The national TB prevalence survey in India found: 1) The prevalence of microbiologically confirmed pulmonary TB among those aged 15 and older was 316 per lakh population. 2) The prevalence was highest in older age groups, males, malnourished individuals, smokers, alcohol users, and those with diabetes or a past history of TB treatment. 3) The prevalence:notification ratio was 2.84, indicating that for every notified TB case, 1.8 cases are missed by the public health system. Improving screening and diagnostic methods like chest x-rays could help detect additional missing cases.

1. National TB prevalence survey results and its implications for
NTEP policies
Dr Raghuram Rao
Asst. Director General (TB)
Central TB Division
National workshop for medical colleges task force mechanism to accelerate ending
TB in India – Kolkata (Nov 2022)

2. UNIQUENESS: NATIONAL TB PREVALENCE SURVEY
• Happened after a gap of 60-years from the first national survey 1955-58
• Largest, nation-wide prevalence survey of TB in the World
• Covering above 350000 population
• Advanced data management systems and digital chest x-rays
• Multi-sectoral involvement including Local, State, and Central Government in this mammoth survey
• Expected to identify areas with high TB burden to prioritise intervention
• Largely funded by the Government of India

3. OBJECTIVES
Primary objectives:
• To estimate the point prevalence of microbiologically confirmed pulmonary TB among
persons ≥15 years in age in India at national level
• To estimate the point prevalence of microbiologically confirmed pulmonary TB among
persons ≥15 years in age for 20 individual states / state groups

4. SECONDARY OBJECTIVES
• To explore health seeking behaviour of survey participants
who are:
• Symptomatic
• Currently on TB treatment
• To estimate the prevalence of TB infection among the
surveyed

5. SURVEY DESIGN
SURVEY DESIGN
• Survey Period: June 1, 2019 to September 3, 2021
• Cross Sectional Survey
• Whole of India
• 3,54,541 Participants screened
Sample Size calculated with expected
Prevalence:270/100000 Population
800 Cluster size
• 20 State groups
• 443/625 clusters

6. DIAGNOSTIC ALGORITHM USED IN SURVEY

7. First sputum
specimen
Second sputum
specimen
Liquid Culture
in Reference
Lab
CBNAAT test in
Mobile Medical
Unit in Field
Smear
microscopy in
Reference Lab
All Eligible Participants enrolled in the TB Prevalence Survey
Symptom Screening using Standard Questionnaire
Chest X-ray PA view for all eligible participants expect Pregnant women
No sputum collected
Sputum Eligibility: Participants with
• Chest Symptoms suggestive of TB and /or
• Past History of TB and/or Currently on TB Treatment and/or
• Abnormal Chest X-ray
Participants with
• No Chest Symptoms suggestive of TB
• No Past History of TB and Not Currently on TB
Treatment
• Normal Chest X-ray
Third sputum
specimen
No TB TB+
Liquid Culture in
Reference Lab
Smear
microscopy in
Reference
Lab
CBNAAT test
in Reference
Lab
No TB TB+
No TB TB+ No TB TB+ No TB TB+ No TB TB+
Conditional 3rd Sputum
If First Sputum Specimen
becomes CBNAAT positive in Field

8. NATIONAL TB PREVALENCE SURVEY - SUMMARY
Burden of TB - High People affected by TB
All forms of TB in all
ages
312
Per lakh population
Adult Micro
confirmed Pulm TB
316
Per lakh population
Male > Female
472 > 154
Per lakh population
Older age group >55
years
588
Per lakh population

9. NATIONAL TB PREVALENCE SURVEY - SUMMARY
How many TB cases
are there for every TB
patient notified
Prevalence : Notification ratio
2.84
Prevalent part notified TB pt
Chest X-ray – Additional yield
42.6%
481 cases out of 981 diagnosed
cases had X-ray abnormality only
Patients with past H/o TB
23.4%
Among those diagnosed 981
in the survey
Past H/O TB
Screening Tests
Interpretation:
• For every 2.8 TB cases prevalent in the community, 1 case gets notified and 1.8 cases get missed.
• Mere symptomatic screening may lead to missed cases
• Addition of diagnostic tests like Chest X ray adds to the yield
• Patients with past H/O TB contribute significantly to the total cases

