Trends in incidence and mortality of tuberculosis in India over past three decades: a joinpoint and age–period–cohort analysis

Background Tuberculosis, as a communicable disease, is an ongoing global epidemic that accounts for high burden of global mortality and morbidity. Globally, with an estimated 10 million new cases and around 1.4 million deaths, TB has emerged as one of the top 10 causes of morbidity and mortality in 2019. Worst hit 8 countries account for two thirds of the new TB cases in 2019, with India leading the count. Despite India's engagement in various TB control activities since its first recognition through the resolution passed in the All-India Sanitary Conference in 1912 and launch of first National Tuberculosis Control Programme in 1962, it has remained a major public health challenge to overcome. To accelerate progress towards the goal of ending TB by 2025, 5 years ahead of the global SDG target, it is imperative to outline the incidence and mortality trends of tuberculosis in India. This study aims to provide deep insights into the recent trends of TB incidence and mortality in India from 1990 to 2019. Methods This is an observational study based on the most recent data from the Global Burden of Disease (GBD) Study 2019. We extracted numbers, age-specific and age-standardized incidence and mortality rates of Tuberculosis for the period 1990–2019 from the Global Health Data Exchange. The average annual percent change (AAPC) along with 95% Confidence Interval (CI) in incidence and mortality were derived by joinpoint regression analysis; the net age, period, and cohort effects on the incidence and mortality rates were estimated by using Age–Period–Cohort model. Results During the study period, age-standardized incidence and mortality rates of TB in India declines from 390.22 to 223.01 and from 121.72 to 36.11 per 100,000 population respectively. The Joinpoint regression analysis showed a significant decreasing pattern in incidence rates in India between 1990 and 2019 for both male and female; but larger decline was observed in case of females (AAPC: − 2.21; 95% CI: − 2.29 to − 2.12; p < 0.001) as compared to males (AAPC: − 1.63; 95% CI: − 1.71 to − 1.54; p < 0.001). Similar pattern was observed for mortality where the declining trend was sharper for females (AAPC: − 4.35; 95% CI: − 5.12 to − 3.57; p < 0.001) as compared to males (AAPC: − 3.88; 95% CI: − 4.63 to − 3.11; p < 0.001). For age-specific rates, incidence and mortality rates of TB decreased for both male and female across all ages during this period. The age effect showed that both incidence and mortality significantly increased with advancing age; period effect showed that both incidence and mortality decreased with advancing time period; cohort effect on TB incidence and mortality also decreased from earlier birth cohorts to more recent birth cohorts. Conclusion Mortality and Incidence of TB decreased across all age groups for both male and female over the period 1990–2019. The incidence as well as mortality was higher among males as compared to females. The net age effect showed an unfavourable trend while the net period effect and cohort effect presented a favourable trend. Aging was likely to drive a continued increase in the mortality of TB. Though the incidence and mortality of tuberculosis significantly decreased from 1990 to 2019, the annual rate of reduction is not sufficient enough to achieve the aim of India’s National Strategic plan 2017–2025. Approximately six decades since the launch of the National Tuberculosis Control Programme, TB still remains a major public health problem in India. Government needs to strengthen four strategic pillars “Detect–Treat–Prevent–Build” (DTPB) in order to achieve TB free India as envisaged in the National Tuberculosis Elimination Programme (2020).

Addressing constraints to informal providers’ involvement in tuberculosis control: a qualitative study of patent medicine dealers and tuberculosis programme managers

