The road to ending tuberculosis

However, there is no clarity on definitions of ‘end’ and the means of verification are not fully in place, indicating that the global response has been lukewarm. 

Tuberculosis

• Tuberculosis is an airborne communicable disease caused by the bacteria Mycobacterium tuberculosis.

• Typically the bacteria grow in the body where oxygen and blood are in high amounts. As a result, 80% of TB cases are pulmonary which infect the lungs and 20% of cases are extra-pulmonary which infect the brain, uterus, stomach, mouth, kidneys and bones.
• Mode of transmission: Airborne- through coughing, sneezing or spitting.
• High-risk groups: People weak immunity like those infected with HIV, Under-nutrition, Diabetes, Smoking and Alcohol consumption.
• TB incidence in India: India tops the list of 20 TB high-burden countries in the world. India has more than 25% of the total TB patients in the world. 

Prevention and Treatment

• Prevention:
  • BCG vaccine for children 
  • Currently no effective vaccine for adults
• Diagnosis:
  • Early diagnosis is extremely important in fighting TB. 
  • Widely followed diagnosis methods include- Sputum smear microscopy which studies the phenotype of the pathogen from the sputum sample of infected patients.
• Treatment: 
  • Strategy: DOTS strategy (Directly Observed Treatment Short Course) is a WHO-recommended cost-effective strategy to reduce the disease burden of TB. It includes sustained political and financial commitment, early diagnosis, standardized short-course anti-TB treatment, and regular and uninterrupted supply of high-quality anti-TB drugs.
  • Antibiotics: Administering commonly used antibiotics like rifampin.
• Challenge: Mycobacterium tuberculosis has developed drug resistance. New-gen drugs like Bedaquiline and Delaminid are recommended for MDR-TB.

Eradicating TB

Global initiatives:

• End TB Strategy: Global strategy developed by WHO that aims to reduce TB deaths by 90% and to cut new cases by 80% by 2030. The strategy includes five pillars: integrated patient-centered care and prevention, bold policies and supportive systems, intensified research and innovation, universal health coverage, and social and economic interventions.
• Global Fund to Fight AIDS, TB and Malaria: The fund began disbursing the first round of money directed towards the global TB epidemic in 2003, and is the single largest channel of additional money for global TB control.
• Stop TB Partnership: This is a global partnership of organizations, governments, and individuals working to eliminate TB. It supports TB research, advocates for political commitment and funding for TB control, and provides technical assistance to countries in implementing effective TB programs. 

India’s Initiatives

• National TB Control Programme is ongoing since 1962 and has not performed up to the mark.
• Revised National TB Control Programme (RNTCP) was adopted in 1997 after WHO declared TB as a global epidemic in 1993.
  • Focus of RNTCP has been Early Diagnosis and Treatment in accordance with DOTS strategy.
  • Patients are supported with free diagnostics and medicines. 
  • Under RNTCP about 4 lakh DOTS centres have been established so far. 
• National Strategic Plan for TB Elimination 2017-2025 was adopted in 2018 in line with the TB Elimination Strategy of the WHO and SDG of the UN.
  • It aims to eliminate TB in India by 2025.
  • Includes 4 strategic pillars: “Detect – Treat – Prevent – Build”.
  • Specific targets include:
    • 80% reduction in TB incidence 
    • 90% reduction in TB mortality 
    • 0% patients having catastrophic expenditure due to TB. 
• Nikshay Portal to serve as a national online individual-based TB notification and management system. Nikshay Poshan Yojana in 2018 to provide free nutritional support of Rs. 500 per month to all the TB patients registered in the Nikshay portal till completion of treatment. 
• Pradhan Mantri TB Mukt Bharat Abhiyan campaign was launched in September 2022 where the community is encouraged to adopt TB patients and support them in the form of nutritional support, nutritional supplements, additional investigations, and vocational support for a minimum period of six months or maximum period of up to three years. 

Existing Issues 

• Lack of monitoring- No prescribed method of monitoring the trajectory of TB control under the RNTCP. However, Nikshay Portal aims to address the issue. 
• Excessive focus on affected patients only while ignoring the ‘potential’ patient who might be in contact with the patients. 
• Gender divide – There is a significant difference in how males, females and transgenders receive such health care services.
• Lack of adequate focus to reduce the burden of smoking and lifestyle diseases. 
• COVID-19 pandemic has increased the TB burden. 

Areas which require immediate action

• Development and wide use of an adult TB vaccine. Currently, the only vaccine for TB – BCG which is delivered at birth and useful particularly for children, is 100 years old. The experience with the COVID-19 vaccine development process gives an understanding that vaccines can be developed with collective will and action.
• Getting newer therapeutic agents for TB. There is a need to develop new anti-TB drugs for widespread use which are effective and inexpensive, and move to an injection-free and shorter all-oral pills regimen for TB (the current standard is for at least six months) to improve compliance and reduce patient fatigue. Given the rising cases of drug-resistant TB, we need a ready pipeline of newer drugs.
• Improving diagnostics.
  • Need for the universal roll-out of technologies like- AI-assisted handheld radiology with 90-second reporting and 95% plus accuracy for diagnosing.
  • Sentinel, passive surveillance and interpretation of cough sounds for TB can allow for unobtrusive home-level screening and monitoring and provides nudges for seeking treatment.
  • Biotech technology and startups should be incentivised to break the complexity of molecular testing and price barriers with affordable high-quality innovations. E.g., Supporting the roll-out of technologies like- Confirmatory diagnosis using nucleic acid amplification. 
• India must take lead in strengthening or radically re-imagining these key areas, to help achieve success in ending TB by 2030. 

Conclusion

India must utilise the opportunity of the G-20 presidency to bring global focus and synergy to health (especially TB eradication). India’s G20 presidency this year, the Varanasi StopTB board meeting in March 2023, and the United Nations High-Level Meeting on TB in September 2023 provide the perfect platform for India’s actions to speak loudly and will enable the world to get to the end of TB sooner.