Tuberculosis (TB) is a communicable disease that is a major cause of ill health and one of the leading causes of death worldwide. Until the coronavirus (COVID-19) pandemic, TB was the leading cause of death from a single infectious agent, ranking above HIV/AIDS. TB is present in all countries and age groups. But TB is curable and preventable. Its persistent morbidity and mortality burden remains one of the major public health challenges in India [1]. Worldwide, in 2020, an estimated 10 million people fell ill with tuberculosis (5.6 million men, 3.3 million women and 1.1 million children). In 2020, 1.1 million children fell ill with TB globally. Child and adolescent TB is often overlooked by health providers and can be difficult to diagnose and treat. In 2020, the 30 high TB burden countries accounted for 86% of new TB cases. Eight countries account  for two thirds of the total, with India leading the count, followed by China, Indonesia, the Philippines, Pakistan, Nigeria, Bangladesh and South Africa. Multidrug-resistant TB (MDR-TB) remains a public health crisis and a health security threat. Only about one in three people with drug resistant TB accessed treatment in 2020. Worldwide, a total of 1.5 million people died from TB in 2020 (including 214 000 people with HIV).

Globally, TB incidence is falling at about 2% per year and between 2015 and 2020 the cumulative reduction was 11%. This was over half way to the End TB Strategy milestone of 20% reduction between 2015 and 2020. An estimated 66 million lives were saved through TB diagnosis and treatment between 2000 and 2020. Globally, close to one in two TB-affected households face costs higher than 20% of their household income, according to latest national TB patient cost survey data. The world did not reach the milestone of 0% TB patients and their households facing catastrophic costs as a result of TB disease by 2020. By 2022, US$ 13 billion is needed annually for TB prevention, diagnosis, treatment and care to achieve the global target agreed at the UN high level-meeting on TB in 2018. Funding in low- and middle-income countries (LMICs) that account for 98% of reported TB cases falls far short of what is needed. Spending in 2020 amounted to US$ 5.3 billion less than half (41%) of the global target. There was an 8.7% decline in spending between 2019 and 2020 (from US$ 5.8 billion to US$ 5.3 billion), with TB funding in 2020 back to the level of 2016. Ending the TB epidemic by 2030 is among the health targets of the United Nations Sustainable Development Goals (SDGs) [2].

Worldwide, TB is the 13th leading cause of death and the second leading infectious killer after COVID-19 (above HIV/AIDS) [3]. According to WHO estimates, around 2.7 million people developed TB in India and over 400,000 people died due to TB in the year 2017 [4]. By WHO estimates, India accounts for 27% of the global estimated 10 million cases and 25% of the estimated 1.6 million deaths. The global burden of disease analysis estimated the number of incident cases to be 3 million people in the year 2016 [5]. A study based on data from the National family Health Survey (NFHS-4) estimates that the self-reported incidence of TB in India is 304/100,000 [6]. United Nation Sustainable Development Goals (SDGs) and WHO’s End-TB strategy aims to end the global TB epidemic with targets to reduce TB deaths by 95% and to cut new cases by 90% by 2035 globally [7]. India’s National Strategic plan 2017–2025 aims to achieve a TB free India, 5 years ahead of the global elimination plan [8].

India had launched a National Tuberculosis Programme (NTP) in sixties following the epidemiological assessment of the situation during 1955–1958 and has already taken several critical steps to showcase itself as a leader for a TB-free world9. Despite these impressive commitments, due to less-than-optimal service delivery and various challenges, it could not make much progress in terms of achieving substantially high cure rates and carries the by-far highest burden of TB and MDR-TB. The actual prevalence of TB in India is likely to be higher than the available prevalence rates. This may be due to the stigma associated with TB and resulting in underreporting. The other factor may be attributed to undiagnosed TB. The major limitation of current estimates of Prevalence and Incidence of TB in India is that India lacks a national TB prevalence survey [10]. Another limitation is incomplete notification from India’s private health sector which uses enormous quantities of anti-TB medications and therefore, disease burden estimates based on TB notifications data may be underestimated. In order to accelerate progress towards the goal of ending TB by 2025, India needs to strengthen the public–private sector response to TB. Thus, India needs to outline the incidence status and trend of TB in India [11]. 