10. Prevalence in States -
Varied
137 to 747
Per lakh population
137 (76-198)
149 (60-237)
179 (88-270)
199 (129-268)
247 (143-351)
261 (189-333)
274 (143-405)
274 (122-426)
288 (164-412)
296 (204-387)
304 (198-410)
312 (286-337)
314 (219-410)
322 (258-385)
337 (174-501)
378 (169-588)
427 (352-501)
432 (322-541)
451 (283-619)
477 (333-620) 747 (510-984)
0 100 200 300 400 500 600 700 800
Gujarat
Kerala
West Bengal
Maharashtra
Odisha
Bihar
Andhra…
North East
Jharkhand
Telangana
Karnataka
India
Punjab
Tamil Nadu
Madhya…
HP,UK,JK
Uttar Pradesh
Rajasthan
Chhattisgarh
Haryana
Delhi
NATIONAL TB PREVALENCE SURVEY - SUMMARY

11. COMPARATIVE PREVALENCE IN OTHER COUNTRIES
(Between 2007 to 2016)
1159
831
759
638 613 595 587 560 558 524
452
401 398 356 344 316 307 287 277 275 242 212 183
119 119
0
200
400
600
800
1000
1200
1400
Prevalence (Microbilogically confirmed TB) - >15 years
Prevalence of bacteriologically positive pulmonary TB cases (above 15 years)
Data source: https://www.who.int/publications/i/item/9789240022430
25 Countries

12. NATIONAL TB PREVALENCE SURVEY - SUMMARY
More in persons with comorbidities
Malnourished
930
Per Lakh pop
Diabetics
511
Per Lakh pop
Smokers
853
Per Lakh pop
Alcohol users
726
Per Lakh pop
LTBI
Prevalence of latent TB infection
31.4%
Among total surveyed
Interpretation:
• Prevalence of latent TB infection is around 1/3rd of the population
• 31% of the survey participants have TB infection. There is a 10% lifetime chance of this infection converting into disease, with 60% of the
probability being in first year
• Presence of co-morbidities has an impact of disease progression, severity, and treatment outcomes.
• Inclusion of Malnourished, Diabetics, Smokers and Alcoholics in other risk groups for TPT if TBI test positive after ruling out active TB

13. Interpretation:
• Patient seek treatment equally from both public and private sector
• Health in terms of chest symptoms is not a felt need
• Patients prefer to get self treated rather than seeking formal health care
• Costs for TB care is present in TB patients seeking care both in the public and private sector.
NATIONAL TB PREVALENCE SURVEY - SUMMARY
Health care seeking behaviour
Did not seek care
63.6%
Among those found to be
symptomatic during the
survey
Costs incurred
– Govt. facility
Rs. 7500
Costs incurred
– Private facility
Rs. 20000
Public and private facility
preferences
49% - 49%
Among the 5156 sought health
care Max: 39000 Min:1500
Median costs among those currently on ATT

14. OBSERVATIONS
• The positivity rate in smear
microscopy (1.1%) was half as
compared to Gene Xpert (2.0%).
• 33% of cases would have missed if
NAAT was not included.
• 1.8% participants had Chest X Ray
abnormality suggestive of TB and was
not microbiologically confirmed.
• 42.6% cases would have missed if
CXR was not included.
• Positivity rate among participants with
no symptoms was 1.9%.
• Higher Prevalence of TB was found
amongst Older Age Group, Males,
unemployed, Smoker, Alcoholics,
Diabetics.
• RECOMMENDATIONS:
• Replace Smear microscopy by NAAT.
• Scale up of Chest X Ray.
• Furter study to address Sub Clinical TB
Disease.
• Focussed interventions may be planned: a)
Screening of Elderly b) Screening at
workplace c) Linking TPT beneficiaries to
TCC & Alcohol deaddiction centre d) Bi-
directional screening to be strengthened.

