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Picture Courtesy:  Down to Earth

Context:

TB cases in the country remain high, with clustering around the eastern and northeastern regions.

What is Tuberculosis (TB)?

Tuberculosis (TB) is a long-standing infectious disease caused by the bacterium Mycobacterium tuberculosis. It most commonly affects the lungs—a condition known as pulmonary TB—but can also spread to other organs such as the lymph nodes, bones, kidneys, and brain, which is referred to as extrapulmonary TB. The disease progresses slowly and is marked by the formation of tiny inflammatory nodules called granulomas.

How is Tuberculosis Transmitted?

TB spreads primarily through tiny respiratory droplets released when a person with active lung infection coughs, sneezes, or even speaks. The risk increases with prolonged and close contact, especially in poorly ventilated environments. Importantly, tuberculosis is not transmitted by casual physical touch, sharing utensils, or food.

Types of Tuberculosis:

Pulmonary Tuberculosis (PTB)

This is the most common presentation of TB, accounting for nearly 85% of cases. It involves infection of the lung tissues and is usually contagious, as bacteria can be released into the air when the infected person coughs or sneezes.

Extrapulmonary Tuberculosis (EPTB)

When the infection occurs outside the lungs, it is classified as extrapulmonary TB. This form constitutes around 15–20% of cases in individuals with a normal immune system, but its prevalence is significantly higher among people living with HIV or other immunocompromising conditions. 

Current Status of Tuberculosis in India:

• 26% of global TB cases in 2023 were from India
• 29% of TB deaths in WHO’s Africa–Southeast Asia region was reported from India
• India appears in all three WHO High Burden lists—TB, TB-HIV, and MDR-TB
• TB prevalence fell from 305/100,000 (2015-16) to 222/100,000 (2019-21). But regional clustering persists—eastern & northeastern states, plus Kerala, Telangana and Andhra Pradesh report higher than national average
• NFHS-5 revealed pervasive misconceptions:
• Over 60% adults misunderstood TB transmission
• Beliefs include transmission via utensils, touching, food, sex, or mosquito bites
• Stigma persists among 15.6% women, and 22.9% men preferred hiding TB diagnosis

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Why eastern and northeastern regions have high TB cases?

• Social vulnerability: States in these regions consistently rank low on nutrition indicators. NFHS-5 data shows Jharkhand, Odisha, Bihar, Assam, and Meghalaya have anaemia levels above 60%, while stunting and underweight rates exceed national averages. Since around 35% of TB cases in India are linked to undernutrition (India TB Report 2023), these regions naturally bear higher risk.
• Weak primary healthcare and difficult terrain: Mountainous landscapes, flood-prone belts, and insurgency-affected zones in northeast India make healthcare access difficult. Many districts have doctor density far below WHO norms. In Tripura and Nagaland, poor diagnostic reach resulted in over 40% delays between onset of symptoms and treatment initiation (ICMR study 2021).
• Migration, informal labour, and crowded living conditions: Eastern states like Bihar, West Bengal, Odisha and Jharkhand supply large migrant labour forces to metros. Migrants often live in congested settlements with poor ventilation—ideal for TB spread—and interrupt treatment when moving between states.

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What are the health system challenges that led to programme failure?

Private sector dominance: A large proportion of TB patients—about 25.65 percent—seek treatment exclusively in private facilities, while more than half first approach private healthcare providers. Since private care is often costly and inconsistent in quality, this dependence results in delayed diagnosis, inappropriate treatment, rising drug resistance, and increased financial vulnerability for patients.

Weak surveillance and under-reporting: Although notification of TB cases from private practitioners has been mandatory since 2012, adherence remains uneven. The persistence of stigma and reluctance to disclose illness further suppresses reporting, masking a significant portion of the actual disease burden and weakening programme planning and control efforts.

Low public investment and fragile infrastructure: India’s public health expenditure—hovering around 1.3 percent of GDP—remains inadequate, limiting the reach of preventive services even when treatment systems exist. Moreover, health priorities and budget allocations were heavily diverted towards COVID-19, pushing TB management into the background and constraining sustained elimination efforts.

Political and media under-prioritisation: Unlike HIV/AIDS, tuberculosis has not commanded strong political advocacy or media visibility, despite its significant mortality burden. Awareness campaigns such as TB Harega, Desh Jeetega were unable to generate deep behavioural engagement, leaving large segments of the population uninformed and unmotivated to adopt preventive practices.

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Government Measures:

National TB Elimination Program (NTEP)

• Formerly the Revised National Tuberculosis Control Program (RNTCP), now revamped as NTEP.
• Objective: End TB in India by 2030, aligned with WHO’s End TB Strategy.
• Key Features:
  • Free diagnosis and treatment for all TB patients
  • Directly Observed Treatment Short-course (DOTS): Ensures patients complete treatment
  • Decentralized care: TB services available at primary health centers and community clinics

TB Mukt Bharat Abhiyan

• Goal: Rapid detection, diagnosis, and treatment to accelerate TB elimination.
• Achievements:
  • Screened over 19 crore vulnerable individuals
  • Detected over 24.5 lakh TB patients, including 8.61 lakh asymptomatic cases (Source: PIB)

Focus on community mobilization, awareness campaigns, and early case detection

What needs to be change?

Nationwide behaviour change mission: India needs communication strategies of the scale and urgency seen during COVID-19. While TB kills ~1,200 Indians every day, awareness remains shockingly low—NFHS-5 showed that over 60% adults carry misconceptions about TB transmission, leading to stigma and delayed care. By contrast, COVID-19 witnessed daily briefings, celebrity campaigns, school messaging and social media saturation, reducing stigma within months. A similar Jan Andolan approach for TB is essential. For example: In Mumbai, the Municipal Corporation’s “Mukti Abhiyan” door-to-door campaign improved early detection and treatment adherence in slums, demonstrating how community-based communication can reduce burden when sustained. 

Integrating TB with nutrition and living conditions: TB thrives where poverty, malnutrition, and overcrowding persist. More than 35% of India’s TB cases are directly linked to undernutrition (India TB Report 2023). The Ni-Kshay Poshan Yojana offering ₹500 per month for nutritional support is important, but several evaluations show delayed transfers and inadequate amounts relative to real dietary needs. Interventions must integrate housing, ventilation, workplace safety for migrants, and urban health planning.                                                                                                                                       For Example: The “Nutrition-TB Synchronisation Project” in Jharkhand’s Gumla district linked community kitchens with TB treatment. Early studies recorded higher cure rates and reduced defaulting among beneficiaries—suggesting that nutrition cannot be an addon but a core TB policy. 

Building Accountability in the Private Sector: With over 50% of TB patients first seeking private care, unregulated prescriptions and fragmented treatment pathways worsen drug resistance. MDR-TB hotspots such as Mumbai and Surat are textbook examples of how unmonitored private antibiotic use leads to resistant strains. 

Decentralised surveillance and real-time digital intelligence: Currently, TB data are largely passive—based on patient reporting, which hides silent burden due to stigma. Localised surveillance, digital dashboards, and AI-based risk mapping are needed to capture early warning signs, especially in urban slums, mining belts, and migrant hotspots. 

Conclusion:

India’s fight against tuberculosis is at a crossroads as treatment gains are visible, but prevention, awareness, and system reforms remain weak. Elimination will be possible only when TB is treated not just as a medical issue but as a development, nutrition, governance, and behavioural challenge, backed by sustained financing and political will.

Source: Down to Earth