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Handbook on

Tuberculosis in India18/1, 3rd floor, Shaheed Bhawan, Aruna Asaf Ali Marg, New Delhi - 110 067, India

Handbook on

Tuberculosis in India

© Global Health StrategiesMay, 2013

All rights reserved. Permission is required to reproduce any part of this publication. Permission will be freely granted to educational or non-profit organizations. Others will be requested to pay a small fee. Please contact: Global Health Strategies Emerging Economies Pvt. Ltd.18/1, 3rd Floor, Shaheed Bhawan, Aruna Asaf Ali Marg, New Delhi- 110067, IndiaTel: +91 11 46564590-95Fax: +91 11 46564599Web: www.globalhealthstrategies.com

EDITORIAL AND RESEARCH TEAMChapal MehraSukriti ChauhanKritika KamthanKarishma SaranArshad Said Khan

PhotographsCover© James Nachtwey Studio

Page 14TB patient covering mouth. © Operation Asha

Page 15World Map. © WHO

Page 16TB patient-Rahima Sheikh. © Chiara Goia/ The Wall Street Journal

Page 20World Map © WHO

Page 21TB patient receiving injection. © WHO/ David Rochkind

Page 27Sleeping workers. © WHO/ David Rochkind

Page 28Men in local train. © WHO/ David Rochkind

0Woman and child. © WHO

Page 32DOTS patient card. © Citizen News Service- CNS

Page 37Man, seated. © Operation Asha

Page 39 Man receiving X-Ray. © WHO/ David Rochkind

ConTenTs

List of Terms and Abbreviations 5Acknowledgements 7Preface 9Executive Summary 11

Tuberculosis: An Introduction 14

What is TB? 14

What is Drug Resistant TB? 15

How is TB Diagnosed and Treated? 17

Tuberculosis: The World and India 19

Global Trends 19

TB in India 20

India’s TB Control Programme 21

How is TB Treated? 23

DOTS-Plus 23

Private Sector Treatment of MDR-TB 24

Risk Factors that Contribute to TB Infection in India 25

Malnutrition and TB 25

Diabetes and TB 26

Migration and TB 27

Urbanization and TB 28

Tobacco and TB 29

Indoor Air Pollution and TB 30

HIV/AIDS and TB 31

Landmark Policy Changes in 2012 32

TB: A Notifiable Disease 32

Ban on Serological Tests for Detection of TB in India 34

Challenges for TB Control in India 35

The Rising Incidence of Drug Resistance 36

Diagnosis of TB in India 38

Private Sector: Drugs and Diagnostics 40

TB/HIV Co-Infection 41

TB and Migration 42

What Can You Do? 43

Be a TB Spokesperson 43

Encourage TB Awareness 43

Encourage Accurate TB Diagnostics 43

Support the Implementation of the Ban on Serological Testing for TB 44

Ensure RNTCP’s Budget is Large Enough to Meet the Goals of Universal Access 44

Conclusion 45

Bibliography 47

5Handbook on TuberCulosIs In IndIa

Active TB Disease – An illness in which TB bacteria attack the body especially, in the majority of the cases, the lungs. It makes the person sick and, in many cases, infectious.

Bacillus Calmette-Guérin (BCG) – A vaccine for TB, given at birth to infants.

TB Contact – A person who has spent a sufficient amount of time with a TB patient to allow for transmission.

Directly Observed Treatment Short Course (DOTS) – A strategy recommended by the World Health Organization (WHO) and implemented in India, under which patients are supervised while medication is administered.

First Line Drugs – The principal drugs used to treat TB, which include Isoniazid, Rifampin, Pyrazinamide, Ethambutol and Streptomycin.

Extensively Drug-Resistant TB (XDR-TB) – A rare type of TB, resistant to all the first line and at least one of the second line drugs used to treat TB.

Extremely Drug-Resistant TB (XXDR-TB) – The rarest type of TB, resistant to both first and second line drugs, making it almost impossible to cure.

Extra Pulmonary TB – Active TB disease in any part of the body other than the lungs (for example, in the pleural lining of the lungs, spine, brain, or lymph nodes).

Latent TB Infection – A condition in which TB bacteria are dormant in the body. People with latent TB infection have no symptoms and can't spread TB to others. However, latent infection can develop into active disease in the future, especially when immunity is compromised. This can be prevented by treating latent infection with a specific drug (Isoniazid) for 6–9 months.

MoHFW – Ministry of Health and Family Welfare

lIsT of Terms and abbrevIaTIons

6 Handbook on TuberCulosIs In IndIa

Multidrug Resistant TB (MDR-TB) – Active TB disease caused by bacteria resistant to two or more of the first line drugs, more specifically, to Isoniazid and Rifampicin.

Pulmonary TB – Active TB disease that affects the lungs, usually producing a cough that lasts two weeks or longer. In most cases active TB disease is pulmonary.

RNTCP – The Revised National Tuberculosis Control Programme

Rifampicin or Rifampin (RIF) – One of the four medicines often used to treat active TB disease. It is a first line drug and the most important for killing TB bacteria.

Isoniazid (INH) – A medicine used to prevent active TB disease in people who have latent TB infection. INH is also one of the four medicines often used to treat active TB disease.

Second line Drugs – Drugs used to treat drug resistant TB. These include Kanamycin, Capreomycin, Cycloserin, Ethionamide and more.

Smear Microscopy – Discovered by scientist Robert Koch, this is a technique for identifying a rod-shaped bacterium, Mycobacterium tuberculosis (as well as a number of bacteria that cause other diseases). Smear microscopy involves collecting a biological sample (usually sputum), fixing it thinly on a glass slide and then staining it with a dye that binds specifically to mycobacteria, making them easier to identify under a microscope.

Sputum – Phlegm coughed up from deep inside the lungs. Sputum is examined for TB bacteria using a smear; it can also be used to conduct a culture test.

TB Skin Test – Used to check if a person is infected with TB bacteria by injecting tuberculin under the skin on the lower part of the arm. If a person has a positive reaction to this test then s/he is infected with TB.

Tuberculin or PPD – A liquid that is injected under the skin on the lower part of the arm during a TB skin test.

USAID – United States Agency for International Development

WHO – World Health Organization


aCknowledgmenTs

This handbook delves into the TB landscape of India. The process has been guided and supported by several experts and close associates. Their insights and suggestions have been critical in

informing this handbook. We are extremely grateful to them for their time and for sharing their knowledge and experience with us. An invaluable debt is owed to our review panel consisting of Dr. Nalini Krishnan and Dr. Madhukar Pai. The handbook has benefitted enormously from their inputs.

