India Splutters Against TB as New Challenges Erupt Worldwide

The bacteria Mycobacterium tuberculosis, the cause of TB. Credit: niaid/Flickr, CC BY 2.0

The bacteria Mycobacterium tuberculosis, the cause of TB. Credit: niaid/Flickr, CC BY 2.0

Cape Town: It will take another 200 years to rid the world of tuberculosis (TB) unless there’s a paradigm shift in the strategies to tackle this killer-disease. This was the message that stemmed from the ongoing 46th Union World Conference on Lung Health here, in South Africa.

On the one hand, new findings from clinical studies presented at the conference showed promise for a shorter nine-month treatment course for multi-drug resistant TB (MDR-TB) as against the standard treatment of 24 months recommended by the World Health Organisation (WHO). On the other, results from a series of studies on TB among imprisoned persons, bovine strains of TB found in cattle that are transmitting to humans, and TB in children showed that key affected populations were facing unique risks that need to be addressed in order to eradicate the disease by 2035, as called by the WHO’s ‘End TB Strategy’.

The prison studies, from Brazil, revealed that a growing TB epidemic among incarcerated persons could partially offset gains made in ridding TB from the general population. Between 2007 and 2013, the annual incidence of TB among prisoners increased by 28% against a 12% decline among non-incarcerated persons. The net effect was an 8% decline in the total population.

“Brazil has the world’s fourth largest prison population, and with a high throughput of inmates, [its] prisons could serve as reservoirs of TB transmission into the general population,’’ said Pau Bourdillon of Yale University, who presented the study.

In another study from Tanzania, a prison screening project has shown promise for reducing TB transmission. Between July 2013 and March 2015, over 6,000 inmates who tested for TB were put on treatment immediately.

A study on cattle and livestock in Nigeria showed over 10% of cattle and close to 43% of herds had TB. Additionally, 86 strains of bovine TB were isolated from slaughtered cattle and, scientists warned, posed a major public health threat. Overall, 4.6% of butchers and 6% of marketers had tested positive for the disease.

A conservative estimate based on available evidence showed that 1.4% of all TB cases had been caused by zoonotic strains – corresponding to approximately 126,000 people affected by zoonotic TB worldwide every year. Health officials had found that when patients of bovine TB were administered pyrazinamide, a key first-line medicine used in the standard TB treatment regimen, the treatment was likelier to fail and for the disease-causing strain to become resistant to the drug.

“The people affected by zoonotic TB who we are now identifying likely represent the tip of the iceberg,’’ said Francisco Olea-Popelka, assistant professor at the College of Veterinary Medicine and Biomedical Sciences at Colorado State University.

All quiet on the Indian front

The findings should ring alarm bells for India, which has the highest burden of TB in the world.

According to the Global Tuberculosis Report 2015, there were an estimated 9.6 million cases of TB worldwide. Of this, India, Indonesia and China alone accounted for 43% of all the cases. There were 220,000 TB-related deaths in India in 2014 – slightly less than the 240,000 deaths reported in 2013. The number of patients living with TB had also declined from 2.6 million in 2013 to 2.5 million in 2014. However, the fraction of new cases had increased in this same period: from 2.1 million to 2.2 million. Most importantly, funding for research in TB has remained extremely low, particularly in the private sector.

India’s response remains far from satisfactory on the issue of addressing this disease. The Revised National TB Programme (RNTCP) had asked for a budget of Rs.1,358 crore for the current financial year but received only Rs.710 crore – 52% of its demand.

“The government needs to understand the repercussions. Medicines arriving late by a day can be disastrous as it can result in drug resistance,” explained Dalbir Singh, president of the Global Coalition Against TB, a body of TB experts and Indian Parliamentarians from India who’ve banded together for a common cause. “We have had stock-outs and cuts in the funds. The government has now started the process of importing GeneXpert testing machines which can give report in two hours, following which treatment can be started on the infected person. But the machines have been available since 2010. One TB patient can infect 60 people in a year, hence it is important to identify TB patients quickly and put them on treatment,’’ he added.

Kalikesh Narayan Singh Deo, a Biju Janata Dal MP and a member of the coalition, feels the government is still in a state of confusion following the Planning Commission’s dismantlement and substitution with the NITI Ayog.

“It is yet to figure out which schemes need to be funded centrally,’’ he pointed out. “We need to waive off import duty or drastically reduce it on these machines and exempt TB drugs from excise duty,’’ he said, while adding that in his capacity as the Finance Committee member, he would write to the Union Finance Minister about this. In its turn its part, the coalition also plans to raise questions in Parliament and seek debates in the Houses to draw the attention of the government.

The government last year released the ‘Standard of TB Care’ in India to introduce uniform standards for care in all sectors, a move that’d key to reducing the national burden of MDR-TB. The Drugs Controller General of India (DCGI) has given also given conditional access to bedaquiline for its distribution within the government-run programme. As a well-known life-saving drug for MDR patients, bedaquiline will be included in the Centre’s TB Control Programme while local clinical trials are set to commence soon for two other new drug combinations.

Tuberculosis remains the oldest known infectious disease. It’s caused by Mycobacterium tuberculosis, and usually affects lungs but can affect other parts of the body as well. How the world plans to grapple with this many-headed monster will be decided at the ongoing conference here. And whatever solutions are drafted, they will also have to have factored in the international transition from the expiring Millennium Development Goals to the more-ambitious Sustainable Development Goals.