India has set an ambitious target to eliminate tuberculosis (TB) by 2025, five years ahead of the global sustainable development goal (SDG) deadline of 2030. The SDG goal for 2030 is 90% reduction in TB deaths and 80% reduction in TB incidence as compared to 2015.
But can India achieve its self-imposed target, especially as TB notifications touched a staggering 26.07 lakh cases in 2024, the highest in recent years? Health experts are divided. Some claimed that the rise in cases is actually a good sign as the country plans to enter the elimination phase while others termed the target unrealistic given the uptick in new TB cases.
Dr Banani Jena, head of the Respiratory Medicine at SUM Hospital, Bhubaneswar and president of Odisha Chest Society, said a spike in TB notifications is a positive development from a public health perspective. It indicates that the system is identifying more cases and bringing them into treatment, which is crucial before entering the elimination phase, she explained.
TB, a bacterial disease caused by Mycobacterium tuberculosis, mainly affects the lungs but can also impact other organs of the body, including the brain, kidneys, and spine. It spreads through the air when people cough, sneeze, or even talk.
Despite being both preventable and curable, TB remains one of the top infectious killers worldwide. According to WHO’s Global TB Report 2024, an estimated 10.6 million people worldwide developed TB, and 1.3 million lost their lives to the disease.
WHO has identified 33 countries with low TB incidence rates as potential candidates for TB elimination. Nations such as Iceland and Cyprus have reached ‘pre-elimination’ levels, reporting fewer than 10 new cases per million people per year. However, no country has yet achieved full TB elimination.
As per WHO’s End TB Strategy, countries are required to reduce deaths due to TB by 75% and incidence (new cases per one lakh population per year) by 50% to meet the 2025 milestone. “India had launched the elimination target in 2018. Had the mass screening been conducted in the year itself or the following year, the country would have achieved it as per the target. Given the rising number of latent and incipient TB cases, India will not be able to even meet the 2025 milestone set by the WHO, let alone achieve the elimination target,” pointed out Dr Niroj Mishra, a public health expert.
UP tops states in TB burden
India alone accounted for over 27% of the global TB burden, making it the country with the highest number of TB cases in the world. Although the incidence rate dropped from 237 per lakh population in 2015 to 195 per lakh in 2023, and TB-related deaths reduced from 28 to 22 per lakh in the same period, experts cautioned that these aggregate improvements mask deep disparities between states.
According to the data presented by Union Minister of State for Health and Family Welfare Anupriya Patel in the Rajya Sabha recently, Uttar Pradesh alone reported a staggering 6.7 lakh TB cases last year, continuing its trend as the state with the highest burden. Maharashtra (2.14 lakh), Bihar (2.03 lakh), Madhya Pradesh (1.77 lakh), Gujarat (1.29 lakh) and West Bengal (97,332) followed closely. Smaller states and Union Territories like Rajasthan (1.68 lakh cases), Delhi (90,281), Telangana (74,711), Punjab (60,456) and Odisha (59,483) have also shown persistent caseloads, reflecting that the burden is not limited to any particular geography.
Patel said India has made measurable progress in its ambition towards eliminating TB. The incidence rate has declined by 17.7% and deaths too saw a 21.4% drop. The number of missing cases has reduced from 15 lakh in 2015 to 2.5 lakh in 2023. TB treatment coverage has also increased by 32% in the last eight years from 53% to 85%, she said.
“The government has decentralised TB screening and treatment services with targeted interventions in high TB burden areas through state and district specific strategic plans. Intensified TB case-finding among vulnerable populations through mobile diagnostic units and provisions of free drugs, diagnostics, and nutritional aid will help achieve the target,” Patel said.
What is ‘elimination’?
In the global health lexicon, ‘elimination’ does not imply zero cases but refers to drastic reduction in incidence to less than one case per million people annually. For India, this would mean reducing the annual caseload to fewer than 1,400, a far cry from the over 26 lakh cases reported last year.
Dr Mishra said the target may not be practically achievable in the next nine months, but it has certainly helped detection of hidden cases which will lead to targeted intervention. “Reaching elimination by 2025 appears overly ambitious given the current incidence levels. Even if the goal is missed, the campaign is building essential health infrastructure and awareness that will yield long-term benefits,” he said.
Dr Sudarsan Pothal, head of pulmonary medicine department at Sri Jagannath Medical College and Hospital in Puri, attributed the sudden rise to intensified screening and latent TB cases. He said more than 40% of the population in India carry the tuberculosis bacteria even if their microbiological test reports are negative.
“Although people carry the bacteria, the disease does not manifest in them and only around 10% of them develop the disease. These asymptomatic people keep spreading the disease. The need is to screen all patients coming to a doctor or hospital for treatment of any disease to detect latent tuberculosis in them. This can be done by using portable X-ray machines,” he said.
Advancements in treatment
India has taken significant steps to modernise its TB diagnosis and treatment strategies. Molecular diagnostic labs have now been established across blocks, offering quicker and more accurate testing. Additionally, mobile diagnostic vans are being deployed to rural and tribal belts, helping identify cases that would otherwise remain undiagnosed. “Treatment protocols have evolved as well. Drug-resistant TB, once a major concern, is now being tackled with newer, shorter, and all-oral regimens like BPaLM (comprising bedaquiline, pretomanid, linezolid and moxifloxacin). These advanced regimens are critical in improving outcomes for drug-resistant cases, which were earlier extremely difficult and costly to manage. The treatment is also for a much shorter duration of 26 to 38 weeks,” said Dr Pothal.
Dr Subhashree Samantaray, associate consultant (infectious diseases) at Manipal Hospitals said drug-resistant TB has become a growing concern. It develops in two forms - multi-drug resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB), both of which do not respond to the standard first-line drugs. Treatment for such cases is more prolonged, toxic, and expensive, requiring specialised care and second-line medications, she said.
“Under India’s National TB Elimination Programme, diagnosis and treatment are provided free of cost. The programme provides free medications for active TB cases known as directly observed treatment short course (DOTS). Management of latent TB cases has been introduced with TB preventive therapy,” Dr Samantaray said.
Preventing TB is as important as treating it. The BCG vaccine, administered to infants, provides protection against severe forms of TB, especially TB meningitis and disseminated TB in children. Although its effectiveness in preventing adult pulmonary TB is variable, it remains a key part of India’s universal immunisation programme.