South Africa Aims to Detect Every TB Patient, While a Million Cases in India Slip Through the Cracks

South Africa has launched one of the most progressive TB screening campaigns in the world. Budget cuts have nearly derailed India's TB programme.

Fellows 2015

By Vidya Krishnan

August 03, 2015

Also published by Scroll.in

This year on March 24, on the occasion of World Tuberculosis Day, global attention was sharply drawn towards the disease when British Prime Minister David Cameron launched a report by an expert panel on anti-microbial resistance. The outlook was dire – over the next 35 years, 75 million people are likely to lose their lives to drug resistant TB, and by 2050, the infection could cost the global economy as much as $17 trillion.

On the same day, half way across the world in a small gold mining town called Kanana in the North West Province of South Africa, the nation’s Health Minister Aaron Motsoaledi launched one of the most progressive TB screening campaigns in the world. Kanana is the birthplace of Nobel Prize laureate and TB survivor Archbishop Desmond Tutu.

Photo: Finbarr O/Reuters

South Africa’s TB epidemic is the third largest in the world behind India and China. The five-year-long campaign called Ending South Africa's TB epidemic: Accelerating our Response in Key Populations aims to ensure that at least 90% of vulnerable populations are screened for TB, at least 90% of all cases are diagnosed, and to ensure at least 90% access to treatment.

“In October last year, there was an international lung conference in Barcelona in Spain," said Health Minister Aaron Motsoaledi in an exclusive interview to Scroll. "We had just come back from Melbourne where the International AIDS conference had adopted 90-90-90 for HIV AIDS. So, when I was in Barcelona for the international lung conference, I said that it would be unfair for the world to adopt 90-90-90 for HIV-AIDS, and not do the same for TB, especially in Africa where the co-infection rate is so high. I said, let's do the same thing for TB.”

To that end, South Africa has identified groups that are most at risk, including the country’s 150,000 men and women in correctional facilities, over 500,000 miners, and nearly 5.1 million people in six high risk areas. Over the next few months, and perhaps longer, each one of these people will not just be screened for TB but also offered treatment and care. In addition, children will receive special attention and will be tested in Early Childhood Development Centres. The clear aim of the campaign is to reduce the number of TB related deaths in South Africa from 1,20,000 to 20,000 per year. The campaign will last until 2017 and will target six mining districts in four provinces.

In a statement, Dr Lucica Ditiu, Executive Secretary of Stop TB Partnership said: “The country's national strategic plan is hugely ambitious with a call for all South Africans to be screened for TB at least once a year. This is a bold step in the direction of moving from just saving the dying to a state of 'keeping the population healthy and devoid of TB."

According to the World Health Organisation, there are 530,000 new infections each year in South Africa. Nearly 66% of those new infections are people who are co-infected with HIV and TB. In the last 15 years, TB incidence in the country has risen by 400%.

South Africa’s new TB screening campaign has far reaching implications for the developing world, particularly the BRICS nations, in diagnosing and treating the disease.

“Within BRICS, we constantly learn from each other’s experiences, strengths and weaknesses. For instance, we are learning technology transfer from India at the moment. Similarly, I spoke to the Minister of Health in India in May about applying the 90-90-90 vision for TB, and we have decided to adopt stricter measures,” Dr. Motsoaledi said.

India's TB programme

While South African TB programme is combing through high risk populations to not let a single person go undetected, India's programme is almost derailing.

According to data presented by the government in the Lok Sabha last month, India had 2.6 million cases of tuberculosis as per the latest count and ranks 14th among 22 high TB burden countries. Further, an estimated 61,000 MDR-TB cases have been reported.

But the numbers could be higher. A leaked report by the Joint Monitoring Mission of the Revised National Tuberculosis Control Programme which assessed India's National Tuberculosis policy has noted that nearly a million people living with tuberculosis in the country have either gone undiagnosed or unreported.

The spread of tuberculosis in India, particularly of the drug-resistant kind, is fast becoming a global concern. In April this year, an Indian woman flew to O’Hare International Airport in Chicago. As per the woman's travel documents, she visited relatives in Illinois, Tennessee and Missouri before realising that she needed medical attention to treat 'extensively drug-resistant tuberculosis', or XDR-TB. The US authorities immediately informed the  health department and the Centers for Disease Control and Prevention and began the gruelling drill of tracing down everyone she had come in contact with across three states. As New York Times reported, the patient from India was transferred to the National Institute of Health in Bethesda where she is seeking treatment.

This case is a perfect example of how a cash-strapped TB programme in India can have global repercussions. In the past decade, India's TB programme has screened over 80 million people, and treated and detected nearly 15 million patients. However, instead of investing in expansion of the programme, budget cuts are threatening the future of TB prevention in India.

“While RNTCP [Revised National Tuberculosis Control Programme] expenditure has increased 27% since 2012, there is a growing gap between the allocation of funds and the minimum investment required to reach the goals of the Plan," said the leaked JMM report. It warned that if the trend continues, final expenditure on the plan would fall to Rs. 3,000 crores, or two-thirds of the minimum required, with 40% of the budget spent on treatment alone. "This threatens the future of TB control in India and underscores the necessity to prevent drug resistance,” it said.

This is the third part in a series that attempts to draw parallels between the health systems of India and South Africa, which face a similar set of challenges when it comes to expanding health programmes within budgetary constraints. Read the others stories here.

Reporting for the series is supported by a grant from the International Reporting Project.