As the world leaders commit to new targets to end Tuberculosis (TB), India as the pharmacy of the world and an established player in vaccine manufacturing, will have a major role to play in achieving the global goal —'End TB' by 2030. And it is an urgent priority for India too as the country itself is witnessing its TB disease burden — more than 3 million cases currently — growing rapidly.
The world leaders at the United Nations General Assembly’s high-level meeting on TB have earlier this week approved a Political Declaration with ambitious new targets for the next five years to advance the global efforts towards ending the TB epidemic.
The targets include reaching 90 percent of people with TB prevention and care services; using a WHO-recommended rapid test as the first method of diagnosing TB; providing social benefit packages to all people with TB; licensing at least one new TB vaccine; and closing funding gaps for TB research by 2027.
In the lead-up to this historic UN meeting, WHO Director-General, Dr Tedros Adhanom Ghebreyesus, officially launched the TB vaccine accelerator council to facilitate the development, licensing and use of new TB vaccines.
Currently, BCG is the only licensed vaccine available against TB infection. While it provides moderate efficacy in preventing severe forms of TB in infants and young children, it does not adequately protect adolescents and adults, who account for the majority (>90%) of TB transmission globally.
Spin off for India
The Declaration can pave the way for an accelerated effort by India to eliminate the disease.
India has pledged to end tuberculosis by 2025, five years ahead of the global Sustainable Development Goals (SDG) target of 2030. This looks like an over ambitious goal considering the various challenges that needs to be addressed.
Tuberculosis is a communicable disease that is a major cause of ill health and one of the leading causes of death worldwide. TB is caused by the bacillus Mycobacterium tuberculosis, which is spread when people who are infected with the bacteria expel it into the air through cough.
TB continues to be a major health problem across the globe, largely in the poor and developing countries, and is still associated with a serious social stigma in many parts of the world. Positive efforts have been made in terms of diagnostics and treatment but monitoring the progress of TB control and the burden caused by the disease continues to be a challenge.
Another major challenge is the high number of drug-resistant TB cases in India. This type of TB is much harder to treat and requires more expensive, specialised drugs and a longer duration of treatment. Lack of research and challenges in implement prevention measures, including the treatment costs, are contributing to the fast spread of the epidemic.
Improve nutritional status, new TB vaccine
Experts maintain that the strategies for elimination of TB needs to be revamped with an active engagement of the private sector. There is a need for decentralisation of services and a spruced apparatus for active case finding. Biotechnology is going to play a part in the integrated holistic healthcare approach towards the elimination of tuberculosis. There should be renewed focus on improving health systems and new tools which includes new medicines.
A new study has quantified the substantial impact of diet on the successful treatment and progression of tuberculosis. The study —The Reducing Activation of Tuberculosis by Improvement of Nutritional Status (RATIONS), recently published in the journal Lancet Global Health shows that nutritional support needs to be an integral component of patient-centred care to improve treatment outcomes.
“India has a big role to play in the TB elimination goals. Any progress that we will make in the elimination of the disease will reflect in the global progress. If the world has to be on track, then India has to be on track,” says Soumya Swaminathan, chairperson of M S Swaminathan Research Foundation and former chief scientist of WHO.
Maintaining that there was a lot of political commitment, Swaminathan said, there are still several challenges because of the huge population. “We need a new vaccine for TB that is effective in various forms of the disease and ideally prevents infection or at least prevents the progression of infection. India should launch a National Mission for TB Vaccine," she said.
"If India takes a lead, other countries will definitely support the initiative, as anything we produce will be affordable and accessible technology. This has to be a sustained effort with a public-private partnership. It is a long-drawn process and the chances of success are moderate, because of the complexities of Mycobacterium tuberculosis and it’s human immune response,” Swaminathan added.
Another area that needs to be prioritised, she said, was point of care diagnostics. “There should be a simple, rapid test that can be done at home. We have the technology, human resources and all the elements to develop a rapid diagnostic test. If done, this will be a game changer.”
Improving the nutritional status of our population could potentially have a big impact on reducing TB incidence as has been shown by the RATIONS trial in Jharkhand. “Supplementation with adequate calories and protein not only reduced death rates among TB patients, but also the incidence of new cases among household contacts,” the report highlighted.
“India houses the largest number of TB patients in the world. Multiple factors are responsible for this. The number of people with latent TB is very high in India and they are really at a high risk,” says Shekhar Mande former Director General, Council of Scientific and Industrial Research (CSIR).
The Directly Observed Therapy (DOT) where a trained health care worker provides the prescribed TB drugs and watches the patient swallow every dose has been extremely effective. "This should be taken up with an enhanced public-private partnership,” Mande said.
“The BCG vaccine has not been shown to be as effective in the adult population and the trials going on the recombinant BCG should be carried out more aggressively,” says Mande
“Ending TB is a wonderful goal. Tuberculosis bacteria are perhaps the biggest pathogens faced by man in terms of lives lost and misery caused,” says Anurag Agrawal, Dean, Trivedi School of Biosciences, Ashoka University and former director CSIR-IGIB
They are also not going to be easy to eradicate, given the billions of latently infected people who will be at risk of reactivated disease over time, some probably carrying highly drug-resistant bugs.
“New science will be needed to win against TB and as far as I can see, we are not investing enough into this fight globally. India may thus need to take an active lead in scientific efforts to end TB,” says Agrawal.
New Tools, Build Communication
Researchers emphasise on the need to focus on improving health systems and designing new tools.
“India faces many challenges for ending TB. Poverty and under-nutrition are major drivers of the TB epidemic in the country and addressing them is critical,” says Madhukar Pai, a Professor at McGill University.
India, he says, is still reliant on old technologies such as smear microscopy for TB detection, instead of rapid molecular testing that is recommended by the WHO. But India now has many domestic molecular tests that are more affordable and scalable.
“There is a need to adopt and scale-up the shortest drug regimens we have today, including the 6-month, all-oral regimens for drug-resistant TB. This is life-changing for people with drug resistant TB,” says McGill International TB Centre's Pai.
The most important thing is to learn from the RATIONS trial in India and provide food to people with TB and their families. “The trial showed that food works like vaccine and cuts the risk of household members developing TB by nearly 50 percent. It is thus clear that people with TB should be provided extra food rations including proteins such as pulses. This will have an impact.”
V V Sundar, an independent national public health communications and advocacy consultant says: “It is imperative for the government and development partners to harness their expertise and global knowledge. Yet, it appears that they remain underleveraged and underinvested.”
Sundar maintains that there is a need for a holistic and comprehensive communications and awareness initiatives. “The absence of a unified and sustained communication and advocacy actions both at the national and regional levels presents a paradox.”
(Edited by : C H Unnikrishnan)
First Published: Sept 29, 2023 1:46 PM IST
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