The Government of India (GoI) has set the target of reducing the incidence of new TB cases by 80% to end TB by 2025. Both the level of TB and efforts towards elimination vary across States/Districts. So the GoI has announced that it will incentivize and reward States/Districts for achieving certain targets. A District or a State/UT will be recognized for "TB Free" efforts, based on the decrease in TB incidence from 2015 to 2021. As it may take some time to achieve TB free status, in order to motivate States/Districts, interim recognition is also being given under the bronze, silver and gold categories based on improvement in TB score, increase in NNT and TB drug sale data [12].

In view of these facts and figures, an extensive secondary data review was done in district Bilaspur of hilly state Himachal Pradesh from 2017 to 2021 for comparison within the state and national level (Table 3).

This is an observational, descriptive study based on secondary data retrieved from Nikshay portal. The study population includes patients notified for tuberculosis from January 2017 through December 2021 in district Bilaspur including those who were diagnosed outside the district and were taking treatment for Tuberculosis in the district and were already assigned treatment outcome.

To keep a track of the TB patients across the country, the Government of India has introduced a system called NIKSHAY. NIKSHAY (www.nikshay .gov.in) is a web enabled application, which facilitates monitoring of universal access to TB patients’ data by all concerned. It was launched by the Government of India in June 2012. 

NIKSHAY has two broad objectives. One is to create database of all TB patients including Multi-Drug Resistant cases across the country and to use this database for monitoring and research purposes at all levels so that TB can be eradicated from India in an effective manner. In the state of Himachal Pradesh, it was made fully functional in the year 2016. 

So, the data on Key Performance Indicators (KPIs) in this study was collected from Nikshay portal for the year Jan, 2017 to Dec, 2021. A total of 3721 TB patients were notified during this period in the district. The data such collected was entered into Microsoft excel spreadsheet and was cleaned. Incidence of disease was calculated using population of census 2011 and annual growth rate of 1.2%. For calculating the Number Needed to Test (NNT) data was collected from hard copies of the Annexure M and CBNAAT and TrueNat indicators. The Diagnostic cohort included the patients who were tested positive for TB on microscopy or CBNAAT or who were diagnosed clinically for TB within the district. The current cohort included patients diagnosed with TB anywhere in the country and presently taking treatment from District Bilaspur. The data was analysed using epi-info version 7. Due permissions were taken from higher authorities for the data collection and publication (Table 2).

A total of 3721 TB patients were notified during this period in the district. The mean age of study participants was 47±9.5 years. Majority (2577 i.e., 69%) of them were males. 298 (8%) were smokers, 59 (1.6%) were contacts of confirmed Tb case, 63 (1.7%) were migrant workers. Out of the total 95 patients were having drug resistant of any kind. 40 of them were put on Mono-H resistant regimen, 37 were on shorter MDR regimen, 8 on conventional MDR regimen, 7 on all longer oral regimen and 3 were on XDR regimen.

445 (12%) out of the total were mapped as key population. 82 (2.2%) of the total were diagnosed out of the state of H.P. and 1046 (28%) were diagnosed outside the district Bilaspur in any other district of H.P. 3517 (94.5%) were notified by the public sector PHIs, 131 (3.5%) by the private health facilities and 73 (2%) by the private labs or chemists.

Out of the total 3721 patients notified, 1512 were diagnosed through microscopy, 1014 through NAAT (CBNAAT and TrueNAT), 141 through Chest X-Ray, 64 through LPA, 6 through culture and 984 were diagnosed through other tests or clinically.

A comparison for KPIs was made between the years 2017 and 2021. There was a significant difference between number of patients notified as per the diagnostic cohort and as per the current cohort which is shown the Table 1. 