It received valuable contributions from David Gold, Victor Zonana, Anjali Nayyar and Katie Callahan.

Lastly, we would like to express our thanks to scholars, reporters whose work and research has served as a critical guide map to understanding the complex TB landscape of India.


prefaCe

For the past two decades, India has witnessed extensive transformations- rising urbanization, industrial growth and rapid economic change. While these developments have

brought increased prosperity to millions, this progress will be unsustainable, if we neglect the critical health challenges.

TB is one such neglected health challenge. The disease kills close to 750 people everyday. Yet, TB occupies little space in our public imagination. TB physically and economically devastates not just individuals but also families and communities. Also worrying is that TB is now increasingly complicated to treat with varying levels of drug resistance being reported.

We have neglected TB for too long at an enormous human cost. The time has come for the disease to become a priority for all of us. For this to happen, there is an immediate need for increased awareness and support from all those engaged in public life: parliamentarians, policy makers, political leaders and activists. India’s remarkable recent achievement with the eradication of polio has made a huge contribution to health not only in India but also worldwide. India is uniquely positioned with a similar opportunity in TB to be a global leader in prevention and control.

The Handbook on Tuberculosis in India has been prepared as a tool for awareness and advocacy for leaders and policymakers. It is a simple but succinct primer on the situation of TB in India. We hope that through this effort, we will increase awareness and galvanize much needed support and attention to TB.


In our continuing fight against TB, awareness and support are the most vital weapons. Our endeavor, through this handbook, is to arm leaders and decision-makers with the relevant information so that they can lead the battle against TB.

Anjali NayyarChapal Mehra


Tuberculosis (TB) is one of the greatest public health challenges of India. India has the highest TB burden in the world and even today, two deaths occur every three minutes from TB – a disease

that is both preventable and curable.2 India accounts for nearly one-fifth of the global incidence of the disease, translating into 2 million cases annually.3

India’s Revised National Tuberculosis Control Programme (RNTCP) is lauded globally for its TB prevention and control efforts in the public sector. However, over half of India’s TB patients seek care in the private sector where the use of inaccurate diagnostics and irrational treatment regimens have led to poor treatment outcomes and increased drug resistance. As a result, India’s TB burden is high, despite a successful TB programme.

“…I call upon all stakeholders to come together for this fight against TB and to undertake all the necessary

steps to achieve the goal of zero TB deaths. Let us all work together to achieve a TB-free India.”

Shri Pranab Mukherjee, President of India,

on World Tuberculosis Day, March 24, 20131

1 Mukherjee, Pranab. “President of India’s message on the occasion of world tuberculosis day”, Press Release issued on March 23, 2013. Available at: http://presidentofindia.nic.in/pr230313-1.html Accessed on: March 24, 2013.

2 TBC India, Central TB Division. Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. Available at: http://www.tbcindia.nic.in/. Accessed on: January 29, 2013.

3 TB India 2012: Annual Status Report. RNTCP, Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. p.8

exeCuTIve summary


TB is the cause of grave human and economic costs, leading to immense pain and suffering for both the individual patient and his or her family. TB primarily affects people in their most productive years of life. (Almost 70 per cent of TB patients are between 15 to 54 years.)4 It is also a disease that continues to be highly stigmatized, often leading to discrimination within both the community and the workplace.

TB is increasingly more complicated to treat with the rising resistance to anti-TB drugs. The recent emergence of highly complicated strains is a warning that drug resistance is only growing. It is important to remember that all drug resistance is man-made. Poor prescribing practices in India’s private sector have been one of the leading factors fuelling the spread of drug resistant organisms. India accounts for approximately one-fifth of the global multidrug-resistant TB (MDR-TB) burden5 and indicators point towards a rising trend. This highlights the need for strengthening research and development of new drugs and vaccines as well as a combined strategy for both public and private sectors.

The year 2012 witnessed a number of positive developments in the TB landscape. On May 7, 2012, the Indian government declared TB a notifiable disease, making it mandatory to report each diagnosed case. All health care providers, in both the public and private sectors, must report a detected TB case to the nodal officer for TB notification. On June 7, 2012, the Ministry of Health and Family Welfare (MoHFW) placed a ban on the manufacture, sale, import and distribution of inaccurate serological (antibody) tests for TB diagnosis; a step in the right direction. These developments are an indication of the government’s determination to improve TB prevention and control.

4 ‘‘World Stop TB Day fact sheet for the media’’, WHO. Available at: http://www.wpro.who.int/mediacentre/factsheets/fs_20050324_Stop_TB_Day/en/index.html Accessed on: January 29, 2013.

5 Prasad, R. “TB control programme to engage private sector”, The Hindu. Available at: http://www.thehindu.com/sci-tech/article3915155.ece. Accessed on: September 20, 2012.


Additionally, the RNTCP’s budget increased from INR 400 crore in the financial year 2011-12 to INR 710.15 crore for 2012-13.6 The 80 per cent hike will provide a much-needed push to India’s fight against TB.

It is important to remember that with proper care and treatment, TB patients can be cured and the battle against TB can be won. However, this needs increased political will from policymakers and parliamentarians who play a critical role in influencing policy decisions.

We can lead the fight against TB and address the needs of vulnerable people affected by this preventable and curable disease. We possess the power to save thousands of innocent lives and make a difference to TB prevention and control, not only in India but also globally. Every life is vital and needs to be protected from this disease.

This handbook has been prepared to provide an overview of TB as a disease, its burden in India, risk factors, key challenges and the role we can play to enhance TB prevention and control in India.

We must act now!

6 TB India 2012. Annual Status Report. RNTCP. Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. p. 18


TuberCulosIs an InTroduCTIon

TB is an infectious disease caused by a rod-shaped bacterium called Mycobacterium tuberculosis. It typically affects the lungs (pulmonary TB) but can affect other parts of the body, as well (extra pulmonary TB). A communicable disease, TB spreads through the air; if left untreated, a person with active TB can infect 10-15 people every year.7

However, not all people infected with TB bacteria become sick. The immune system either kills the microbes or ‘walls off’ the TB bacteria, where they can lie dormant for years (this is called ‘latent infection’). Failure of the immune system to control infection leads to active disease. As a result, one third of the world’s population carries the bacterium but does not develop the symptoms. The bacteria can become active due to various factors that reduce a person’s immunity. These include advancing age, HIV/AIDS or a medical condition, like diabetes.

