What Tuberculosis-Free Certification Means
On March 24, 2023, Prime Minister Narendra Modi honoured Karnataka and Jammu and Kashmir with the tuberculosis (TB)-free award. But a TB-free award does not mean a state is free of the disease. We explain
Prime Minister Narendra Modi while addressing the One World TB Summit on March 24, World Tuberculosis (TB) Day in Varanasi, launched several initiatives, including the TB-Mukt Panchayat, a shorter TB Preventive Treatment (TPT), and a family-centric care model for TB. He also released India's Annual TB Report 2023 and dished out awards to states, Union territories (UT) and districts for their progress towards ending TB.
“Karnataka and Jammu and Kashmir have been honoured with the TB-Free Award. Awards have also been given for the best work at the district level,” said the Prime Minister.
The Sustainable Development Goal (SDG) for TB requires a 90% reduction in mortality and an 80% reduction in the incidence rate of TB cases by 2030 from the 2015 baseline. India had an estimated 2.8 million new cases of TB in 2015. India had an estimated 2.9 million new cases of TB in 2021, as per the WHO Global TB Report 2022.
“To incentivize states/UTs and districts to continue working towards the SDG target, the TB-free award was introduced in 2020. This award is linked with incentives, encouraging states/UTs and districts to achieve various milestones in a short period of time. This fosters healthy competition among them and keeps them motivated,” said a senior government official in the Central TB Division, who did not want to be named.
The TB-free award acknowledges accomplishments in decreasing the incidence of TB cases through four distinct categories, with 2015 as the base year. Districts and states/UTs that successfully reduce the incidence of TB cases by 80%, meeting the SDG target, are granted the highest level of recognition, which is the TB-free status. The other categories comprise the gold medal category, granted for a 60% reduction, the silver medal category for a 40% reduction and the bronze medal category for a 20% reduction in TB incidence.
Karnataka received the silver medal, indicating a 40% reduction in incidence of TB cases from 2015, while Jammu and Kashmir bagged the bronze medal, indicating a 20% decline in incidence of TB cases compared to 2015. Three districts--The Nilgiris (Tamil Nadu), Pulwama (J&K), Anantnag (J&K)--received the TB-free status as they reduced the incidence of TB by 80%.
How the TB-free awards are decided
Criteria for “Progress towards TB Free” certification
Award criteria, based on decline in TB incidence compared to 2015
Monetary award for District (INR)*
Monetary award for States/UTs (INR)*
Bronze ≥20% decline
Medal and Felicitation at the National Level
Silver ≥40% decline
Gold ≥60% decline
TB Free District / Cities ≥80% decline
Certification and Felicitation at the National level
* For States /UTs with population less than 50 lakh and districts with population less than 2 lakh, the award amount shall be 50% of the amounts considered.
* District level awards will be financed through the States/UTs PIPs.
Source: India TB Report 2023
A national task force of experts from the Indian Council for Medical Research (ICMR), the National Institute of Epidemiology, the National Institute for Research in TB, World Health Organization India and the Indian Association of Preventive and Social Medicine independently verifies districts and states/UTs under different categories.
The senior government official explained three methods used by the experts for verification of TB-free status. The first method is called the Inverse Sampling Methodology or direct survey, which involves identifying a pre-determined figure of 30 cases based on the prevalence of TB in the community and screening of the population to find those cases. The survey is completed in the district either when 5% of the district’s population is covered, or at least 10,000 households are screened, or 30 cases are found, whichever happens first. In addition to the survey, there is a thorough verification of secondary data available in the district.
The second method involves examining the sale of TB drugs in the private sector in the district from 2015 onwards, while the third method assesses the district's performance in terms of key programme indicators, such as the number of people tested and the number of negative tests, etc.
Two of the three methods should show a reduction according to the set criteria for the district to be awarded.
The reason the sale of TB drugs is tracked is because often, TB cases in the private sector go unreported to the government, and therefore, the sale of TB drugs is a better indicator of how widespread the disease is. (That said, private sector notifications have grown over the years.)
Districts and States/UTs Achieving Reduction in TB Incidence: Awards and Recognitions (2020-2022)
In 2020, Budgam district in Jammu and Kashmir and the UT of Lakshadweep became the first district and UT, respectively, to attain over an 80% decrease in TB incidence. As of now, a total of four districts and one UT have received the TB-free certification.
Claims submitted by district and states/UTs
67 districts and 3 state/UTs submitted claims
TB-Free: 1 (Budgam)
Bronze: 2 (Kerala and Puducherry)
TB-Free: 1 (Lakshadweep)
201 districts and 10 state/UTs submitted claims
Bronze: 5 (Gujarat, Himachal Pradesh, Sikkim, Tripura and Ladakh)
Silver: 3 (Kerala, Dadra and Nagar Haveli and Daman and Diu, Puducherry)
302 districts and 14 state/UTs submitted claims
TB-Free: 3 (The Nilgiris, Pulwama and Anantnag)
Bronze: 1 (Jammu & Kashmir)
Silver: 1 (Karnataka)
Source: India TB Report 2023 for the years 2020 and 2021, data provided by senior government official for the year 2022
India’s TB elimination goals
The award is given by India’s National TB Elimination Programme (NTEP), implemented by the government under the National Health Mission (NHM). The National Strategic Plan (NSP) 2017-2025 for TB Elimination has set targets to reduce the incidence of new TB cases by 80% and to eliminate TB by 2025, which is five years ahead of the global timeline. Elimination of TB means India would have to reduce the incidence rate of the disease to 44 cases per 100,000 population by 2025.
Notifications refers to cases of TB registered with the government. The government mandates that any case of TB, whether treated in the private or public sector, be registered with the government.
With 2,420,000 cases and an approximate notification rate of 172 cases per 100,000 population in 2022, TB case notification in India increased by 0.6% from 2019. Detecting (and notifying) new TB cases in 2020 and 2021 had become harder because of the Covid-19-related lockdowns and the burden on the health system, and notifications had dropped during this period, even as the TB case burden was estimated to be the same.
“We are confident in achieving the 2025 target of eliminating TB in India because we are currently performing better than other countries. Despite facing challenges, we are focused on expanding prevention measures such as the shorter TPT initiative, which we believe will lead to a significant reduction in new cases next year,” said the senior government official. The shorter TPT initiative includes a weekly regimen of 12 doses for three months, and was announced during the One World TB summit.
But experts point out some challenges that need to be overcome for India to achieve its goals. Blessina Kumar, CEO of the Global Coalition of TB Advocates, a coalition of people affected by TB from across the globe, said that the “diagnostic tools are available but uninterrupted supply of commodities like cartridges [used in testing machines] remains a challenge at the ground level”.
Dr Shibu Vijayan, a public health expert working in the field of TB for the last 25 years, and currently medical director of Global Health Qure.ai, an AI startup for Chest X-ray interpretation for TB triaging, said that within the next six months India needs to roll out the shorter drug regimen for Multidrug-resistant TB (MDR-TB), which will bring down the time to treat from 18-24 months to 6-9 months. He added that, globally, there have to be accelerated innovations in TB treatment and vaccinations.
Kumar and Vijayan say that India still needs to implement initiatives faster, and effectively. “India has a significant burden of TB, and commitments must be translated into effective implementation on the ground,” said Kumar.