Table1: Comparison of Diagnostic and Current Cohort

Table 2: Comparison of Key Performance Indicators (Kpis) Between the Years 2017 To 2021

Table 3: Various Facts and Figures Related To Kpis Combined From 2017 To 2021

Table 4: Distribution of Extrapulmonary Patients According To Site of Disease

The National TB Elimination Programme (NTEP) is an on-going Centrally Sponsored Scheme, implemented under the umbrella of NHM with a vision of TB Free India, where free diagnostic and quality assured treatment is provided to all TB patients. The National Tuberculosis Programme of India NTP was initiated in 1962 and RNTCP was rolled out in 1997. In January 2020, the programme was renamed as National Tuberculosis Elimination Programme (NTEP) in line with the vision of GoI [13]. 

Over the recent years, India had been successfully inching its way towards bridging the gap between the WHO estimated number of incident (new+relapse) TB cases and the number of incident TB cases notified by the National TB Elimination Programme (NTEP). The scale of achievement over the last five years is depicted as under In 2019, the NTEP achieved a notification rate of 159 TB cases / lakh population against an estimated 199/lakh. Although the NTEP missed notifying around 2,40,000 cases of the estimated 26,40,000 incident cases of TB in 2019, the number of missing cases is significantly lower than the missing millions of the previous years. The year 2020 began with a renewed vigour and an ambitious target of notifying 29,99,000 Total cases was fixed. With focussed efforts, the NTEP managed to notify 4,11,242 Total TB cases in the first two months itself - which was about 6% more than the notifications in the corresponding months of the previous year. However, the unprecedented COVID-19 pandemic derailed the momentum gained by the TB programme and like all other national programs, the routine TB related services were adversely affected across the country due to covid containment measures [14] (Table 4).

Bilaspur is high performing district in TB KPIs according to CTD. The difference of approximately 30% notifications was observed during all these 5years between diagnostic cohort and the current cohort. These 30% cases are diagnosed mostly at IGMC Shimla and Dr RKGMC Hamirpur. The reasons behind this gap seem to be lack of testing facilities (only 2 NAAT sites in district out of which one was established late in 2021), lack of specialised care, shortage of specialist physicians/pulmonologists, lack of CT/MRI facilities, lack of centres to collect difficult to collect samples and geographical position of the district.

Further, 29% of cases are being diagnosed clinically, which is clearly higher than expected national figure of 15-20%3. Reasons behind may be same as that of the gap in diagnostic and current cohort notifications.

The death rate of 6.5% in the district is one of the highest among high performing district of the country (country average 4%). The main reason for high death rate may be lack of specialised care and late diagnosis due to lack of awareness in the public. In the country, of the reported 24.04 lakh TB cases in 2019, treatment success was 82 per cent, the mortality rate was 4 per cent. 4 percent of patients were lost to follow up and treatment failure and regimen change after initiation of treatment were about 3 per cent. In our study group, initial loss to follow-up was 1% which is better than the overall 5% initial loss to follow-up in the country in 2020 [2].

Covid-19 has hit the globe, country, state and district badly in terms of TB and diseases other than Covid. In 2020, there were 18.05 lakh TB notifications, which was a fall of 24 per cent from 2019 due to the disruptions caused by the Covid-19 pandemic. The notifications rose in the beginning of 2020 (6 percent more than 2019) and by December, we witnessed 11% increase from April projections as per the National Tuberculosis Elimination Programme (NTEP). Due to lockdowns, notifications fell by 38 per cent and 44 per cent in the public and private sectors respectively. On similar lines 20% decline was recorded in Bilaspur district in 2020 compared to 2019 incidence and further 4% decrease in incidence in 2021 compared to 2020 data. 30% decrease in total tests done was recorded in 2020 compared to 2019 and further 22% decrease in total tests done in 2021 compared to 2020. There are a lot of factors responsible for this like fall in the approved budgets toward the programme from Rs. 3,333 crores in 2019-20 to Rs. 3,110 crore in 2020-21, decreased differentiated TB care, decreased testing facilities, use of CBNAAT and TrueNAT machines for Covid-19 testing instead of TB testing. Further this decline may be attributed to decrease in Active Case Finding for TB (ACF) campaign. In 2019 3 rounds of ACF campaign were carried out in the state which decreased to 1 round in 2020 and 2021 [15]. 