What is tB?

7 Tuberculosis Fact Sheet No. 104. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs104/en/. Accessed on: November 6, 2012.

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This is a TB disease type that shows no response to first line

anti-TB drugs. It develops when the TB drug regimen is poorly administered, or when patients stop taking their medicines before the disease has been fully treated. Multidrug resistant TB (MDR-TB) is defined by resistance to the two most commonly used drugs: Isoniazid and Rifampicin. The primary causes of MDR-TB are mismanagement caused by inappropriate treatment, misuse of anti-TB drugs and the use of poor quality medicines. India and China are currently home to half of the globe’s MDR-TB cases, clearly representing a growing challenge for India’s TB control.

MDR-TB can be treated and cured using second line drugs. However, the treatment for MDR-TB is extremely complex, expensive and has severe side effects. Second line treatment options are limited and recommended medicines are not always available. The extensive chemotherapy required (up to two years of treatment) is costly and can lead to adverse drug reactions. Patients in the private sector are often unable to afford this treatment.

What is Drug resistant tB?

Global Tuberculosis Report 2012

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“India has been a global leader in TB control. To maintain the significant advances made over the last

decade, it is essential to ensure universal access to accurate diagnosis and timely treatment. It is a need that is both

immediate and urgent.”

Dr. Peter Small, Senior Program Officer, Bill and Melinda Gates Foundation

Source: Chiara Goia/The Wall Street Journal


In some cases, more severe forms of drug resistance, such as extensively drug resistant TB (XDR-TB), can develop when the second line drugs are misused or mismanaged and therefore become ineffective. XDR-TB responds to even fewer available medicines.

Moreover, to make matters worse, recently in India, an advanced form of drug resistance TB known as extremely drug resistant TB (XXDR-TB) has been reported. In this form of disease none of the known TB drugs, or combinations of them, work.8

8 Anand, Geeta, “A Woman’s Drug-Resistant TB Echoes Around the World”, The Wall Street Journal. Available at: http://online.wsj.com/article/SB10000872396390444273704577633431646496346.html. Accessed on: September 8, 2012.

9 “Why is research essential to stop TB”, Stop TB Partnership. Available at: http://www.stoptb.org/global/research/funding.asp. Accessed on: September 30, 2012.


TB is diagnosed by finding the presence of Mycobacterium tuberculosis, the bacteria

responsible for causing TB. The most common method used to diagnose TB is sputum smear microscopy. In the private sector, ineffective TB diagnostics is a lucrative market, leading to patient suffering and a waste of resources. Many tests to diagnose TB are either outdated or inaccurate. Sputum smear microscopy (looking for TB bacteria under a microscope) is the primary tool for detecting TB in the public sector but it is 125 years old and detects only half of the cases. This also delays diagnosis, leads to incorrect treatment and the increasing likelihood of infection.9

With delayed diagnosis, individuals who develop pulmonary TB may not be effectively treated in a timely manner and continue to transmit TB.10

hoW is tB DiagnoseD anD treateD?

Facing Page- Rahima Sheikh’s years- long effort to beat tuberculosis left her in the end all but untreatable. She displays scans in the Mumbai slum she shared with her husband and daughter.


India’s private sector treats almost half of all TB patients. The private sector also misuses tests. For example, the Interferon Gamma Release Assay (IGRA) is meant for detecting latent TB but is widely used to diagnose active TB. Though there is a ban on the use of serological tests (blood tests) to detect TB, they continue to be used and lead to incorrect diagnosis and treatment. This, in turn, fuels India’s TB epidemic.

Several new rapid tests are available or are being developed for faster and more accurate TB diagnosis. The new tests can detect TB in patients co-infected with HIV as well as patients with resistance to Rifampicin, one of the first line drugs. These are prescribed in countries like Brazil and South Africa.

Newer and more effective diagnostic technologies approved by the World Health Organization (WHO) have been introduced globally. The public sector in India has introduced some of these technologies but they remain inadequate to address the TB challenge. India needs to make immediate efforts to improve techniques for diagnosing TB in the public sector. It also needs to regulate the private sector’s indiscriminate use of ineffective diagnostics.


Although our understanding of this curable disease has improved over time, our ability to tackle it

remains challenged. TB re-emerged as an epidemic in the 1980s with the development of drug resistance and co-infection with HIV/AIDS. The WHO declared the spread of TB as a global emergency in 1993.

The following five countries showed the highest rates of incidence of TB in 2009:11

• India:2.3million• China:1.3million• SouthAfrica:0.49million• Nigeria:0.46million• Indonesia:0.43million


gloBal trenDs

TuberCulosIs THe world and IndIa


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In 2011, the WHO estimated the incidence of TB in India to be between 2.0 million and 2.5 million. This accounts for 26 per cent of global TB cases.13

TB is the cause of extensive economic losses, which lead to individual and community suffering:

• Approximately70percentofTBpatientsareagedbetween15to 54 years and are key breadwinners for their families. If they are left incapacitated by TB, it often leads to impoverishment.

• TBalsoresultsinanaveragelossof20-30percentofannualhousehold income. The high cost of treatment leads to debt traps for many.

• ThedirectandindirectcostsofTBinIndiastandatUS$23.7billionannually, causing substantial economic losses to the country.

tB in inDia

12 Tuberculosis Fact Sheet No. 104. WHO. Available at: http://www.who.int/mediacentre/factsheets/fs104/en/ Accessed on: November 6, 2012.

13 Global Tuberculosis Report 2012. WHO. Available at: http://apps.who.int/iris/bitstream/10665/75938/1/9789241564502_eng.pdf Accessed on: April 22, 2013.

In 2011, 1.4 million people died globally as a result of TB. The estimates of TB incidence for that year were as follows:12


A patient receives a daily injection at the Group of TB Hospitals in Mumbai

The Revised National Tuberculosis Control Programme (RNTCP) was launched in 1997 for the control

and prevention of TB in India. Based on the Directly Observed Treatment Short Course (DOTS) strategy recommended by the WHO, it expanded services across the country in a phased manner.14 The RNTCP has many achievements to its credit. Some of these include the nationwide introduction of the DOTS programme, which led to a reduction in India’s TB mortality and treatment numbers. The programme addressed the needs of vulnerable populations by focusing on poorer and more isolated geographic areas. It also introduced uniform activities at Anti-Retroviral Therapy (ART) centres and Integrated Counselling and Testing Centres (ICTCs) nationwide for intensified TB case finding and reporting.

