Epidemiology of Tuberculosis:

Key interventions & Management issue

Dr Chirag Bhola,
Associate Professor,
SD Gupta School of Public Health,
IIHMR University, Jaipur

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 What is Tuberculosis??
• Tuberculosis is specific infectious disease caused by M. tuberculosis
• Disease primarily affects Lung – Pulmonary Tuberculosis, but it can affect intestine,
meninges, bones and joints, lymph glands, skin and other tissue of the body
• Disease is usually chronic with varying clinical manifestation
• Animal Tuberculosis is known as bovine tuberculosis

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 TB: Global Public Health Problem
• Estimated that about one-third of the current global population is infected
asymptomatically with tuberculosis, among them 5 to 10 % will develop clinical
symptoms during their lifetime
• Most new cases and deaths are in developing countries
• Annual risk of TB infection in high burden countries is estimated to be 0.5 to 2 %
• Infectious patient can transmit disease to 10-15 persons in a year
• In 2017, there were fewer than 10 new cases per lac population in most high-income
countries, whereas it was 150-400 case per lac population in most of 30 high TB burden
countries as per WHO reporting

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 TB: Global Public Health Problem (Contd..)
• There was gap of almost 36 % case reporting against estimated cases in 2017 globally
• Globally almost 16% of TB cases die from the disease – estimated 1.6 million deaths
due to Tuberculosis in 2017
• It is assumed that about 10% of total TB load is found in children and about 1 million
TB cases of pediatric TB are estimated to occur every year
• In SEAR, estimated 4.44 million incidence of TB in 2017 among them 2.65 million are
new cases – it is 44% of global TB burden
• India is among the six countries of SEAR which are part of 30 high burden countries
globally with 214 incidence of TB per lac population

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 TB: Public Health Problem in India
• India is highest TB burden country in the world in terms of absolute number of new
cases in a year
• It is estimated that one case in every four new TB cases is from India
TB case notifications, 2017
Total Cases notified 19,08,371
Total new and relapse cases 17,86,681
% cases tested with rapid diagnostics at time of diagnosis 40%
% with known HIV status 64%
% pulmonary 85%
% bacteriologically confirmed among pulmonary 60%
TB preventive treatment, 2017
% of HIV positive enrolled on preventive TB 10%
% of children household contact of bacteriologically confirmed TB cases on preventive treatment 11% 5
 Age group wise distribution of new smear positive
cases in India (2006)
160000 22.5 25.0
140000 21.0 20.3
20.0
120000 16.3
100000 15.0
80000 11.2
60000 10.0
6.6
40000
5.0
20000 2.0
0 0.0
0-14 15-24 25-34 35-44 45-54 55-64 65+
No of cases % of cases
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 Socioeconomic burden of TB
• Premature death (more than 80%) is the main cause of burden in terms of DALYs lost
• TB kills more people in India than HIV/AIDS, STD, Malaria, Leprosy and tropical disease
combined
• TB causes poverty and also found more among the poor, majority of victims are migrant
laborers, slum dwellers, resident of backward areas and tribal pockets
• Poor living condition, malnutrition, shanty housing and overcrowding are the main reasons for
the spread of disease
• Direct and indirect cost of TB to the country amount Rs 13,000 crore per year
• Every year more than 17 crore days are lost to the National economy on account of TB at a
cost of Rs. 700 crore (GOI 2001)
• As per ICMR in year of 2005, average treatment cost for TB patient in India is more than Rs
13,000

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What should be done for prevention and
control of TB ?

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We all know the Epidemiological Triad….
Agent

Host Environment
Disease

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Program implementation frame
IEC

Political will

Skilled Manpower
Infrastructure

Resources
Community Engagement/Participation
IEC 10
 WHO End TB strategy and its evolution
2015

2006 End TB strategy

Integrated patient center care and
prevention
1994 Stop TB strategy Bold policies and supportive
High quality DOTS expansion system
Address TB/HIV and MDR TB Intensified research and
The DOTS strategy challenges innovation
Govt commitment Health System Strengthening
Case definition Engage all care providers
Standardized short course Empower people with TB
chemotherapy
Promote research
System of regular drug supply
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Monitoring system
 Vision, Goal and Indicators of End TB strategy
Vision – A World free of TB – zero deaths, disease and suffering due to TB

Goal: end the global TB epidemic

Indicators Milestone Targets

Reduction in number of TB deaths compared 2020 2025 SDG 2030 END TB 2035
with 2015 (%) 35% 75% 90% 95%
Reduction in TB Incidence rate compared with 20% 50% 80% 90%
2015 (%) (< 85/Lac) (< 55/Lac) (< 20/Lac) (< 10/Lac)
TB affected families facing catastrophic costs
0% 0% 0% 0%
due to TB

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Evolution of TB control program in India

National TB
Elimination
Program
RNTCP 2021
1992
National TB
control Program
1962

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National Strategic Plan for TB elimination by 2025
• The NSP 2017-2025 which builds on the success and learnings of the last NSP, and
articulates the bold and innovative steps required to move towards TB elimination, is a
3-year costed plan and 8-year strategy document
• The NSP will guide the development of the national project implementation plan (PIP)
and state PIPs, as well as district health action plans (DHAP) under the national health
mission (NHM)
• The development of this NSP has been a collaborative effort between all the
stakeholders including national and state governments, development partners, civil
society organizations, and private sector in India which was led by the Central TB
Division, Ministry of Health and Family Welfare