SDG 3.3 has emphasized on ending epidemic of TB by 2030. India has set the target of TB free country by 2025 and Himachal Pradesh has more optimistic target of achieving TB free status before 2023. This seems to be unrealistic as incidence needs to be brought to as low as 55 cases per lakh population. H.P. currently has incidence of 165 per lakh. NNT needs to be increased up-to 80 to achieve TB free status, but Bilaspur and HP has present NNT at 20 [6]. 

The Lancet quoted “India’s goal to end the epidemic by 2025 (five years ahead of the UN SDG) is too “ambitious", “unrealistic", and, therefore, unattainable. As it requires high quality of care to every person from diagnosis to treatment” [16] and this quote rightly fits for Himachal Pradesh and Bilaspur too.

The TB free status is far away to the district and state of H.P. and needs rigorous efforts in terms of diagnostics, treatment, and specialised care for better care of patients. Advocacy, Communication and Social Mobilisation (ACSM) activities need to be strengthened in order to reduce stigma of disease to achieve TB free status for the district.

1. Uplekar M. et al. “WHO’s new end TB strategy.” The Lancet, vol. 385, no. 9979, 2015, pp. 1799-1801.

2. Pai M. et al. “Reducing global tuberculosis deaths—time for India to step up.” The Lancet, vol. 389, no. 10075, 2017, pp. 1174-1176.

3. World Health Organization. Global TB report. 2020, https://www.who.int/tb/publications/global_report/en/. Accessed January 2022.

4. World Health Organization. Global TB report. 2021, https://www.who.int/tb/publications/global_report/en/. Accessed January 2022.

5. World Health Organization. Global tuberculosis report 2018. WHO, 2017, Geneva.

6. Arinaminpathy N. et al. “The number of privately treated tuberculosis cases in India: An estimation from drug sales data.” The Lancet Infectious Diseases, vol. 16, no. 11, 2016, pp. 1255-1260.

7. Mazumdar S. et al. “Self-reported tuberculosis in India: Evidence from NFHS-4.” BMJ Global Health, vol. 4, no. 3, 2019, pp. e001371.

8. Uplekar M. et al. “WHO’s new end TB strategy.” The Lancet, vol. 385, no. 9979, 2015, pp. 1799-1801.

9. Central TB Division, Directorate General of Health Services, Ministry of Health and Family Welfare. National strategic plan for tuberculosis elimination 2017–2025. 2017, New Delhi.

10. Indian Council of Medical Research. Tuberculosis in India: A sample survey, 1955–58. Tuberculosis Sub-Committee, 1959.

11. Onozaki I. et al. “National tuberculosis prevalence surveys in Asia, 1990–2012: An overview of results and lessons learned.” Tropical Medicine & International Health, vol. 20, no. 9, 2015, pp. 1128-1145.

12. Dhamnetiya D. et al. “Trends in incidence and mortality of tuberculosis in India over past three decades: A joinpoint and age–period–cohort analysis.” BMC Pulmonary Medicine, vol. 21, no. 1, 2021, pp. 1-4.

13. “RNTCP gets name change, now called National Tuberculosis Elimination Program (NTEP).” 2020, https:// medicaldialogues.in/rntcp-gets-a-name-change-now-calle d-national-tuberculosis-elimination-program-ntep. Accessed January 2022.

14. Department of Health and Family Welfare, Government of India. Annual report 2020–21. 2021, https://main.mohfw.g ov.in/sites/default/files/Annual%20Report%202020-21 %20English.pdf. Accessed December 2021.

15. World Health Organization. Global tuberculosis report 2021. WHO, 2017, Geneva.

16. Houben R.M. et al. “Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: A combined analysis of 11 mathematical models.” The Lancet Global Health, vol. 4, no. 11, 2016, pp. e806-e815.