However, as India continues to have the highest TB burden in the world, many challenges remain. The current focus of the programme is on ensuring universal access to timely, good quality diagnosis and treatment for all TB patients.

inDia’s tB control programme

14 Global Tuberculosis Control 2011. WHO. Available at: http://www.who.int/tb/publications/global_report/. Accessed on April 12, 2012..

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RNTCP is focused on achieving the following targets:

• Early detection and treatment of at least 90 per cent ofestimated TB cases in the community, including HIV-associated TB;

• Initialscreeningofallre-treatmentofsmearpositiveTBpatientsfor drug resistant TB and provision of treatment services for MDR-TB patients;

• HIVcounsellingandtestingforallTBpatientsandlinkingHIV-infected TB patients to HIV care and support;

• Successful treatment of at least 90 per cent of all new TBpatients and at least 85 per cent of all previously treated TB patients;

• ExtendingRNTCPservicestopatientsdiagnosedandtreatedin the private sector.15

The RNTCP service expansion has especially focused on poorer and more isolated geographic areas. The programme has developed and begun to implement a Tribal Action Plan which includes the provision of additional TB units in tribal/difficult areas, compensation for transportation of patients and attendants in tribal areas, higher salaries for contractual staff posted in tribal areas and studies to document utilization by marginalized groups.

In terms of providing accurate diagnosis, the RNTCP has initiated the evaluation of a new and improved diagnostic for TB detection, in line with global consultation guidelines. This project has been funded by USAID’s Country Mission for India with technical assistance from WHO, India. It has been introduced in 18 sub-district level settings. These new tests remain largely unavailable to patients accessing the private sector.

15 Global Tuberculosis Control 2011. WHO. Available at: http://www.who.int/tb/publications/global_report/. Accessed on April 12, 2012.



16 Global Tuberculosis Report: 2012. WHO. Available at: http://www.who.int/tb/publications/global_report/en/index.html. Accessed on: November 30, 2012.

17 “DOTS-Plus Guidelines”, RNTCP. Available at: http://tbcindia.nic.in/Dotsplus.html. Accessed on March 8, 2012

Based on the WHO recommendations, India launched the Directly Observed Treatment

Short-course (DOTS) strategy in 1997. DOTS is a six-month-long regimen of four first-line drugs – Isoniazid, Rifampicin, Ethambutol and Pyrazinamide. Under the RNTCP, patients are provided with information, supervision and support by a health worker or trained volunteer. Using the DOTS strategy, an infectious patient is ensured a complete course of treatment with proper administration of medicine under supervision.

Treatment for MDR-TB is longer and requires more expensive and toxic drugs. The current regimen recommended by the WHO for most patients with MDR-TB lasts for 20 months.16

hoW is tB treateD?

In order to fight the drug resistant form of TB, RNTCP has initiated the DOTS-Plus regimen. The programme adds components to DOTS in the case of a diagnosis of MDR-TB, allows for increased efficacy in management of the disease and the employment of standardized second line drug regimen. The primary objective of DOTS-Plus is to address the causes of inadequate treatments and other reasons that lead to drug resistant TB. The programme intends to treat at least 30,000 drug resistant cases by the end of 2013.17 DOTS-Plus services are supplementary services under the expanded framework of the DOTS package. Therefore, in every DOTS-implementing unit of the country, DOTS is prioritised above DOTS-Plus with the view that DOTS reduces the emergence of MDR-TB and henceforth, the need for DOTS-Plus over time.

Dots-plus


The private sector consists of clinics, laboratories, hospitals and individual health care professionals who may or may

not be adequately qualified. These diverse providers within the private sector offer treatment at varying costs and quality. Providers often use non-standard regimens, prescribe non-quality-assured drugs, make patients pay for drugs which they may not be able to afford, and provide treatment without ensuring patient adherence through supportive supervision. Though there are clear regulations around the sale and dispensation of over-the-counter anti-TB drugs, they remain weakly implemented, leading to drug resistance.18 With a large population accessing medical services outside the RNTCP sphere, large-scale distribution of anti-TB drugs has become rampant in the private sector. This has harmful implications for all patients.

India’s large and diverse private sector treats close to half of all TB cases. Misdiagnosis due to inaccurate and outdated tests, combined with the pervasive availability of over-the-counter drugs, aid the development of MDR-TB. The private sector needs to be regulated to eradicate such misuse and malpractice.There are a number of reasons why people seek care outside RNTCP. These include:

• PoorknowledgeaboutTB;• Poor knowledge about free services available through the

national programme;• Convenientdiagnosticsandtreatmentbysomeoneknownto

the patient;• Adesireforconfidentiality;• Adesireforpersonalizedcare.19

However, lack of sufficient regulation of the private sector and ignorance of poor treatment practices followed by private providers has put patients at an enormous risk. Clearly, there is a critical need for the public and private sector to work together to address the issue of TB.

private sector treatment of mDr-tB

18 Dhar, Aarti. “Calling for restrictions”, The Hindu. Available at: http://www.thehindu.com/news/cities/Delhi/calling-for-restrictions/article4422385.ece. Accessed on March 14, 2013

19 TB in India. TB Facts. Available at: http://www.tbfacts.org/tb-india.html Accessed on: December 6, 2012.



20 Anand, Geeta. “The Budget’s Big Focus on Malnutrition”, The Wall Street Journal. Available at: http://blogs.wsj.com/indiarealtime/2012/03/16/the-budgets-big-focus-on-malnutrition/?mod=google_news_blog Accessed on: March 16, 2012.

21 Sharma, Pratul. “Malnutrition stunting growth in Indian children, says report”, India Today. Available at: http://indiatoday.intoday.in/story/malnutrition-stunting-growth-in-indian-children-report/1/223810.html. Accessed on: October 8, 2012.

22 Sharma, Pratul, “Malnutrition stunting growth in Indian children, says report”, India Today. Available at: http://indiatoday.intoday.in/story/malnutrition-stunting-growth-in-indian-children-report/1/223810.html. Accessed on: October 8, 2012.

23 Gupta, K. et al. “Tuberculosis and Nutrition”, Lung India, Vol. 26(1), Jan-March 2009. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2813110/. Accessed on: June 6, 2012.

