Focus Tb Strategy to Curb and Eliminate Tuberculosis

The TB control journey so far... The National Tuberculosis Programme of India (NTP) was initiated in 1962 for domiciliary treatment, using selfadministered standard drug regimens. However, it could not achieve its objectives of TB control and hence, on the recommendations of an expert committee, a revised strategy to control TB-Revised National Tuberculosis Control Programme (RNTCP) was started in 1997. This programme used the DOTS (Directly Observed Treatment, Short course chemotherapy) strategy and has achieved several milestones related to TB diagnosis and treatment services since 2006.

National AIDS Control Programme and RNTCP have developed a 'National framework of joint TB/HIV Collaborative activities'. The Government also proactively engages with private practitioners, number of private organizations, NGOs, Professional bodies like Indian Medical Association, to enhance notification of TB cases. The Standards for TB Care in India (STCI) have been published jointly by RNTCP and World Health Organization (WHO) in 2014, which own the uniform standards for TB care for all stakeholders in the country

The Government of India, Ministry of Health and family Welfare made a landmark move by prohibiting the import of sero diagnostic test kits for TB and also the manufacture, sale, distribution and use of such kits for TB. The banning of serological tests for diagnosis of active TB, saved countless persons from inaccurate test results and unnecessary expense and treatment.

An innovative and visionary electronic recording and reporting system (Nikshay) was also rolled out across the country in 2012, with 98% of reporting units sending in case-based reporting of TB patients, including notifications from private providers. Modern media creatively used for TB control with India's leading actor, Amitabh Bachchan's campaign, "TB Harega, Desh Jeetega", with commendable investments by the Ministry and corporations to broadcast these messages.

At the start of 2020 the central government has renamed the RNTCP as the National Tuberculosis Elimination Program (NTEP). In a letter to all the State Chief Secretaries of states and UTS, the commitment is emphasized on the Union government achieving the sustainable development goal of ending TB by 2025, five years ahead of the global targets.

Now, India has been engaged in TB control activities for more than 50 years. Yet it continues to be India's severest health crisis. Decades of unrestrained transmission has left millions of Indians with latent TB infection, which may re-activate at any time. A significant ratio of the population is undernourished, weakening the Immunity and driving TB reactivation. Infectious TB cases spread the disease to their family and community, perpetuating the age-old cycle of transmission and risk. Tens of millions with previous, inadequately treated TB may recur at any time. This brings a need for an end to this continued suffering, tragic loss of life, poverty with concerted efforts from all of us.

Strategic Pillars Of "Detect - Treat - Prevent - Build"
The National Strategic Plan for moving towards TB elimination has been integrated into the four strategic pillars of "Detect-Treat - Prevent-Build."

Detect all Drug Sensitive TB and Drug Resistant TB cases with an emphasis on reaching TB patients who seek care from private providers and undiagnosed TB in high-risk populations

Treat-Initiate and sustain all patients on appropriate anti-TB treatment wherever they seek care, with patient friendly systems and social support

Prevent the emergence of TB in susceptible populations

Build and strengthen enabling policies, empowered institutions and human resources with enhanced capacities

What can doctors do to help?
Because pulmonary TB is a potential public health threat, patients who are living in close quarters with other susceptible individuals (eg, in homeless shelters, prisons, nursing homes, or in house with children below 5 years) should not be discharged to these settings if the risk of the disease is significant. These patients should be kept in the hospital until appropriate testing is performed. Providers cannot legally detain patients against their will for known or suspected TB because that requires a court order from a judge. If a patient poses a real risk to the community, we can give our best to convince them to stay. If they insists on leaving, obtain the best contact information available and notify your TB liaison or department of public health.

On the flip side, for patients who are at low risk for active pulmonary TB and are reliable for follow-up, outpatient evaluation and management may be considered. These patients should have sputum sent off for acid-fast bacilli stain, PCR and culture before discharge. The provider must then notify the department of public health within 24 hours for additional testing and evaluation to be arranged

How is TB controlled and prevented?
DOTS is a treatment cum control strategy recommended by the WHO and being widely used as a part of RNTCP in our country. DOTS has been described using five important elements by WHO as follows:
1. Political commitment with increased and sustained financing This element describes a need for committed support from National government in order to ensure an effective adoption of DOTS for TB treatment and its eradication. Strategic plans thus to be implemented are required to cover all the aspects involved, such as proper infrastructures, financial requirements, drug supply to the center dedicated for DOTS, sourcing of qualified health care workers attending the patients, etc. This, in the end, will aid in attaining a broad reach to the affected individual in a given demography.

2. Case detection through quality-assured bacteriology Another crucial aspect is detection of the disease. Accurate and timely diagnosis of the disease is the first step towards achieving a control over it and hence, a need for well-managed network of laboratories is seen. Bacteriology is the recommended method for an accurate diagnosis of the disease and thus, the laboratories involved should be well-equipped to manage the samples and should have well-trained microbiologists and other personnel to attend the same.

3. Standardized treatment, with supervision and patient support This element puts forth the need to follow an appropriate treatment regimen which is standard throughout the country for all types of patients thus addressed, be it adult or pediatric. An emphasis is also put on adhering to uncompromised and uninterrupted support, and supervision for the patients during DOTS implementation.

4. An effective drug supply and management system This defines the need for a well managed and effective supply of drugs for treatment of TB. Accurate management and sustaining supply of quality anti-TB drugs is of fundamental importance. Hence, an unfaltering management system in place to support uninterrupted supply and distribution of drugs to all the facilities dedicated towards DOTS program is essential.

5. Evaluation and monitoring system As stated, it involves implementation of accurate monitoring and evaluation systems to manage records of patient data including even the treatment outcomes. The data thus will also serve to analyze the efficacy of treatment and for building strategies for betterment, and to ensure consistent high quality measures are in place. Having summarized on the implementation of DOTS for treatment of TB, the situation is not as planned throughout the Indian demography.

The resources present are not adequate enough and thus we need to put in extra effort to get additional resources mobilized for a progress in eradication strategy through implementation of DOTS. Improvement in channels aiding financial support for overall management of the project and many critical aspects such as accurate healthcare workers, drug distribution, proper guidance in following the course without interruption, etc. is still needed. The centers thus built for attending the requirement of TB patients should be proactive even in addressing the nation's concern in micro yet effective levels. Awareness about the disease with equal importance in rural and urban areas is needed. This will contribute in addressing TB at a thoughtful level and hence eventually, a complete eradication.

Prompt diagnosis and effective treatment are the only solutions to curb the emergence and spread of drug resistance. Being aware of the complications associated with a disease and getting timely diagnosis for it are also important aspects of disease prevention and management