of eradicating pulmonary TB by 2025 – or at least meet the WHO-recommended target of reducing TB incidence by 80 % by 2030.

Chahat Rana is an Indian journalist who specialises in public health. 
ranachahat11@gmail.com 
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