There exists a strong relationship between malnutrition and TB. Malnutrition reduces a person’s

immunity, making them more susceptible to diseases like TB. Malnutrition also leads to higher mortality and morbidity in TB patients. Though India has witnessed rapid economic growth, the country has struggled with persistently high rates of malnutrition, far worse than in many ill-performing economies.20

According to the 2012 report by the Ministry of Statistics and Programme Implementation, 48 per cent of children under the age of five are stunted (too short for their age), indicating that nearly half of India’s children are chronically malnourished.21

The risk of falling ill with TB is increased for those who are malnourished.22 Fighting TB requires a diet rich in fats, vitamins, minerals and proteins which is difficult for many of the poorer TB patients to obtain, making it tough for them to fight the infection.23 TB coupled with malnutrition reinforces the cycle of ill-health and poverty.

malnutrition anD tB

rIsk faCTors THaT ConTrIbuTe To Tb InfeCTIon In IndIa


The evidence for the link between TB and diabetes is also well documented. Diabetes

triples the risk of developing TB and India has a rapidly increasing burden of diabetes.24 The WHO has projected that India will have 80 million diabetics by the year 2030.25 Patients with diabetes are at an increased risk of developing active TB and have higher rates of treatment failure and death, even when placed on appropriate TB treatment.26

This link may become even more meaningful in coming years, as the prevalence of diabetes is expected to rise dramatically in resource-poor areas where TB thrives. Recognizing this link, the RNTCP has made a policy for bi-directional screening. TB patients will be screened for diabetes and diabetic patients will be screened for TB.

DiaBetes anD tB

24 “Collaborative framework for care and control of tuberculosis and diabetes”, International Union Against TB Lung Disease, WHO. Available at: http://www.who.int/diabetes/publications/tb_diabetes2011/en/index.html. Accessed on: November 13, 2012.

25 Wild, Sarah et al. “Global Prevalence of Diabetes”, WHO. Available at: http://www.who.int/diabetes/facts/en/diabcare0504.pdf Accessed on: November 14, 2012

26 Sullivan, Timothy et al. “The Co-Management of Tuberculosis and Diabetes: Challenges and Opportunities in the Developing World”, Public Library of Science Medicine, Available at: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001269. Accessed on: September 26, 2012.


It is estimated that two-thirds of the world’s population will live in cities by

2030.27 About 285 million people live in approximately 5,161 towns, making India the second-largest urbanized country in the world. The number of people living in cities is expected to sur-pass 550 million by 2021 and 800 million by 2041.28 Of these, India’s largest cities are witness to poor, migratory, homeless and slum populations.

Drug resistance rates are also proportionally higher amongst migrant labourers who are least likely to seek treatment and frequently evade existing government TB treatment programmes.29 They are often unable to access diagnosis and treatment in the public sector due to lack of identity-proofs or quality services in the private sector owing to high costs. Hence, special attention must be given to these migratory populations, in order to prevent and control the spread of TB.

migration anD tB

27 “How India and China will be more powerful than the US by 2030”, Mail Online. Available at: http://www.dailymail.co.uk/news/article-2245987/How-China-India-powerful-US-2030.html. Accessed on: February 21, 2013.

28 “Creating evaluation frameworks for sustainable cities”, Technology Education Research Integrated Institutions. Available at: http://www.teriin.org/themes/sustainable/frame-sus-cities.php. Accessed on: December 21, 2012

29 Politzer, Malia, “Fighting Drug-Resistant TB: Chinks in India’s Armour”, Live Mint. Available at: http://www.livemint.com/Politics/bsWjPBLT7E6xbIVlbylkiJ/Fighting-drugresistant-TB-chinks-in-Indias-armour.html?facet=print. Accessed on: July 14, 2012.

27

Men rest after a long day working in a tailoring shop. The men are migrants, coming from all over India, and do not have the money to rent rooms to stay in. They work about 16 hours a day sewing clothing together and then sleep together in the workshop.

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Linked to migration is the issue of urbanization which tends to increase the rate of TB incidence

in India. Urbanization leads to higher population densities, crowded living conditions and increased mobility among migrants seeking temporary work.30 A large part of urban India resides in slums. 52 per cent of Delhi31 and 62 per cent of Mumbai’s population cannot afford lodging outside slums.32 Poverty and urbanization create the perfect conditions for TB transmission.

Research indicates that the annual risk of TB infection was 69 per cent higher in urban than rural areas. Other factors such as the prevalence of diabetes and transmissibility of disease are higher in urban areas which also contribute to the greater prevalence of TB in these areas.33

urBanization anD tB

30 Schmidt, Charles W. “Linking TB and the Environment: An Overlooked Mitigation Strategy”, Environmental Health Perspectives November, 2008 116(11): A478–A485. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2592293/. Accessed on: January 31, 2013.

31 “52 per cent of Delhi lives in slums without basic services”. The Hindu. Available at: http://www.thehindu.com/news/52-per-cent-of-delhi-lives-in-slums-without-basic-services/article66507.ece Accessed on: March 22, 2013.

32 Jain, Bhavika. “62% of Mumbai lives in slums: Census”. Hindustan Times. Available at: http://www.hindustantimes.com/India-news/Mumbai/62-of-Mumbai-lives-in-slums-Census/Article1-614027.aspx Accessed on: March 22, 2013.

Men crowd in a commuter train leading from the poor suburbs to downtown Mumbai. Crowded environments are one of the risk factors in concentrated urban environments, making it much easier for TB to be passed from one person to another. It is estimated that nearly 1 in 3 people in India are infected with the bacteria that can cause active TB.

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Tobacco is one of the leading preventable causes of death in the world today.34

Smoking has been associated with TB since 1918, however it is only recently that the association has been given widespread attention.35 Studies have found links between smoking and many aspects of TB:36

• Smoking and passive smoking are significantly associatedwith TB. Smokers face double the risk of developing active TB (as compared to non-smokers), and about a third of TB deaths in India have been attributed to tobacco smoking.

• Thenumberofcigarettessmokedand the duration of smoking may also influence the risk of infection.

Tobacco use is highly prevalent in India, and has been suggested to be a potent contributor to TB-related mortality in India.37 Nearly 17 per cent of the world’s smokers live in India.38 According to WHO, smoking substantially increases the risk of TB and death from TB. More than 20 per cent of the global TB incidence may be attributed to smoking. It increases the risk of contracting TB by more than two-and-a-half times.39

toBacco anD tB

33 Dye C. et al. “Nutrition, Diabetes and Tuberculosis in the Epidemiological Transition”, Public Library of Science One. Vol. 6, Issue.6, 2011.p.1 -7. Available at: http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0021161. Accessed on: April 4, 2012.