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 NSP Results Framework
(impact and outcome indicators and targets)
Baseline Target
IMPACT INDICATORS
2015 2020 2023 2025
1 To reduce estimated TB Incidence rate (per 100,000) 217 142 77 44
2 To reduce estimated TB prevalence rate (per 100,000) 320 170 90 65
3 To reduce estimated mortality due to TB (per 100,000) 32 15 6 3
4 To achieve zero catastrophic cost for affected families due to TB 0 0 0 0
Outcome Indicators 2015 2020 2023 2025
1 Total TB patient notification 1.74 M 3.6 M 2.7 M 2M
2 Total patient Private providers notification 0.19 M 2M 1.5 M 1.2 M
3 MDR/RR TB patients notified 28,096 92,000 69,000 55,000
4 Proportion of notified TB patients offered DST 25 80 98 100
5 Proportion of notified patients initiated on treatment 90 95 95 95
6 Treatment success rate among notified DSTB 75 90 92 92
7 Treatment success rate among notified DRTB 46 65 73 75
8 Proportion of identified targeted key affected population undergoing active case finding 0 100 100 100
9 Proportion of notified TB patients receiving financial support through DBT 0 80 90 90
Proportion of identified/eligible individuals for preventive therapy / LTBI s - initiated on 15
10 10 60 90 95
treatment
National TB Elimination Programme
Overview - Key Priorities
TB Free India
• India has committed to End TB by 2025, 5
years ahead of the global SDG target

• Prime Minister of India launched TB Free

India campaign at ‘Delhi End TB Summit’
on 13th March, 2018

• The campaign calls for a social movement

focused on patient-centric and holistic care
driven by integrated actions for TB Free
India
 States committing to Ending TB
Chhattisgarh Tamil Nadu

2020- Kerala
2021- Himachal Pradesh
2022- Gujarat, Lakshadweep &
Sikkim
Himachal Pradesh
2025- Bihar, Chhatisgarh, Daman &
Kerala
Diu and Dadra & Nagar Haveli,
Jammu & Kashmir, Jharkhand,
Madhya Pradesh, Puducherry, Tamil
Nadu and Andaman & Nicobar
Islands
Lakshadweep
Jharkhand
 National Strategic Plan (2017-25)

Multi-
sectoral
Community
response Active Case
Engagement Finding
ICT tools stand for
Information
Communication
Technology tools.
The ICT tools means TB
to digital
infrastructures like
Preventive
Measures Strategies Co-morbidities
computers, laptops,
printers, scanners,
software programs,
data projectors, and
interactive teaching ICT Tools for Private sector
box. adherence and engagement
monitoring Drug
Resistant
TB
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Organizational structure
Supporting Facilities

▪ National Reference Laboratories (6)

▪ Intermediate Reference Laboratories (31)
▪ Culture and DST Laboratories (81
including IRL/NRL)
▪ CBNAAT Laboratories (1268)
▪ DRTB Centres- 703
 Key Services
1. Free diagnosis and treatment for TB patient
2. Public health action- contact tracing, testing for co-morbidities etc.
3. Treatment adherence support
4. Nutrition assistance to TB patients (DBT-Nikshay Poshan Yojana)
5. Preventive measures Direct benefit transfer
 Strengthening Case Finding in the Public Sector
PASSIVE APPROACH TO CASE FINDING ACTIVE APPROACH TO CASE FINDING

Chest X Ray: Intensive Case Finding in Health facilities-

Clinically diagnosed TB Screening for TB among:
increased from 8.8 lakhs in -DM patients increased from 11.5 L in
2017 to 12.7 lakhs in 2019 2018 to ~20 L in 2019
- ICTC/ART referrals increased from 3.35
L in 2017 to 3.94 L in 2019

Revised Diagnostic
Algorithm for TB: Increase Active Case Finding in
in DR-TB cases from 38,000 vulnerable population: from 5.5
in 2017 to 66,000 in 2019 crore population screened in
2017 to 28 crores screened in
2019. Yield increasing from
~27,000 to ~63,000 TB patients.
Upfront Rapid Molecular
Testing: Increased from
5.23 lakhs upfront tests in Leveraging Outreach of other
2017 (16% yield) to 11.34 Healthcare Programs: 8.3 lakhs
lakhs in 2019 (17% yield) referrals from Health & Wellness
Centres
Strengthening Case Finding in the Private Sector
Schedule H1 Implementation: The number of chemists
registered in Nikshay increased from 15221 in 2017 to
over 43000 chemists notifying 20,609 TB cases in
2019.

