Three major shortcomings of the Revised National TB Control Program need correction
Three major shortcomings of the Revised National TB Control Program need correction
Tuberculosis is the worst of the endemic diseases, killing 1.5 million people each year (WHO). TB affects adults in their most productive years and therefore impoverishes families and the nation. In India, the TB capital of the world, this disease kills about 1,400 people every day. These are gross estimates, as our health management system has no way of counting exact numbers.
In the 1950s and 60s, India was a global leader in research in epidemiology, transmission and home treatment of TB. The National TB Control Program of 1962 was a district based program with public-private partnership. However, expansion of the model proved unsuccessful and the program failed to control TB. Simultaneously we lost confidence and started doing what we were asked to do under the Revised National TB Control Program (RNTCP) by WHO. WHO experts used theoretical constructs of TB control to design the RNTCP, regardless of the difference between the TB epidemiology of poor and rich countries. By 2018, India realized that the light at the end of the tunnel was still elusive.
flaws in the program
RNTCP has obvious flaws. First, for a program that is heavily funded by the government, there is no set way of monitoring the trajectory of TB control. Compare this with the National AIDS Control Programme. Prior to the establishment of the National AIDS Control Organization, the Indian Council of Medical Research-managed AIDS Control Task Force had a unique method of monitoring the control trajectory, popularly known as ‘sentinel surveillance’. Through this, we have data on the prevalence of infection that can be compared over the years from 1986 to the present day. There was pressure from WHO experts to drop it, but it must be credited for politely but firmly refusing to oblige Dr. Sriram P. Tripathi, the then Director General of ICMR.
Recently India faced WHO estimates on COVID-19 deaths in India. It was a good sign that the government could publicly stand before the WHO. We must now boldly point out the flaws in the WHO-designed RNTCP and formulate our comprehensive strategy.
Second, the notion that only treating pulmonary TB patients would control TB was epidemiologically incorrect in India. The theoretical principle is ‘source reduction’. If one patient is the closest source of infection and disease to another in the community, early diagnosis and treatment will serve as source reduction. India is a heavy burdened country. A large proportion of adults have TB infection in the lungs in a life-threatening state (latent TB). Some of them worsen and develop markedly TB disease (reactive TB). HIV infection, diabetes, undernourishment, lung damage due to pollution, tobacco smoking, decline in immune functions due to chronic diseases, alcoholism, etc. accelerate reactivation.
Third, the RNTCP has failed to achieve people’s participation in TB control. Public education was given high priority in India’s AIDS control programme. Red Ribbon Clubs in schools and colleges are its legacy. Without informed participation of the people, the stigma and delay in seeking help will continue.
Realizing that TB was not under control, WHO called for another program amendment to eliminate TB by 2035 through a World Health Assembly resolution in 2014. Encouraged by the promise of an effective strategy, the Prime Minister announced in 2018 that India would eliminate TB by 2025. ,
controlling TB
From an epidemiological point of view, human mastery over microbes includes control, eradication, and eradication. Control refers to reducing the disease burden to a pre-determined level through specific interventions over a pre-determined time period. Evidence would have to show that the reduction was due to those interventions and not a ‘secular trend’. With better housing, nutrition, education and income, social determinants of diseases tend to decline over time – a ‘secular trend’. Globally, from this ‘secular trend’, the TB burden was falling by 1% or 1.5% per year.
Elimination refers to achieving zero frequency of new cases. Since we have a large backlog of latent TB, we cannot eliminate TB, but we should aim for a high level of control (from 200 per lakh cases per year to 50 per lakh per year) and with measurement It should be documented. This will do justice to the vision of the Prime Minister. Higher control is achievable as we have major assets through RNTCP. Trained state and district TB officers are already on the job and we have an extensive network of TB clinics and an army of community and field workers. Once the deficiencies listed above are corrected, we can control TB.
T. Jacob John is the President of Rotary Club of Vellore TB Control Society, and Sushil Mathew John is Professor of Community Health, Christian Medical College, Vellore.