World TB Day: As India's eradication deadline nears, Bimaru states a drag

Experts say that despite the decline in incidence rates, the 2025 deadline may be ambitious

With India’s 2025 deadline to end tuberculosis (TB) drawing near, some states are lagging behind others. While India’s TB cure rate stands at 27.8 per cent, 11 states have rates lower than the national average, according to data from the India TB Report 2023.

These laggards account for a third of India’s notified patients, with the majority residing in the Bimaru (acronym for Bihar, Madhya Pradesh, Rajasthan, and Uttar Pradesh) states. Coined in the 1980s, the ‘Bimaru’ refers to states lagging in key economic and other indicators, including the availability of health services needed to address diseases like TB.

Globally, March 24 marks World TB Day, commemorating the discovery of the bacteria causing the disease.

Bihar reports the lowest cure rate at 12.2 per cent, followed by Madhya Pradesh at 21 per cent, Uttar Pradesh at 23 per cent, and Rajasthan at 25.9 per cent.

Additionally, states like Goa and Maharashtra also exhibit low cure rates.

Together, the Bimaru states account for two-thirds of the population in states with cure rates below the national average.

The Central TB Division, under the Ministry of Health and Family Welfare, oversees the National TB Elimination Programme (NTEP). However, it did not comment on the reasons for the disparity among states.

An official from the Ministry of Health suggested that long treatment regimes and under-reporting in rural areas might explain the variation in cure rates.

The cure rate represents the number of TB patients cured among those notified.

Among the 25 states with cure rates exceeding the national average are Lakshadweep, West Bengal, Sikkim, Odisha, Tamil Nadu, Telangana, Karnataka, Andhra Pradesh, Kerala, and Gujarat, among others.

India aims to eradicate TB by 2025, five years ahead of the global sustainable development goal targets.

TB ranks as the second leading cause of infectious deaths globally, following Covid, according to the World Health Organization.

While an estimated 11 million people worldwide were diagnosed with TB in 2022, over a million died from it.

To eliminate TB in India, the Centre notified the National Strategic Plan for TB 2017-25, setting yearly targets for TB impact indicators.

Based on a 2015 baseline, India targeted a reduction in the TB incidence rate (incidence per 100,000 people) between 36 and 158 and a TB mortality rate (per 100,000 people) between 3 and 4 by 2025. The goal also aimed to ensure that no family suffers catastrophic costs due to TB by 2025.

Targets for 2023 were set at an incidence rate of 49-185 and a mortality rate of 5-7 relative to the population. However, by the end of 2022, India’s TB incidence stood at 199, with a mortality rate of 24, according to the Global Tuberculosis Report 2023.

Vivek Anand Padegal, senior consultant in pulmonology at Fortis Hospital, Bengaluru, said, “While the goal of eliminating the disease by 2025 may be ambitious, there have been improvements in cure rates. Treatment success rates are inching closer to the national target of 85 per cent.”

India still accounts for a third of global TB cases and deaths. In 2022, India reported 2.8 million TB cases compared to 3.4 million two decades ago.

Other high TB incidence countries such as China, the Philippines, and Pakistan reported fewer than a million cases in 2022. TB caused approximately 342,000 deaths in India in 2022.

Padegal highlighted the role of programmes like NTEP and PM-Nikshay in reducing incidence and mortality rates.

He noted, “These initiatives focus on early diagnosis, ensuring patients complete treatment, and providing nutritional support, which has contributed to higher cure rates and reduced TB spread.”

The schemes also emphasise mandatory TB notification, requiring the reporting of diagnosis and treatment information to designated public health authorities. Failure to comply is a punishable offence.

Another factor contributing to reduced TB incidence in India is the easy availability of drugs.

Sandeep Nayar, principal director and head of the department of chest and respiratory diseases at BLK-MAX Super Specialty Hospital, Delhi, mentioned that all first-line TB drugs are now accessible even in remote areas.

He said, “Costly medicines like bedaquiline are available in government institutions, aiding in curing many cases of multidrug-resistant TB (MDR TB).”

MDR TB is of particular concern as the bacteria develop resistance to TB drugs, increasing the risk of death. However, the development of newer drugs is underway.

Kuldeep Kumar Grover, head of critical care and pulmonology at CK Birla Hospital, Gurugram, reported that at least 16 new drugs are undergoing Phase I or II clinical trials, with an additional 22 in pre-clinical stages.

“Research on shorter treatment regimens is also ongoing, potentially improving patient compliance and reducing the risk of drug resistance,” he added.