Aiming for a tuberculosis-free India: Perspective of a highly endemic Particularly Vulnerable Tribal Group (PVTG)

Tuberculosis (TB) is an infectious disease, caused by a bacterial pathogen, Mycobacterium tuberculosis, and is one of the top-ten causes of death in human (about 1.5 million each year) due to a single infectious agent. The global TB report published by the World Health Organization (WHO) indicated TB infection in about 10 million people in the year 2018, with the global average of 130/100,000 population.1WHO Global TB Report.2019https://www.who.int/tb/publications/global_report/en/Date accessed: January 15, 2020Google Scholar While the Southeast Asian countries contributed the most (44%), India ranked the highest among all endemic countries (27%) with about 2.7 million cases in the year 2018 with an average of 199/100,000 population. Besides being the highest contributor to TB incidences and second in term of TB-related death in the globe, India contributed largely to the gap (25%) between the number of new cases reported and the estimated incident cases, and also combinedly with China shared 43% gap between treatment enrolments and estimated number of new cases of multidrug- and rifampicin resistant TB in the year 2018.1WHO Global TB Report.2019https://www.who.int/tb/publications/global_report/en/Date accessed: January 15, 2020Google Scholar Further, in recent years, numbers of Human Immunodeficiency Virus (HIV)-infected patients developing TB and pediatric TB in India are on rise.2Central TB Division India TB Report.2019https://tbcindia.gov.in/WriteReadData/India%20TB%20Report%202019.pdfDate accessed: May 10, 2020Google Scholar Although state-wise data indicate major contribution of total TB cases (20%) by the largest Indian state of Uttar Pradesh, contribution of India's 8.6% tribal populations (about 104 million, year 2011 census of India) to TB prevalence needs attention, if targeted TB-free India is to be achieved. This is because, pulmonary tuberculosis has been reported to be a major public health problem among Indian tribes in general with a whooping 703 per 100,000 population,3Thomas B.E. Adinarayanan S. Manogaran C. Swaminathan S. Pulmonary tuberculosis among tribals in India: a systematic review and meta-analysis.Indian J Med Res. 2015; 141: 614-623Google Scholar about three times higher than the Indian average of 199/100,000.1WHO Global TB Report.2019https://www.who.int/tb/publications/global_report/en/Date accessed: January 15, 2020Google Scholar Of relevance are 75 different highly marginalized tribal communities, otherwise known as Particularly Vulnerable Tribal Groups PVTGs. One particular PVTG named Saharia with about a total of 0.6–0.7 million population (the year 2011 census of India), is confined to eight districts under the Gwalior and Chambal divisions of the state of Madhya Pradesh and one district of the state of Rajasthan with high burden of TB.4Chakma T. Rao P.V. Pall S. et al.Survey of pulmonary tuberculosis in a primitive tribe of Madhya Pradesh.Indian J Tubercul. 1996; 43: 85-89Google Scholar Prevalence of pulmonary TB in Saharia tribes was found to be 1518/100,000 in Sheopur5Rao V.G. Gopi P.G. Bhat J. et al.Pulmonary tuberculosis: a public health problem amongst the Saharia, a primitive tribe of Madhya Pradesh, central India.Int J Infect Dis. 2010; 14: e713 6Google Scholar and 3294/100,000 in Gwalior6Rao V.G. Bhat J. Yadav R. et al.Pulmonary tuberculosis - a health problem amongst Saharia tribe in Madhya Pradesh.Indian J Med Res. 2015; 141: 630-635Google Scholar districts, much higher (about 7–15 times) than Indian average. Furthermore, higher TB prevalence in adult males has been reported compared to females in Saharias.6Rao V.G. Bhat J. Yadav R. et al.Pulmonary tuberculosis - a health problem amongst Saharia tribe in Madhya Pradesh.Indian J Med Res. 2015; 141: 630-635Google Scholar,7Sharma P.R. Jain S. Bamezai R. Tiwari P.K. Increased prevalence of pulmonary tuberculosis in male adults of saharia tribe of India: a revised survey.Indian J Community Med. 2010; 35: 267-271Google Scholar What makes the Saharia tribes highly vulnerable to TB? Research works have indicated several key factors, e.g., nutrition, living conditions, migration, access to healthcare and substance abuse etc. that might be contributing to high TB prevalence in this group.8Bhat J. Rao V.G. Sharma R.K. et al.Investigation of the risk factors for pulmonary tuberculosis: a case-control study among Saharia tribe in Gwalior district, Madhya Pradesh, India.Indian J Med Res. 2017; 146: 97-104Google Scholar In addition, other aspects, e.g., literacy, socio-economic status, socio-cultural/mythological belief on health, roles of traditional healers in the community etc. indirectly affect health outcome in general, and TB infection and transmission, in particular. Several social/personal behavior which the community regularly practices, e.g., open-spitting, sharing of country-made cigarette wet with saliva, wetting the fingers by saliva for distributing playing cards, etc. can contribute to effective transmission of M. tuberculosis in the community. Furthermore, living and sleeping inside a poorly-ventilated single-room house provide conducive situations for transmission of TB bacterium among family members, and livestock populations as well. Which specific strategies are needed to make the Saharia tribe free from TB? Political commitment to end TB through United Nation Sustainable Development Goals (SDGs) and WHO's End-TB Strategy to wind-up the TB epidemic by 2030 globally and India's National Strategic Plan (NSP) 2017–2025 to achieve the ambitious target of TB-free India, five years ahead of the global elimination plan, are welcome moves in this direction. Also (i) India's recent quadrupled increase of domestic funding on TB and (ii) India s high TB treatment success,1WHO Global TB Report.2019https://www.who.int/tb/publications/global_report/en/Date accessed: January 15, 2020Google Scholar leading to decline in TB prevalence in the Saharia tribe (from 3003 to 1995/100,000 population)9Rao V.G. Bhat J. Yadav R. et al.Declining tuberculosis prevalence in Saharia, a particularly vulnerable tribal community in Central India: evidences for action.BMC Infect Dis. 2019; 19: 180Google Scholar are positive indications. Furthermore, recently initiated intensive research jointly being undertaken by the Indian Council of Medical Research and Madhya Pradesh government by early active case detection, prompt treatment and follow-up for drug compliance and mass screening in Saharia population for asymptomatic bacterial load, etc., would help developing a model for bringing down TB prevalence in a high endemic setting. While global end-TB program will highly depend on the success of M72/AS01E vaccine that was found to be protective against TB in Phase-II(b) trial and awaiting confirmation in the Phase-III trial,10Ginsberg A.M. Designing tuberculosis vaccine efficacy trials lessons from recent studies.Expert Rev Vaccines. 2019; 18: 423-432Google Scholar for Saharia tribe, handfasting by different government ministries and departments to provide basic need of nutritious food, safe drinking water, smoke-free cooking facilities, ventilated house, education on health and hygiene and other tailor-made strategies specific for Saharia tribes could go a long way to control, if not completely terminate TB in this PVTG by the year 2025. None declared.