34 “The World Health Report 2003 - Shaping the Future”, WHO. Available at: http://www.who.int/whr/2003/en/. Accessed on: March 16, 2012.

35 Slama K. et al. “An educational series about tobacco cessation interventions for tuberculosis patients: what about other patients?” International Journal of Tuberculosis and Lung Disease, 2007 11:244. Accessed on: December 9, 2012.

36 A WHO/ The Union monograph on TB and tobacco control: joining efforts to control two related global epidemics, 2007. WHO. Available at: www.theunion.org/component/option,com_guide/Itemid,218/. Accessed on: October 8, 2012.

37 TB India 2012. RNTCP Status Report, 2012. Ibid.38 John, R.M. “Tobacco consumption patterns and its health implications in India”, National Center for

Biotechnology Information. Available at: http://www.ncbi.nlm.nih.gov/pubmed/15607383. Accessed on October 11, 2012.

39 Factsheet on Tuberculosis and Tobacco, 2009.WHO. Available at: http://www.who.int/tobacco/resources/publications/fact_sheet_set09/en/index.html. Accessed on: 30 June, 2012.


According to the National Family Health Survey (NFHS) nearly three-quarters of Indian households rely primarily

on biomass fuels for cooking.40 Cooking is often done under poorly-ventilated conditions, using inefficient stoves that produce a substantial amount of smoke. Evidence from India has shown that exposure to smoke released from biomass fuels, such as fuel used for cooking, plays a causal role in the development of TB.41 The smoke released reduces the body’s immunity, making it difficult to fight infection.

inDoor air pollution anD tB

40 Mishra, Vinod K. et al. “Cooking with Biomass Fuels Increases the Risk of Tuberculosis”, National Family Health Survey 1999, International Institute for Population Science, Mumbai. Available at: http://scholarspace.manoa.hawaii.edu/bitstream/handle/10125/3467/NFHSbull013.pdf?sequence=1. Accessed on: June 27, 2012.

41 Mishra, Vinod K. et al. “Biomass cooking fuels and prevalence of tuberculosis in India”, International Journal of Infectious Disease Vol. 3 (3), 1999. p. 119-129. Available at: http://www.ncbi.nlm.nih.gov/pubmed/10460922. Accessed on: June 27, 2012.

Source: Eco Systems and Human Well Being: Health Synthesis, WHO

Exposure to smoke from biomass fuels can reduce immunity and hasten the development of TB.


TB is the leading cause of mortality in people living with HIV/AIDS. In 2009 an estimated

2.39 million people in India were living with HIV/AIDS, while an estimated 4.85 per cent of TB patients were also HIV positive.44 People living with HIV/AIDS (PLHAs) as well as TB also suffer the inconvenience of visiting two separate testing centers and need multiple testing appointments. The cost of transport and loss of income may prohibit many from accessing treatment. A person living with HIV and infected with TB is 21 to 34 times more likely to develop active TB disease than a person without HIV.45

hiv/aiDs anD tB

Adults in households who cook with biomass fuels like wood and dung suffer a significantly higher risk of TB, compared to adults in households that cook with cleaner fuels. An estimated 51 per cent of the active TB cases reported in the NFHS can be attributed to exposure to cooking smoke from biomass fuels.42 Pollutants released from these fuels can increase the risk of TB infection and disease.43

42 Mishra, Vinod K. et al. “Cooking with Biomass Fuels Increases the Risk of Tuberculosis”, National Family Health Survey 1999, International Institute for Population Science, Mumbai. Available at: http://scholarspace.manoa.hawaii.edu/bitstream/handle/10125/3467/NFHSbull013.pdf?sequence=1. Accessed on: June 27, 2012.

43 Fullerton, G.D. et al. “Indoor air pollution from biomass fuel smoke is a major health concern in the developing world”, Transactions of the Royal Society of Tropical Medicine and Hygiene.Vol 102(9), 2008. p. 843-851. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2568866/#bib38. Accessed on: May 9, 2012.

44 TB India 2011. RNTCP Annual Status Report. RNTCP, Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare. Available at: http://www.tbcindia.org/pdfs/RNTCP%20TB%20India%202011.pdf. Accessed on: November 29, 2012.



landmark polICy CHanges In 2012

On 7th May 2012, the MoHFW made TB a notifiable disease. As a result, now all health care providers must notify

the local authorities (i.e. District Health Officer/Chief Medical Officer of a District and Municipal Health Officer of a Municipal Corporation) every month in a particular format, every time there is a TB case.

Early diagnosis and complete treatment of TB is the cornerstone of a comprehensive TB prevention and control strategy. Inappropriate diagnosis and irregular/incomplete treatment with anti-TB drugs may contribute to complications, spread of disease and emergence of drug resistant TB.

tB: a notifiaBle Disease

A patient card for monitoring the DOTS treatment

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This notable step will facilitate early diagnosis; rational treatment; prevention of complications; drug resistance and; will also, reduce TB deaths. It will help health care providers offer better linkages for quality diagnostic and treatment services to TB patients through the public sector. It would also enable the National TB Control Programme to realistically estimate the TB disease burden, plan resources and control measures that commensurate with the actual burden of disease.46

In September 2012 the government launched a case-based, web-based recording and reporting system named the Nikshay portal which was developed to facilitate the reporting and tracking of TB cases.

“The claims of every manufacturer are extremely tall and misguiding. All Indian manufacturers have claimed high accuracy. Indeed, all these claims are based on in-house or small studies with no proper validation. Sensitivity or

ability to diagnose true TB cases is very critical and any test which has lesser detection rate than sputum microscopy

does not warrant serious attention.”47

Dr. V.M. Katoch, Director General (ICMR) and Dr. Sarman Singh, Prof. and Head, Clinical Microbiology Division.

Dept. of Laboratory Medicine (AIIMS)

46 “TB is now a notifiable disease in India”, Core Programme Clusters: Communicable Diseases and Disease Surveillance: Tuberculosis. WHO. Available at: http://www.whoindia.org/en/Section3/Section123_1888.htm. Accessed on: 17 July, 2012.

