Tuberculosis in India

Tuberculosis (TB) is one of the most persistent and serious public health challenges in India. It is a communicable bacterial disease caused by Mycobacterium tuberculosis, primarily affecting the lungs (pulmonary TB), though it can also impact other organs such as the bones, kidneys, and lymph nodes (extrapulmonary TB). India carries the highest burden of tuberculosis in the world, accounting for a substantial share of global cases and deaths. Despite major control initiatives and advances in diagnostics and treatment, TB remains a key health and developmental concern in the country.

Overview and Epidemiology

Tuberculosis is transmitted mainly through airborne droplets expelled when an infected person coughs, sneezes, or speaks. Once inhaled, the bacteria can remain dormant in the body for years before becoming active, particularly in individuals with weakened immune systems.
According to the World Health Organization (WHO) and the India TB Report 2024, India accounts for around 27% of global TB cases and approximately one-third of TB-related deaths worldwide. The estimated incidence is about 210 cases per 100,000 population per year, with approximately 2.8 million new cases reported annually. Although the disease affects all age groups, it is more prevalent among adults aged 15–45 years — the most economically productive age group.

Causes and Risk Factors

Several social, biological, and environmental factors contribute to the high prevalence of TB in India:

• Poverty and Malnutrition: Poor nutrition weakens immunity, making individuals more susceptible to infection.
• Overcrowding and Poor Housing: High population density, particularly in urban slums, facilitates transmission.
• HIV Co-infection: People living with HIV are 20–30 times more likely to develop active TB.
• Tobacco Use: Smoking and air pollution damage lung tissue, increasing vulnerability.
• Diabetes Mellitus: India’s growing diabetes burden increases the risk of TB infection and relapse.
• Limited Health Access: Delayed diagnosis and incomplete treatment remain common in some regions.

Forms of Tuberculosis

1. Pulmonary TB – Affects the lungs and is the most infectious form. Symptoms include prolonged cough, fever, night sweats, weight loss, and fatigue.
2. Extrapulmonary TB – Affects other organs like lymph nodes, bones, brain (tubercular meningitis), or kidneys. It is less contagious but equally serious.
3. Drug-Resistant TB (DR-TB) – Occurs when the bacteria become resistant to first-line drugs such as isoniazid and rifampicin. India has one of the highest burdens of multi-drug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) in the world.

National TB Control Programmes

India has made significant progress through successive national health initiatives aimed at controlling and eventually eliminating TB.

1. National Tuberculosis Programme (NTP), 1962
   • The first organised TB control programme in India.
   • Based on case detection through microscopy and treatment using standard drug regimens.
   • Had limited success due to weak implementation and poor follow-up systems.
2. Revised National Tuberculosis Control Programme (RNTCP), 1997
   • Introduced the Directly Observed Treatment, Short-course (DOTS) strategy recommended by the WHO.
   • Focused on ensuring regular drug intake under supervision, improving cure rates, and preventing drug resistance.
   • Expanded nationwide by 2006 and significantly increased treatment success rates.
3. National Strategic Plan for TB Elimination (2017–2025)
   • Envisions a TB-free India by 2025, five years ahead of the global Sustainable Development Goal (SDG) target of 2030.
   • Emphasises early detection, universal drug susceptibility testing, private sector engagement, nutritional support, and digital monitoring.
   • Integrates TB services with general healthcare through the National Health Mission (NHM).
4. Ni-Kshay Portal and Ni-Kshay Poshan Yojana
   • The Ni-Kshay Portal is a digital platform for TB surveillance and patient management, ensuring real-time reporting from both public and private sectors.
   • Ni-Kshay Poshan Yojana, launched in 2018, provides ₹500 per month nutritional support to every notified TB patient during treatment.
5. National Tuberculosis Elimination Programme (NTEP), 2020 onward
   • The restructured RNTCP with an expanded focus on universal access to TB care, treatment of drug-resistant forms, and multi-sectoral collaboration.
   • Introduces innovations such as GeneXpert testing, digital adherence tools (99DOTS), and community-based TB care models.

Diagnostic and Treatment Approaches

• Diagnosis: Based on clinical symptoms, sputum smear microscopy, molecular tests (GeneXpert/CBNAAT), culture methods, and radiological imaging.
• Treatment: Standardised regimens under Directly Observed Treatment (DOT), using first-line anti-TB drugs such as isoniazid, rifampicin, pyrazinamide, and ethambutol for six months.
• Drug-Resistant TB Management: Involves second-line medications like levofloxacin, bedaquiline, and delamanid, often for extended durations (9–20 months).
• Preventive Therapy: The use of isoniazid preventive therapy (IPT) for latent TB infection among high-risk groups such as HIV patients.

Geographical Distribution and Trends

The burden of TB in India is unevenly distributed across states and regions:

• High-burden states include Uttar Pradesh, Bihar, Madhya Pradesh, Maharashtra, Rajasthan, and West Bengal.
• Tribal and rural areas report higher prevalence due to limited health infrastructure.
• Urban slums in major cities such as Delhi and Mumbai also experience high transmission rates due to overcrowding and migration.

In recent years, India has seen improvements in case detection and cure rates, largely due to enhanced surveillance and free treatment programmes. However, the COVID-19 pandemic temporarily disrupted TB services, leading to underreporting and delayed treatment in 2020–2021.

Challenges in TB Control

Despite progress, several challenges continue to hinder TB elimination:

• Drug Resistance: Increasing incidence of MDR-TB and XDR-TB strains.
• Private Sector Involvement: A large portion of TB patients first seek treatment in the private sector, where practices often vary.
• Social Stigma: Persistent misconceptions lead to delayed diagnosis and social isolation of patients.
• Treatment Adherence: Long treatment duration leads to dropouts and relapses.
• Co-morbidities: Rising rates of diabetes, HIV, and malnutrition complicate management.
• Funding Gaps: Sustained financial and logistical resources are required for the ambitious 2025 elimination goal.

Government and International Collaboration

India’s TB elimination efforts are supported by global partners such as the World Health Organization (WHO), The Global Fund, USAID, and Stop TB Partnership. National initiatives like TB Mukt Bharat Abhiyan and TB Harega, Desh Jeetega campaigns promote awareness, early diagnosis, and community engagement.

Future Goals and Strategies

• Achieving the target of TB elimination by 2025 through intensified case finding and community participation.
• Expanding use of AI-based screening, digital adherence monitoring, and point-of-care diagnostics.
• Strengthening public-private partnerships for comprehensive TB care.
• Addressing social determinants of health, including nutrition, housing, and economic support.
• Promoting vaccine development, such as the BCG booster and new-generation TB vaccines under clinical trials.