15. OBSERVATIONS
• Prevalence of all forms of TB varies
from 747/lakh in Delhi to 137/lakh in
Gujarat.
• Prevalence: Notification ratio also
varies from 5.30 in Chhattisgarh to
0.91 in Gujarat.
• Crude Prevalence & Odds Ratio for
participants having past H/O TB was
3260 & 14.23 respectively. 23% of
diagnosed TB cases had past H/O TB.
• Only 36.4% of participants sought care
for their symptoms and the choice of
healthcare was equally distributed
among Public & Private.
• RECOMMENDATIONS:
• State/UT to be prioritized as per
burden and focussed interventions may
be planned to address the risk factors
driving the epidemic.
• Strengthening case finding to bridge
the gap between Prevalence &
Notification.
• Post Treatment Follow Up of all TB
cases and focussing for ACF.
• Social Behaviour Communication
Change (SBCC) strategies may be
developed to improve awareness and
also Community engagement activities
needs to be strengthened.

16. OBSERVATIONS
• The median total cost for Patients having
Past H/O TB & Currently on ATT were
10000 INR.(Diagnosis-2000, Treatment-
5000, Indirect-2000). Cost in Public
hospital is less than NGO/Trust/Private
hospitals.
• The prevalence of TB Infection as
observed in this survey was 31.6%.
• RECOMMENDATIONS:
• Programme Strategies to be restructured to
reduce OOPE.
• Scale up of TPT interventions.
• Considering booster dose for BCG in
adolescents/whole population.
• Sustaining COVID appropriate behaviour.
• Need for preventing breakdown to active
TB by inclusion of Malnourished,
Diabetics, Smokers and Alcoholics in
other risk groups for TPT if TBI test
positive after ruling out active TB.

17. SUMMARY
• Prevalence of Microbiologically confirmed Pulmonary TB among 15 years and above
• India is 316/lakh population
• Prevalence associated with Past H/O TB treatment, Older age group, malnourished, known diabetics,
smokers and alcohol users
• COVID has impacted the community level Chest abnormality in general
• Prevalence of all forms of TB for all ages 312(95% 286-337) for 2021
• National P:N ratio was 2.84 (2.61 - 3.07)
• Highest was observed in Chhattisgarh and lowest was observed in Gujarat
• Prevalence of TB infection among the surveyed i-31.4 percentage
• 63% of the chest symptomatic did not seek health care
• Majority had ignored the symptoms and did not recognized it as illness.
• Consulted have equally approached the public(49%) and private sector (49%)

18. STRATEGIES – CASE FINDINGS
Using X-ray in addition to symptom screening to be stressed during active/ passive/
intensified case finding
Leverage the use of technology though Telemedicine / AI based solutions
Decentralized molecular diagnostics up to block level
Increased referral from OPDs/ ART centre/ NCD clinics/Tobacco cessation units/ NRC
Decentralization of TB services up to HWC

19. STRATEGIES – TREATMENT SUCCESS
Continued efforts towards bidirectional screening for TB among ILI/ SARI/ COVID patients
with X ray as screening tool
TB screening among comorbid patients and vulnerable groups
Post TB treatment follow up for TB and COVID patients
Implementation of differentiated TB care approach
Shorter oral MDR/RR-TB regimen

20. STRATEGIES – PRIVATE SECTOR
Enforcement of mandatory notification and schedule H1 monitoring
Linkages with private sector through interface agencies, associations, chemists
Need based engagement with private labs with X ray and/or molecular diagnostics
services
To address OOP - Insurance / Partnerships for free Drugs and Diagnostics

21. STRATEGIES - PREVENTION
Intensified contact tracing
TB preventive treatment in children below 5 years in contact of pulmonary TB patients
Expansion to age group above 5 years, contacts of pulmonary TB
TB preventive treatment (TPT) to PLHIV and other risk groups
Newer skin test (CyTB) and New shorter oral regimen (INH + Rifapentine)
Increased awareness in the community, and intensified IEC activities
Air-borne infection control measures

22. THANK YOU