47 Sinha, Kounteya. “Ban on inaccurate blood tests to diagnose TB”, Times of India. Available at:http://articles.timesofindia.indiatimes.com/2012-06-20/india/32334338_1_tb-detection-tb-diagnosis-tb-cases. Accessed on: May 9, 2012.


In June, 2012, the MoHFW banned the manufacturing, im-

port, distribution and sale of serology-based tests for the diagno-sis of TB. These tests provide inconsistent and inaccurate results for TB, leading to incorrect diagnosis. India is the first country to ban these tests.

WHO had issued a ‘negative policy recommendation’ against the use of such tests in 2011 and called on governments to immediately ban blood tests prescribed and used to detect TB, mainly in the private sector.48 These inaccurate diagnostic tests lead to delays in case-finding which perpetuate the cycle of TB transmission. It is estimated that patients have spent approximately Rs.75crore($15million)annuallyonthesetests.49

Leading Indian newspapers have carried advertisements about the ban but much more needs to be done to enforce it and prevent companies and distributors from selling such tests to labs.

Ban on serological tests for Detection of tB in inDia

48 “Private doctors use wrong TB test to earn more”. IBN Live. Available at: http://ibnlive.in.com/news/private-doctors-use-wrong-tb-test-to-earn-more/173130-17.html. Accessed on: March 11, 2013.

49 Sinha, Kounteya. “Ban on inaccurate blood tests to diagnose TB”, Times of India. Available at:http://articles.timesofindia.indiatimes.com/2012-06-20/india/32334338_1_tb-detection-tb-diagnosis-tb-cases. Accessed on: May 9, 2012.

Challenges for TB ConTrol in india

36 handBook on TuBerCulosis in india

Drug resistance develops when the TB drug regimen is poorly administered or when patients stop taking their medicines before the disease has

been fully treated.50 This poses a significant challenge for TB control in India.

The treatment for MDR-TB is complex, expensive and has severe side effects. With the recently discovered extremely drug-resistant TB strain (XXDR-TB) at Hinduja Hospital, Mumbai, the threat seems to have worsened. In this form, none of the known TB drugs or combination work. Recent reports have indicated that close to two dozen patients suffer from XXDR-TB in Mumbai alone.51 The rising levels of drug resistant TB are a concern and challenge for TB control. In 2012, Mumbai reported 1,407 positives among the 6,561 patients tested for drug resistant TB.52 In 2010, the WHO estimated that India had 63,000 cases of MDR-TB. Of these, 2,967 cases had been notified and the same number of patients were reported to be enrolled for treatment.53

The Rising incidence of dRug ResisTanT TB


51 “2 dozen XXDR-TB cases in city: BMC”, DNA. Available at: http://www.dnaindia.com/mumbai/report_2-dozen-xxdr-tb-cases-in-city-bmc_1786063. Accessed on: February 19, 2013.

52 “Mumbai finds 1,407 patients with drug-resistant TB”, Times of India. Available at: http://articles.timesofindia.indiatimes.com/2012-08-22/mumbai/33321694_1_drug-resistant-mumbai-s-tb-tb-control. Accessed on: February 27, 2013.

53 Global Tuberculosis Control 2011. WHO. Available at: http://www.who.int/tb/publications/global_report/. Accessed on April 12, 2012.

TB is easily curable if accurately detected and treated on time. However, it continues to be one of the most serious public health challenges for India. TB control in India is

plagued by a number of complex and interconnected issues which need to be comprehensively addressed to reduce India’s TB burden. These include:

handBook on TuBerCulosis in india 37

• Delays in Detection and Referral: In most instances, detection ofdrug resistant TB is delayed due to the limited availability of good diagnostic services. This perpetuates a cycle of TB transmission. By the time an infected patient is diagnosed, s/he has usually visited several doctors and in the process may have infected many others with drug resistant strains of TB.

• AdherencetoTreatmentRegimens:Topreventdrugresistance,it isvital to ensure treatment adherence and access to quality medication. Many patients do not maintain the recommended TB drug regimens, which promotes resistance.

• ExpensiveDrug Regimens: While a course of standard TB drugscosts approximately Rs. 1000, MDR-TB drugs can cost more than Rs. 1 lakh,54 and the cost of XDR-TB treatment is even higher. This has a significant impact on the livelihoods of drug resistant patients and prevents many from completing treatment.

Factors Leading to Drug Resistance:

54 Singh, S. “Breathing Uneasy Over TB”, The Hindu. Available at: http://www.thehindu.com/opinion/op-ed/breathing-uneasy-over-tb/article3606725.ece. Accessed on August 5, 2012.

Source:OperationAsha


Inaccurate diagnosis of TB is one of the critical challenges facing TB

control in India. Ineffective and inaccurate diagnosis leads to patient suffering, perpetuating the cycle of TB transmission and is fuelling India’s TB epidemic.

AccesstoqualitydiagnosisforallTBpatientscontinuestobeachallenge in India for two key reasons:

• OutdatedTechniques:ManyteststodiagnoseTBareeitheroutdated or inaccurate. Sputum smear microscopy (looking for TB bacteria under a microscope) is the primary tool for detecting TB, but it is 125 years old and detects only half of the cases.55 This leads to delay in diagnosis, incorrect treatment and increased infection.

• Misuseof Tests in the Private Sector: Serological (antibodydetection) tests are highly inaccurate. However, these tests have been widely misused by the private sector for diagnosis of TB. The development, manufacture and sale of these tests have been banned in India but how stringently this is implemented remains to be seen. The private sector also

diagnosis of TB in india

“Drug resistant TB is the leak that if not plugged will sink the national TB program. If the tide is not stemmed we

will only replace one type of TB with its much more deadly doppelgänger. Totally Drug Resistant TB is not just hype but

deadly reality.”

Dr. Zarir Udwadia, Consultant Chest Physician, Hinduja Hospital, Mumbai

55 “Why is research essential to stop TB”, Stop TB Partnership. Available at: http://www.stoptb.org/global/research/funding.asp. Accessed on September 30, 2012.

39handBook on TuBerCulosis in india

misusestestssuchasIGRAs(‘TBGold’)todiagnoseactiveTBwhenthey are actually intended to detect latent TB.

Improving the diagnosis of TB in India is critical for TB control and will depend on the successful implementation of the ban on serological testing for TB in conjunction with the initiation of a programme to roll out accurate and WHO-approved rapid diagnostic tests across India.

