For a disease that has plagued mankind for millennia, humans have never been in a stronger position to eradicate tuberculosis than they are today. The diagnosis of the disease used to be hampered by the low sensitivity of sputum smears and up to 40% of those with the disease were missed.
Treatment used to be prolonged, initially up to 18 months, but even the “short-term” treatment is six months in duration. Prolonged, daily treatment with multiple drugs often led to patients not completing their courses of treatment, and consequently suffering a relapse.
Curing drug-resistant forms of the disease, which emerged over 30 years ago, was even more challenging: the diagnosis often took weeks and the treatment lasted up to two years, with daily injectable drugs being mandated for the initial six months of treatment.
The past two decades have witnessed tremendous scientific leaps in the fight against tuberculosis. Molecular tests have now made a point-of-care diagnosis possible within hours, including the diagnosis of multidrug resistant tuberculosis. The accuracy of such tests has been constantly improving, with genomic sequencing likely to refine this further, making diagnosis both rapid and accurate.
The TRUNCATE-TB trial, published earlier this month, concluded that a two-month treatment for drug-susceptible tuberculosis is a real possibility. The BPaL regimen involves three oral drugs – Bedaquiline, Pretomanid and Linezolid – prescribed for six months, and has been reported to have success rates of 90% for highly resistant forms of the disease. Close to half of such patients would have had poor outcomes with conventional treatment strategies, despite the prolonged courses of treatment and the use of injectable drugs.
Yet, the ground reality paints a starkly different picture. After the Covid-19 pandemic, in 2020 and 2021, there was an increase in the number of tuberculosis deaths for the first time since 2005. There also appears to be an increase in the number of individuals developing the disease.
In India, tuberculosis services were widely disrupted leading to delays in diagnosis, treatment, access and possibly increased suffering and mental health problems for those affected. The long-term impact of Covid-19 on tuberculosis is yet to be ascertained.
How can the key gaps in tuberculosis be addressed? There is the need for broad commitment to ensure that every possible patient is traced, provided free, high-quality diagnosis and treatment, and to ensure that such care reaches the last mile.
Those affected must be provided access to information and awareness on tuberculosis. Even today, most Indians remain uninformed about tuberculosis. Contrast this with Covid-19, where effective awareness led to behaviour change, increased testing, and prudent infection control measures. Can’t this be done for tuberculosis?
Diagnosis is the first step in the fight against tuberculosis, but this is where failures are the most. Even today, physicians often use outdated and inaccurate tests to diagnose tuberculosis. As a result, delays in diagnosis are common. Even in the public sector, reliable diagnostic centres with trained personnel are not universally accessible.
In rural India, people often travel long distances just to access diagnosis. India needs to urgently to scale up and invest in new diagnostic technologies and skilled manpower. This can be done by incentivising international diagnostic firms to invest in India (American diagnostics company Cepheid launching a manufacturing unit in India is an example), and expanding the public-private partnership for deepening access.
Community-based screening for tuberculosis in high burden areas is needed for people to access testing without travel. Finally, the extensive investments made in diagnostic platforms during the Covid-19 pandemic must be leveraged for tuberculosis.
Wider access to new drugs such as bedaquiline, pretomanid and delaminid is needed, especially in the private sector where patients with drug-resistant tuberculosis struggle to procure such medication. For instance, Hinduja Hospital has a successful private-public partnership that ensures access to bedaquiline for patients in the private sector. Such models need to be replicated and scaled up rapidly.
From a health system perspective, the biggest challenge to address is the quality of tuberculosis care in the private sector. India’s private healthcare providers continue to diagnose and treat close to 50% of India’s tuberculosis cases. Yet, misdiagnosis and incorrect treatment are common, often leading to suffering, the emergence of drug resistance and patient debt.
Healthcare providers need to be held accountable, with monitoring of their quality and engaging with them to provide support. Standards that are stringently implemented and an open door collaborative policy to work with private sector as partners will reap dividends. Here again, Covid-19 shows that this is possible and rapidly scalable, if we so desire.
Finally, it is important to remember that tuberculosis is a social disease and cannot be tackled unless the structural issues of poverty, undernutrition, gender, stigma and mental health are addressed. Lived experiences and survivor narratives show that these are critical for patients in choices to seek care, continue treatment and live productive lives post-recovery.
India has neglected these issues for very long, focusing purely on the clinical aspects of this epidemic. Patients with tuberculosis and their families need economic support. We also need counselling to provide mental health support to those affected, and reduce stigma associated with the disease.
There has never been a better time to fight tuberculosis. We have the right tools, the evidence and the experience of fighting Covid-19. All we need now is collective will and action.
Dr Lancelot Pinto is at consultant pulmonologist and epidemiologist at Hinduja Hospital, Mumbai. Chapal Mehra is a public health specialist.
Courtesy: Scroll |