77% Increase in
Mandatory Notification of TB: Gazette notification private sector
issued in March 2018; Provisions of Sections 269 and notification from
270 of the Indian Penal Code (IPC) in 2019 3.8 lakhs in 2017
to 6.8 lakhs in
2019

Patient Provider Support Agency through JEET and

Domestic Resources: From 48 PPSAs in 2017 to 220
PPSAs in 2019 and 266 PPSAs in 2020.
 Direct Benefit Transfer (DBT) schemes
1. Honorarium to Treatment Supporters – For provision of treatment support to TB
patients (Adherence, ADR monitoring, counselling @Rs.1000/- to Rs.5000/-) Adverse Drug Reactions

2. Patient Support to Tribal TB Patients (Financial Patient Support @Rs750/-)

3. Nutritional Support to All TB patients (Financial Support to Patients @Rs.500/-month)

4. Incentives to Private Providers (Rs.500/- for Notification & Rs.500/- for reporting of
Treatment Outcome

5. Incentives to Informant (Rs. 500/- is given on diagnosis of TB among referrals from

community to public sector health facility)
Treatment and Support
• Daily Regimen
Treatment • Shorter Regimen
• Newer Drugs
• IT Enabled Adherence
Support
Patient Centric Care
• Comorbidity
management
• Financial incentives
Reduce Out-of-pocket
• Direct Benefit Transfer
Expenditure
Preventive approach

• Air borne infection control

measures
• Strengthen Contact
Investigation
• Preventive treatment in high
risk groups
• Manage Latent TB Infection
• Address determinants of disease
Inter-Ministerial Coordination
AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy)
• 1st meeting of National Technical Expert Group on NTEP-AYUSH Collaboration & e-consultation of
experts held
• 2nd draft of Policy Document and Joint Letter drafted

Railways
• Joint Working Group to be formed to monitor implementation

Defence
• Action Plan developed.
• 95 Ex- Servicemen Contributory Health Scheme (ECHS) Polyclinics registered in Nikshay,
remaining underway
Labour and Employment
• MoU signed in September 2020
 Multi-sectoral Engagement

TB care services in Socio-economic support

health infrastructure & Empowerment

Infection Prevention Information Education

Address Determinants Communication

Prevention and Care at Corporate

Work Place Social Responsibility

TB - A social problem & needs multi-sectoral approach

 Call Centre- Nikshay Sampark
▪ 1800-11-6666 Counselling

▪ Outbound & Inbound Nikshay Treatment

Poshan Yojana
▪ Time – 7 to 11 Adherence

▪ Languages – 14
▪ 100 call centre agents Information
Grievance
Redressal
▪ Pan-India coverage
Presence Across Nation
▪ Citizen – Patient - Providers
TB Notification Follow Up
An inbound call is initiated by the
customer or prospect. An
Policy Updatecall
outbound in RNTCP, 2018 by a call
is initiated
center representative.
 Community Engagement
➢Transformation of TB survivors to TB TB Forums at the National, State and
District level to provide a platform for all
champions stakeholders, including the community,
➢Capacity building and mentoring program to voice their views

➢Engagement of existing community

groups like PRI, SHG, VHSNC, Youth
Club
➢Grievance redressal mechanism
➢Involvement of community
representatives in different forums
National TB Elimination Program

TB Notification under NTEP

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30 28.8 28.7
27.4 26.4
25 26.9 24.04 lakhs
23.2 21.5 lakhs
20 18.3 lakhs 5.3 lakhs (25%)
6.8 lakhs (28%)

3.8 lakhs (21%)

15 12% increase in case
18% increase in case finding
10
finding 16.1 lakhs (75%) 17.2 lakhs (72%)
14.4 lakhs (79%)
5
0
2017 2018 2019
Public Private NTEP Target Incidence Estimate (WHO Global Report)

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 Sub-National Disease Certification
District
Criteria
Monetary Award for
Award Decline in incidence rate compared to
District (in Rs.)
2015
Bronze 20% 2 lakhs
Silver 40% 3 lakhs
Gold 60% 5 lakhs
TB Free Status 80% 10 lakhs

State
State/UTs with population State/UTs (population 50 State/UTs population
Award
<50 lakh lakh – 5 Cr >5 Cr
Bronze 10 lakhs 15 lakhs 25 lakhs
Silver 20 lakhs 35 lakhs 50 lakhs
Gold 40 lakhs 60 lakhs 75 lakhs
TB Free Status 60 lakhs 75 lakhs 1 Crore
 Key Challenges
1. Under reporting and uncertain care of TB patients in private sector

2. Reaching the unreached – Slums, Tribal, vulnerable

3. Drug Resistant TB

4. Co-morbidities – HIV, Diabetes

5. Undernutrition, overcrowding

6. Lack of awareness and poor health seeking behaviour lead to delay in diagnosis
 Key Take Away
• Improve TB notification rate Ensure mandatory TB notification from private
sector
• Active TB Case Finding to reach the unreached
• Optimum utilization of CBNAAT machines Cartridge Based Nucleic Acid Amplification Test

• Expand Universal Drug Sensitivity Testing coverage

• NIKSHAY Poshan Yojana to every TB patients
• 100% reporting through NIKSHAY
• Collaboration with Line Ministries to tackle social determinants of TB
• Community participation for TB Elimination
 Bending the Curve
Accelerating towards a TB free India
Thank You