Background A major constraint to tuberculosis control is low case finding with under-reporting to national authorities. Evidence shows that Patent Medicine Dealers are first port of call for most people with symptoms of tuberculosis, yet there is poor referral of such clients to tuberculosis treatment facilities for further evaluation. This study investigated constraints to involvement of Patent Medicine Dealers in tuberculosis control. Methods This was a cross-sectional qualitative study among Patent Medicine Dealers and Tuberculosis Control Programme Managers in Ebonyi State Nigeria. Sixty-four Patent Medicine Dealers and five Tuberculosis Control Programme Managers were interviewed using Focus Group Discussion and In-Depth Interview respectively. Data was collected with electronic audio-recording device and analyzed using thematic approach. Results There are some knowledge gaps about tuberculosis signs, symptoms, free-treatment policy and mode of operation of care service among Patent Medicine Dealers. Patent Medicine Dealers and Tuberculosis Control Programme Managers are willing to collaborate in tuberculosis control effort but constant demand for incentives by Patent Medicine Dealers and inability of National Tuberculosis Control Programme to keep up with such demands are obvious constraints. Conclusions Knowledge gaps in tuberculosis, its control, constant demand for incentives by Patent Medicine Dealers and inability of National Tuberculosis Control Programme to satisfy such demands are constraints to involvement of Patent Medicine Dealers in tuberculosis control. More robust engagement of Patent Medicine Dealers in tuberculosis control with clear job description through tuberculosis education and provision of incentives to support them are recommended policy approaches to improve linkage of clients to tuberculosis treatment facilities.

Drug resistance in tuberculosis- resurvey in Wardha district, India after implementation of revised national TB control program

Level of drug resistance among new TB patients indicates the efficacy of any control programme. A drug resistance survey, as a part of global study in new pulmonary tuberculosis (NPTB) patients, was conducted in Wardha district, India under WHO /IUTLD in 2001, before the implementation of the Revised National Tuberculosis Control Programme (RNTCP) which was implemented in the district in 2002. The present study was conducted in Wardha district in 2014-2015, thirteen years after the implementation of RNTCP, and the drug resistance in isolates from NPTB patients was compared to the results of 2001 survey. The methodology used was same in both the surveys. : In addition to 132 isolates from Wardha, the study also included 112 isolates from adjoining city, Nagpur and total of 244 sputum isolates were subjected to drug sensitivity by standard 1% proportion method on Lowenstein Jensen’s medium. In addition molecular typing of resistant strains was done.: In Wardha, compared to 2001 survey, overall susceptibility to first line drugs washigher (94.7% vs 80.2%); and resistance to streptomycin (3% vs 7.6%) and isoniazid (2.2% vs 15.2%) were significantly lower (p≤ 0.05). MDR was 0.75% against 0.50% in the earlier study but the difference was statistically not significant. Only two MDR isolate were recovered, of which only one was from Wardha.After the implementation of RNTCP in Wardha District, drug resistancein new PTB patients has shown a decline and MDR continues to be low reflecting upon the efficiency of the program.

Journey of Tuberculosis Control in India: From then till now

The history of Tuberculosis control in India dates back to 1951 with mass vaccination with BCG and it started as a National Programme in 1962. Radical changes in the form of DOTS were incorporated with the start of Revised National Tuberculosis Control Programme (RNTCP) in 1997. Since then, TB control efforts have witnessed many changes in the form of daily DOTS, Injection free regimen for both drug sensitive & drug resistant TB, moving from fixed Categories of treatment regimen to Individualized treatment regimen based on prior Universal Drug susceptibility testing. Flexibility has been incorporated in the programme to accommodate Private practitioners in the form of various incentives. Introduction of Active case finding strategy has helped in early diagnosis leading to prompt treatments. Engagement of Community and leaders from all sectors and various organizations has helped to reach all communities in this fight against TB. India hopes to End TB by 2025 with rechristening the programme to National TB Elimination Programme (NTEP) and bringing in the much needed changes & flexibilities in the programme.

