Tuberculosis (TB) continues to remain one
of the most pressing health problems in India. India is the highest TB
burden country in the world, accounting for one fifth of the global
incidence - an estimated 1.96 million cases annually(1). Approximately 2.9
million people die from tuberculosis each year worldwide; about one fifth
of them in India alone(1). Nearly 500,000 die from the disease – more than
1000 per day–one every minute(2). The disease is a major barrier to social
and economic development. An estimated 100 million workdays are lost due
to illness. The society and the country also incur a huge cost due to
TB–nearly US$ 3 billion in indirect costs and US$ 300 million in direct
costs(2). The situation is more complicated considering that TB
disproportionately affects the young population in India. TB mortality in
the country has reduced from an estimated 42 per lakh population in 1990
to 28 per lakh population in 2006, and the prevalence of TB in the country
has reduced from 568 per lakh population in 1990 to 283 per lakh
population by the year 2007(1).
Annual rate of tuberculosis infection (ARTI) is a most
sensitive indicator of prevalence of TB infection in a community. For
adequate control of TB infection, we should have an average ARTI of about
0.07% below 14 years of age. A nation-wide survey among young children
show very high figures of ARTI in almost all the regions- highest in north
zone (1.9%) followed by west zone (1.8%), east zone (1.3%.) and lowest in
the south zone (1.0-1.1%)(3). The results indicate a high rate of
transmission of infection due to high load of infectious cases in the
ARI and Pneumonia
Every year, acute respiratory infections (ARI-including
both upper and lower) are responsible for an estimated 3.9 million deaths
worldwide. It is estimated that Bangladesh, India, Indonesia and Nepal
together account for 40% of the global ARI mortality(4). On an average,
children below 5 years of age suffer about 5 episodes of ARI per child per
year, thus accounting about 238 million attacks. ARI is responsible for
about 30-50% of visits to health facilities and for about 20-40% of
admissions to hospitals. It is also a leading cause of deafness as
sequelae of acute otitis media(4).
ARI is one of the major causes of death. Hospital
records from high mortality states show up to 13% of inpatient deaths in
pediatric wards are due to ARI(4). According to recent WHO/Unicef data,
about 20% of all deaths in children under 5 years are due to acute lower
respiratory infections (pneumonia, bronchiolitis and bronchitis); 90% of
these deaths are due to pneumonia. Studies have shown that up to 19% of
children hospitalized with pneumonia die in India(5).
Progress and the Challenges
In terms of population coverage, India now has the
second largest DOTS program in the world(2). The program has helped to
achieve a case detection rate of 68% (2007) and a treatment success rate
of 86% (2006). Treatment success rates have tripled from 25% to 86% and TB
death rates have declined from 29% to 4% (2). On the other hand, there is
little or no evidence that it has resulted in appreciable decline in the
incidence of TB infection.
There are several challenges as India strives to
achieve the objective of TB control, foremost being the threat of
multi-drug resistance TB (MDR-TB). The problem of drug resistance has been
further compounded with the emergence of extensively drug-resistant TB (XDR-TB),
which is a subset of MDR cases with additional resistance to key second
line drugs. In India, though the prevalence of XDR-TB is low but the
potential threat is of real concern. Unregulated availability and
injudicious use of the first and second line anti-TB drugs outside of
RNTCP, along with non-existent systems to ensure standardized regimens and
treatment adherence have been attributed for emergence of drug resistance
The Revised National Tuberculosis Control Program is at
best is only a "TB-treatment" program. The tool to ensure primary
prevention i.e. an effective vaccine, is nonexistent. The program also
does not envisage any measures to detect and actively treat latent
infections–a very crucial pool of individuals responsible for circulating
the bacteria amongst susceptible population. Until these two aspects are
addressed, effort to contain or eliminate the disease would remain a mere
Despite being responsible for most under-5 deaths
worldwide, there was no comprehensive sound strategy to specifically
target pneumonia so far. The scenario was further compounded by lack of
availability of authentic epidemiological data on the incidence and
prevalence of different major pathogens responsible for pneumonia cases in
the country. Recently, WHO and Unicef have jointly launched a Global
Action Plan for Prevention and Control of Pneumonia (GAPP) to include a
package of interventions to prevent
most deaths from pneumonia among the most vulnerable groups(6). A package
of $39 billion has been promised to implement the action plan in the 68
poor nations between 2010 and 2015. Half of this fund will be spent in
India and China. The action plan aims to reduce mortality from pneumonia
in the under 5s by 65% by 2015, reduce the incidence of severe pneumonia
by 25%, and to reach 90% coverage of each relevant vaccine(6).
Need of the Hour
The case detection rates under RNTCP need to be
improved further. The program has to be extended to the remaining
population; and the private and non-governmental sectors have to be
encouraged to follow national guidelines in case detection and treatment.
Enabling and promoting research for the development of new drugs,
diagnostic and vaccines along with operational research will go a long way
to bolster, and improve program performance. The irrational and
unsupervised use of anti-TB drugs needs to be actively discouraged.
The need of the hour is to undertake multi-pronged
approach for preventing and treating pneumonia. Protection from
malnutrition, pollution and overcrowding; prevention through effective
mass vaccination; and treatment with appropriate antibiotics at facility
and community level should be taken up as key activities.
Competing interest: None stated.
1. Global Tuberculosis Control Report 2009. Available
from: URL: http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf.
Accessed November 30, 2009.
2. Tuberculosis Control-India. Available from: http://www.tbcindia.org.
Accessed November 30, 2009.
3. Annual risk of tuberculosis infection in different
zones of India. Available from: http://ntiindia.kar.nic.in/docs/ari2000-03/index.html.
Accessed December 2, 2009.
4. Acute respiratory infections in children. Available
from: http://www.who.int/fch/depts/cah/resp_ infections/en/. Accessed
December 2, 2009.
5. Pneumonia–a major killer in children: prevention
possible with safe and effective vaccines. Available from: http://www.whoindia.org/EN/Section6/Section453.htm.
Accessed December 2, 2009.
6. Global Action Plan for Prevention and Control of
Pneumonia (GAPP). Available from: www.who. int/child_adolescent_health/documents/fch_cah_
nch_09_04/en/index.html. Accessed December 2, 2009.