Source: WHO/ David Rochkind

A man receives a chest X-Ray during the admission process at the Group of TB Hospitals in Mumbai

“There is an urgent need to develop novel, economic, easy to use methods for diagnosis of all kinds of TB. This is perhaps the most important unmet scientific challenge besides the development of an efficacious TB vaccine.”

Dr. V.S. Chauhan, Director, International Center for Genetic Engineering and Biotechnology, New Delhi


India is facing a growing crisis in the form of the unregulated sale and use of anti-TB drugs

outside government-sponsored programmes. Private providershave poor compliance with treatment regimens, leading to errors in both the dosage of drugs and the duration of treatments.

Althoughthereareclearregulationstocontrolover-the-countersale of anti-TB drugs, they remain weakly implemented. The government is expected to announce a new scheme to strengthen drug regulation which will enable patients accessing both the public and private sectors to avail of free yet quality-assured TB drugs from the government.56 The private sector continues to employ the highly inaccurate serological (antibody detection) tests to diagnose TB despite the ban on them.

PRivaTe secToR: dRugs and diagnosTics

According toDr.Manoharan,MedicalDirector, International TrainingandEducationCentreonHIV/AIDS,“Whenwetalkofanti-TBtreatmentwe have to cure TB, prevent relapse and prevent drug-resistant TB. The keyissueswehavetotacklewhilemanagingTBinHIVpatientsare:

1. When should one start antiretroviral therapy in HIV-associatedTB?

2. What should be the duration of the treatment?3. Should it be daily or intermittent therapy?4. What should be done in case of relapse of infection?”

56 “Free TB drugs soon under new scheme”, Indian Express. Available at: http://www.indianexpress.com/news/free-tb-drugs-soon-under-new-scheme/1045136. Accessed on: March 9, 2013.


In India, TB is the leading cause of mortality in people living with

HIV/AIDS(PLHAs).In2009,anestimated2.39millionpeoplein India were living with HIV/AIDS, while an estimated 4.85percentofTBpatientswerealsoHIVpositive.57 Tamil Nadu, AndhraPradeshandMaharashtraaresomeofthestateswheretheco-infectionrateofTB/HIVisthehighest.58

Some of the challenges in controlling the growing rates of TB/HIVco-infectionare:

• The absence of community-based TB/HIV collaborativeprogramsforPLHAs;

• LowlevelofTBawarenessandeducationinPLHAnetworks;

• Lack of outreach activities for detection of suspected TBcasesamongPLHA;

• LackofcoordinationbetweentheoutreachactivitiesofAIDScontrol and TB control programmes.

Tackling TB amongst the most vulnerable is critical, both to protect the individual as well as the community that needs to be targeted to address challenges of TB.

TB/hiv co-infecTion


58 Jha P. et al. “HIV mortality and infection in India: estimates from nationally representative mortality survey of 1.1 million homes”, British Medical Journal. Available at: http://www.bmj.com/content/340/bmj.c621. Accessed on: January 17, 2013.


Population migration is one of themost critical challenges for effective

TB prevention and control. According to the 2001 censusapproximately 14.4 million people migrated from rural to urban or semi-urban areas.59 The most affected areas remain the urban slums which become centres of infection. The situation is worsened by the fact that migration remains high there. Other factors supporting the spread of TB are incomplete treatment and high anti-TB drug default rates. The problem of migration arises in TB control for a number of reasons:

• Lackofanational-levelstrategyandguidelinesforTBcareandcontrolformigrants;

• Large numbers of migrants who are working in theunorganized sectors without any health facilities or financial protectionagainsthealthcrises;

• Highnumbersoftreatmentdefaultersinmigrantpopulationsduetofrequentmobilityandnon-reportingtotheprovider;

• LackofawarenessaboutTBdetectionandtreatment

TB and MigRaTion

59 “Migration, Rural to Urban: Back to Social Vulnerable Groups”, India Development Gateway. Available at: http://www.indg.in/social-sector/social-vulnerable-groups/migration-2013-rural-to-urban. Accessed on: March 6, 2013.


WhaT Can You do?

We call upon all of you to make a change and save the people of India from the expanding scourge of TB. You can:

• Be a TB Spokesperson: You can be an important spokesperson to raise awareness about TB at the national level and within various states. Methods of raising awareness may include highlighting critical issues around TB to key stakeholders such as fellow parliamentarians, policy makers, civil society and the media.

• Encourage TB Awareness: Utilize your powerful position to create and support awareness around TB. It is important to spread the message that TB is “preventable and treatable”.

• Encourage Accurate TB Diagnostics: Accuratediagnosisiscentralto the controlanderadicationof TB in India. TheRNTCPhas seta target of early detection and treatment of at least 90 per cent of estimatedTBcasesinthecommunity,includingHIV-associatedTBby


2015. To meet this goal, you can encourage the introduction of the latest and most accurate diagnostic tests in the public and private sectors in India.

• Support the Implementation of the Ban on Serological Testing for TB: In 2012, the government took an important policy decision to ban the use of ineffective serological tests for TB. You can play an important role in ensuring stringent implementation of the ban nationwide.

• Ensure RNTCP’s Budget is Large Enough to Meet the Goals of Universal Access.Although,thebudgetforTBhasbeenincreasedsignificantly, fighting the disease needs constant funding and support. The rising incidence, burden and drug resistance are witness to the fact that growing resources are the need of hour to ensure accurate diagnosis and patient care.


ConClusion

India needs to recognize the problem of TB in its entirety, given the importance of achieving universal access objectives for economic developmentandinclusivegrowth.Thegovernment’svisionofa‘TB

Free India’ is possible through commitment to TB prevention, control and treatment in India.

There is hope that in the future, home-grown and locally manufactured technologies to prevent and treat TB will be discovered and made available for public use. It is important to ensure that novel diagnostic technologies are implemented widely. It is also important to strengthen service delivery in India to ensure access to vital diagnostics for effective TB prevention and control.

The ambitious goal of providing universal access to quality diagnosis and treatment to the entire population can only be achieved via adoption of novel and innovative technologies and greater regulation of the private sector.


The prevention of drug resistant TB relies heavily on the effectiveness of efforts to treat TB patients in both the public and the private sectors. We must take a multi-pronged approach for TB control. Otherwise, India must prepare itself to address growing drug resistance, rising treatment costs and extreme human suffering from what is a preventable and easily treatable disease. We cannot overlook the enormous social and economic burden that TB places on India. It is essential that the people of our nation, especially its most disadvantaged, be protected from TB.


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