Analysis of the Factors Leading to Causation of Multidrug Resistant Tuberculosis among Cases Registered under Revised National Tuberculosis Control Programme in East Sikkim – A Case Control Study

BACKGROUND Tuberculosis (TB) is a curable and preventable disease. Emergence of multi drug resistance TB (MDR TB) threatens to undo the progress made towards control of TB. While treatment is available for MDR TB, it is of a long duration and is also more expensive and toxic. Understanding the various factors that are associated with MDR TB may help to formulate and implement effective preventive practices for control of MDR TB. We wanted to assess the various epidemiological factors among MDR TB cases registered under Revised National Tuberculosis Control Programme (RNTCP) in East Sikkim and study the current & past TB treatment including adverse drug reactions. METHODS A community-based case control study was conducted over 4 months in the eastern district of Sikkim. MDR TB cases registered under Revised National Tuberculosis Control Programme (RNTCP) in the first two quarters of 2019 were compared with matched healthy controls. Data was collected by a door to door survey using a pre-designed and pre-tested questionnaire and analysed on Statistical Package for the Social Sciences (SPSS) 20. RESULTS A total of 62 cases (14 non-respondents) of MDR TB were identified and were matched with 63 controls. 30.5 % cases were young adults in the age group 15 to 25 years, 66 % of the cases reported being currently unemployed, 16 % were homemakers, 11 % of cases fell below poverty line. A higher proportion of cases as compared to controls reported a habit of skipping a meal, poor housing conditions and comorbidities than controls. A known history of contact with a case of tuberculosis was given by 11.3 % cases; 18 % cases gave a previous history of TB; about 51 % cases reported a delay in diagnosis which delayed treatment initiation. CONCLUSIONS Previous history of TB with history of relapse / failure, contact of MDR TB emerged as the most significant risk factors and presence of comorbid conditions like diabetes & hypertension can be used to indicate higher risks of drug resistance. KEYWORDS Multi Drug Resistant Tuberculosis, MDR TB, Case control, Revised National Tuberculosis Control Programme, Sikkim

Tuberculosis control programme from NTCP to RNTCP to NTEP

India, the highest TB burden country in the world, is having an estimated incidence of 26.9 lakh cases in 2019 (WHO). The year 2019 marks another milestone year for TB surveillance effort in India, with a record high notification of 24 lakhs cases; an increase of over 12% as compared to 2018. Of the 24 lakhs TB cases,(1) 21.6 lakhs were incident TB cases (New and Relapse/ Recurrent). This amount to an incident notification rate of approximately 159 cases/lakh against the estimated incidence rate of 199 cases/ lakh population; thus, closing the gap between the estimated and notified incident cases to just 40 Cases per lakh population, or an approximate of 5.4 lakh missing cases across India.

Impact and operational feasibility of TrueNat™ MTB/Rif under India’s RNTCP

Background: The Revised National Tuberculosis Control Programme (RNTCP) in Andhra Pradesh, India, introduced TrueNat™ MTB/Rif, a rapid molecular test for detecting Mycobacterium tuberculosis (MTB) and rifampicin (RIF) resistance at 193 TB units (TUs) in October 2018. We evaluated its impact on TB diagnosis and assessed the operational feasibility of its deployment at point-of-care (POC) settings.Methods: We compared the number of presumptive TB cases tested and the number (proportion) of microbiologically positive before (January–August 2018) and after (January–August 2019) the deployment of TrueNat. We interviewed laboratory technicians and Senior TB Laboratory Supervisor from 25 randomly selected TUs to assess operational feasibility.Results: In 2018, 10.5% (range 8.9–13.1) of 245,989 presumptive cases tested were positive. In 2019, of the 185,435 presumptive cases tested, 13.7% (range 9.6–18.9) were positive. The proportion of presumptive TB cases in whom MTB was detected using TrueNat was 14.4% (range 10.0–21.2). TrueNat significantly increased case detection (incidence rate ratio [IRR] 1.30; 95%CI 1.15–1.46), yielding an additional 18 TB cases per 100 000 population. Laboratory technicians became comfortable in performing TrueNat after a median of 10 tests (interquartile range 5–17.5). Invalid reports declined from 6.8% to 3.6%.Conclusion: The deployment of TrueNat as POC diagnostic test improved case detection and was operationally feasible under RNTCP.