Close the tap: Mopping the floor approach is not enough to end TB

Shobha Shukla *

As per the latest Global TB Report of the World Health Organization (WHO), globally 10.6 million people developed TB in 2021 - an increase of 4.5% from 10.1 million in 2020. Eight of the thirty high TB burden countries (India, Indonesia, China, Philippines, Pakistan, Democratic Republic of the Congo) accounted for 68% of the global total with India leading the pack at 28%.

We are off track in our goal of ending TB by 2030. The rate at which TB has declined every year (if at all) in recent times, is at least 5-6 times less than what it should be to end TB by 2030. While great scientific advancements are happening by way of improved diagnostics and treatment modalities, prevention has taken a back seat. Unless we break the chain of transmission, TB will continue to spread and find newer victims.

"Find TB to end TB" mantra

Every new person who develops TB has been infected by someone in their household, workplace or community with infectious (read pulmonary) TB. So the mantra is ‘to find TB to end TB’, said Professor (Dr) Guy Marks, a noted respiratory medicine physician and President of the International Union Against Tuberculosis and Lung Disease (The Union).

“The key to ending TB is finding and treating all people with infectious TB, to prevent them from infecting others and developing the disease”, he says.

He emphasises that “If we find just a few cases of TB and treat them, then every such case is replaced by a new case. Active case finding means finding all, (or nearly all) the cases. Do not focus on just high risk groups or those with symptoms. Do not ask people to volunteer but screen and test everyone. Then ensure that all positive cases are linked to appropriate therapy. This exercise will have to be repeated regularly for a few years until prevalence reduces to less than 50 in every 100,000 population.”

The key to end TB is finding people with TB and treating them, at a faster rate than new people getting infected and developing TB.

Professor Marks shares the example of a recent pilot study which was conducted in selected villages of Vietnam- a high TB burden country. A population-wide active case finding was done through house-to-house screening and collection of sputum from all adults, regardless of whether they had TB symptoms or not. TB testing was done using molecular diagnostic tests and those found positive were put on treatment. Over a period of years TB prevalence in the study area declined by 72% (an annual decline of 33%) and TB incidence reduced by 57%.

Close the tap, mopping the floor is not enough

There were an estimated 2.95 million (29.5 lakh) TB cases in India in 2021- an increase of 50,000 (0.5 lakh) from 2020, even as TB treatment coverage increased from 57% to 67%. As per India TB report 2023, 2.42 million (24.2 lakh) TB cases were notified in 2022 - which means half a million (5 lakh) cases are still missing. This shows that diagnosing and treating people with TB is not enough. We have to stop the spread of the disease and prevent people from getting infected in the first place.

Agrees Professor (Dr) Surya Kant, Head of the Respiratory Medicine Department at King George’s Medical University (KGMU) that the real challenge is in preventing transmission of TB. Prof Surya Kant was the Scientific Chairman of 77th National Conference of Tuberculosis and Chest Diseases (NATCON) held recently.

“While TB Preventive Therapy (TPT) can help in controlling transmission, it is far from being enough. To prevent TB we also have to control the underlying risk factors for TB - like malnutrition, pollution, tobacco smoking, diabetes, alcohol, etc and address the many social biases and stigmas prevalent in our society (that put women more at risk of TB)”, he says.

Feed them and not just treat them

Food sovereignty is an indispensable human right. It also is an important cog-in-the-wheel if we are to end TB (and hunger). Undernourishment accounts for nearly one-fifth of the annual new TB cases globally. It is the biggest risk factor for developing TB in a majority of the 30 high TB burden countries, including India. A recent study estimated that undernutrition contributes to 902,000 of India’s annual TB cases.

Undernutrition or malnourishment not only increases the chances of active TB disease but also increases the severity of the disease. It can delay recovery and even increase the risk of mortality or of a relapse after successful completion of treatment. A tweet by Indian government's Ministry of Health and Family Welfare also says "Optimum & appropriate nutrition is essential during TB treatment. Along with proper nutrition, take your TB medicines regularly".

The Indian government’s 'Nikshay Poshan Yojana' scheme gives a ridiculously small amount of INR 500 (~USD 6) a month to those diagnosed with TB for nutritional support, which is just not enough.

Tackling malnutrition in children and in women is a big challenge, laments Prof Surya Kant.

"There is huge gender bias as far as nutrition is concerned. While children and mothers should be prioritised for the nutritional food available in the family, the Indian concept is that one who earns, eats first and eats the best. So the breadwinner of the family gets priority as far as nutrition is concerned and women are left behind. Also, early pregnancy, shorter interval between two pregnancies and repeated pregnancies make women more vulnerable to developing TB", says Prof Surya Kant.

Ending TB will be an uphill task if we brush aside and fail to address the social enablers of TB like poverty, malnutrition, cramped living conditions and stigma.