India has most number of TB cases in world: What’s going wrong?

Tuberculosis (TB) continues to be a problem for India. As per the World Health Organisation, India in 2022 recorded the most TB cases of any country. It also recorded nearly a third of all the TB cases around the world. But what does the report show exactly? And why does India continue registering such a high number of TB cases? Let’s take a closer look: What does the report show? The survey entitled World Health Organization (WHO) 2023 Global Tuberculosis (TB) report showed that around 7.5 million people were diagnosed with TB in 2022. The report, which contained data from 192 nations, also stated that the number of people that fell sick worldwide increased to 10.6 million in 2022 from 10.3 million in 2021.

However, there is some good news in the report.

It showed a “significant worldwide recovery” in the scale-up of TB diagnosis and treatment services in 2022. The report added that TB services – which were disrupted by COVID – are beginning to get back on track. The WHO chalked up the increase in diagnosis to good recovery in access to and provision of health services in many countries. India, Indonesia and the Philippines, which together accounted for over 60 per cent of the global reductions in the number of people newly diagnosed with TB in 2020 and 2021, all recovered to beyond 2019 levels in 2022, it said. “For millennia, our ancestors suffered and died with tuberculosis, without knowing what it was, what caused it, or how to stop it,” said Tedros Adhanom Ghebreyesus, WHO director-general in a statement. “Today, we have knowledge and tools they could only have dreamed of. We have political commitment, and we have an opportunity that no generation in the history of humanity has had: the opportunity to write the final chapter in the story of TB,” Ghebreyesus said. Geographically, in 2022, most people who developed TB were in the WHO Regions of South-East Asia (46 per cent), Africa (23 per cent) and the Western Pacific (18 per cent), with smaller proportions in the Eastern Mediterranean (8.1 per cent), the Americas (3.1 per cent) and Europe (2.2 per cent). The total number of TB-related deaths (including those among people with HIV) was 1.3 million in 2022, down from 14 million in 2021, according to the report. [caption id=“attachment_13370312” align=“alignnone” width=“640”] India, with 27 per cent of the world’s TB cases, remains far ahead of Indonesia (10 per cent) and China (7.1 per cent).[/caption] However, during the 2020-2022 period, COVID-19 disruptions resulted in nearly half a million more deaths from TB. TB continues to be the leading killer among people with HIV, it said. The report noted that multidrug-resistant TB (MDR-TB) remains a public health crisis. While an estimated 410,000 (4.1 lakh) people developed multidrug-resistant or rifampicin-resistant TB (MDR/RR-TB) in 2022, only about two in five people accessed treatment. There is some progress in the development of new TB diagnostics, drugs and vaccines. However, this is constrained by the overall level of investment in these areas, according to WHO. What about India? As per The Wire, India, with 27 per cent of the world’s TB cases, remains far ahead of Indonesia (10 per cent) and China (7.1 per cent). These nations are followed by the Philippines (7.0 per cent), Pakistan (5.7 per cent), Nigeria (4.5 per cent), Bangladesh (3.6 per cent), and the Democratic Republic of the Congo (3 per cent). As per NDTV, while India has reduced TB cases overall from 258 patients per 1,00,000 people in 2015 to 199 per 1,00,000 people in 2022, this remains far above the global average of 133 patients per 100,000 people. Meanwhile, India’s Case Fertility Ratio (CFR) – which estimates how many people died of the disease – is at 12 per cent.

The global average, meanwhile, is 5.8 per cent.

The Union Health ministry of Wednesday said the WHO had recognised India’s success in reducing the incidence of tuberculosis by 16 per cent – almost double the pace at which global TB incidence is declining – and mortality due to it by 18 per cent since 2015. The ministry citing the report said India has made tremendous progress in improving case detection and reversed the impact of COVID-19 on the TB programme. But as per The Wire, India remains far away from achieving the interim TB goals the WHO laid out for all countries. The WHO had set a target of reducing the TB incidence rate by 2025 to around half of the 2015 levels. It had also set the nations the goal of reducing the mortality from TB by 75 per cent. The ministry, meanwhile, highlighted the positives. “The treatment coverage has improved to 80 per cent of the estimated TB cases, an increase of 19 per cent over the previous year.” It also noted that the WHO had downwardly revised India’s 2022 TB rates. “The World Health Organization has made a downward revision of the TB mortality rates from 4.94 lakhs in 2021 to 3.31 lakhs in 2022, a reduction of over 34 per cent,” the ministry said. In the Global TB Report 2022, the WHO and the Health Ministry had agreed to publish the data for India as “interim” with an understanding that the WHO would work with the technical team of the ministry to finalise the figures. Following this, there were more than 50 meetings between the technical teams of WHO and the health ministry. At the meetings, the ministry’s team presented all new evidence generated, the in-country mathematical modelling developed including the data from Ni-kshay portal which captures the lifecycle of every TB patient during the course of their treatment, the ministry said. “The WHO team intensively reviewed all data presented and not only accepted but also appreciated the efforts made by the country. This year, the Global TB Report has acknowledged and published the revised estimates for India with a downward revision of the burden estimates, especially TB-related mortality figures,” it stated. The report also noted that India’s intensified case detection strategies have resulted in the highest-ever notification of cases in 2022 –  during which over 24.22 lakh TB cases were notified, surpassing the pre-COVID levels. However, more context is needed. As per The Wire, the report noted that the increase in ‘new’ cases in 2022 could potentially be ‘a sizeable backlog of people who developed TB in previous years [of 2020 and 2021].’ This could be due to a number of government services, including those for TB, being shutdown during the COVID-19 pandemic – leading to delays in TB detection. TB remains a problem for India The data shows TB in India continues to remain a problem.

Part of it is down to MDR-TB.

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As per The Wire, India (27 per cent), Philippines (7.5 per cent) and Russia (7.5 per cent) – comprised 42 per cent of the estimated global number of people who developed MDR or RR-TB in 2022. In India, 2.5 per cent of the new cases and 13 per cent of the previously treated cases were reported to be MDR-TB. Cost is another factor. India Today quoted a 2019 study of 50 patients at Hinduja Hospital in Mumbai as saying the average treatment cost for pulmonary MDR TB was Rs 4.7 lakh. And those are simply the ones that can afford such treatment. Experts say detection of TB particularly MTR-TB also remains an issue. A piece in Indian Express noted, “…last year in India, only about 23 per cent of those presumed with TB underwent these initial diagnostics tests — the traditional sputum smear microscopy was the initial diagnostic investigation for 77 per cent of the suspected patients. Microscopy, a century-old tool, cannot detect drug-resistance, and detects only half of all people with these tests.” The piece also noted that while the WHO says India sees 119,000 new cases of MDT-TB every year, it in 2022 recorded just half of such cases. The WHO defines “catastrophic health expenditure” as a household spending more than 10 per cent of its annual income on medical treatment. While exact figures for India remain unknown, the WHO says it expects the percentage of TB patients in India facing such a state far higher than the percentage of the population of other countries. More than 20 per cent of India’s population in 2022 had to incur ‘catastrophic expenditure’ on health, as per the report.  With inputs from agencies