Today, WHO released its 2016 Global TB Report. The news is not good! The report shows that the TB burden is actually higher than previously estimated, reflecting new data from India. In 2015, there were an estimated 10.4 million new TB cases worldwide. Six countries accounted for 60% of the total burden, with India bearing the brunt, followed by Indonesia, China, Nigeria, Pakistan and South Africa. India alone accounted for 2.8 of the 10.4 million new TB cases.
An estimated 1.8 million people died from TB in 2015, of whom 0.4 million were co-infected with HIV. Gaps in testing for TB and reporting new cases remain major challenges, as they have in the past. Of the estimated 10.4 million new cases, only 6.1 million were detected and officially notified in 2015, leaving a big gap of 4.3 million cases that are ‘missing’ – either not diagnosed, or managed in large unregulated private sectors and not notified to TB programs. In addition, the rate of reduction in TB cases remained stagnant at 1.5% from 2014 to 2015.
These numbers are disappointing and underscores the need for greater investments in global TB control. In particular, India really needs to wake up to the enormity of the epidemic in the country, and put some serious money behind its under-funded TB program. For a long time, India ignored TB patients managed in the private sector, and national prevalence and drug-resistance surveys were not periodically done (unlike other countries such as China). Furthermore, the Indian TB program was (and still is) heavily reliant on insensitive diagnostic tools such as sputum smears that miss many TB cases. All of this meant that India has been under-diagnosing and under-reporting the burden of TB for a long time.
With new data, our understanding is improving. We are now aware that private sector manages over half of all TB in India, new research suggests that enormous quantities of TB drugs are sold in the Indian private market. In addition, although India made TB notification mandatory in 2011, it has taken a few years for private sector notifications to accumulate. Now, thanks to several public-private partnership programs (e.g. Mumbai, Patna and Mehsana), we are seeing significant increases in case notifications from private sector. This is also telling us that huge numbers of TB patients are getting managed in the private sector.
The latest Global Burden of Disease estimates from IHME show TB to be a major cause of adult mortality in India. Here again, official government reports have been under-estimating the real burden of TB deaths in India.
Overall, the message for India is very clear – acknowledge the reality, collect better data on true burden of TB, deaths, and drug-resistance, and allocate greater funding to tackle this huge problem! Nearly 27% of the world's TB cases are in India. So, global TB elimination is an impossible goal without significant progress in this emerging superpower. With its strong research expertise in TB, and technological and pharmaceutical capacity, India has the potential to make great progress against this disease. And with strong financial and political commitment from the Prime Minister, engagement of both public and private sectors, and continued engagement with partners, India can not only beat TB, but lead the world in our quest to end the TB epidemic.