(Focus - India)
As March 24th is recognized as World TB Day, so, acknowledging the significance of March, we present to you an interview featuring Dr. Aleemuddin Naveed, an acclaimed pulmonologist from India who has explained the Importance of Tuberculosis awareness program.
Our service adopted the usage of telephone and whatsApp to answer patient queries. We also ensured that the existing patients under treatment do not miss the dose and their treatment goes uninterrupted. After the pandemic, we have more aggressive case-finding programs in the town.
We understand that to achieve a TB-free India; we need to diagnose TB effectively and efficiently. What do you think will be the role of point-of-care diagnostics in this context?
Dr. Aleemuddin: There is a lot of work going on for the PoC (point of care) tests. But I feel it might be easy and feasible to improve the infrastructure and services at the point of care rather than developing newer PoC tests.
It is about putting in more money than brains as we already have many PoC tests available, like GeneXpert, Xpert Ultra, and Xpert Omni. So, we can make the program successful by investing in infrastructure and improving the PoC services.
Xpert Omni can be a game-changer if it improves the number of tests and turnaround time (TAT). Currently, Xpert Omni can perform one test in 60 to 90 minutes, and this setup gives only one test at a time. Other PoC tests like LAM-Ag, DNA isolations, and whole-genome sequencing are coming, and they can act as weapons in the armamentarium.
In the current pandemic situation, a drop of around 25 to 30% in tuberculosis case notification was reported in three high-burden countries - India, Indonesia, and the Philippines - between January 2020 and June 2020. What is your thought on how the COVID 19 pandemic impacted tuberculosis treatment and management in India?
Dr. Aleemuddin: Yes, hurdles are expected. For the past two years, we have been facing a pandemic; in the future, we may have another reason, but what we need to understand is that we need to give everything its due importance. Why should anyone disturb the existing infrastructure for a new requirement? Does it mean we are still thinking that TB is not important? This leisureliness must go! We must act before we reach a point of no return.
When we have pledged to eliminate TB by 2025, we should not disturb the ongoing program for any reason. I understand the disruption for a month or two, where everyone was stunned by how the pandemic has attacked humanity. Still, I think understanding the disease has helped us take control over the COVID 19. We must act in a similar way where the existing services for TB should go on undisturbed or uninterrupted
Can you talk more about how COVID-19 has impacted TB Control in India?
Dr. Aleemuddin: I have seen other countries like the South African countries have still not come out of that situation. The graphs of India and the Philippines have picked up, their control programs and notification rates have also come up, but in South African countries, certain places have still not gained the momentum back. India has definitely done it, but now we are trying to achieve the expected mark.
Because of this pandemic, we see more severe TB cases. In the last six months, we have probably seen several disseminated TB cases than I have seen in my previous 15 years of practice. They are usually full-blown diseases that have reached many other organs apart from the lung, so it is terrible for the patients.
What measures did your hospital take to overcome the challenges due to COVID-19?
Dr. Aleemuddin: Firstly, we ran our advanced monitoring grid uninterrupted because that did not require any physical contact. Also, our service adopted the usage of telephone and WhatsApp to answer patient queries. We also ensured that the existing patients under treatment do not miss the dose and their treatment goes uninterrupted. After the pandemic, we have more aggressive case-finding programs in the town.
The Tuberculosis Control program needs much advertisement to raise awareness and a lot of public discussions. The government needs to ensure the uninterrupted availability of manpower and consumables and update CMEs. There should be extraordinary reach to the stakeholders involved and those not directly affected
ICMR has recruited about 12,000 participants for a Phase III study of two potential TB vaccines – Immuvac (mycobacterium indicus pranii) and VPM1002 (recombinant BCG). What are your thoughts on these vaccines?
Dr. Aleemuddin: Vaccines are a new weapon, as they fight against the disease, but it must be noted that MTB is different from other vaccine-preventable infections. A vaccine should give life-long protection against any existing or potentially variable strain. So, vaccines will help, and I wish to see these vaccines come up as a great help.
And when it comes to the answer to your question - Will it impact the RNTCP 2025? My answer is yes, partially. Because they are in Phase III, and by the time they roll out the vaccine, it may be already 2025. However, they will definitely help execute the elimination program, but I think for the 2025 target, vaccines may not play that much a more prominent role. The development of vaccines should go as a breakthrough intervention.
As we know, it has been more than two decades since India launched the Revised National Tuberculosis Control Program based on the DOTS strategy. Do you think this program will successfully meet India's goal of TB elimination by 2025?
Dr. Aleemuddin: I wish and hope that it will be, but at the same time, I am skeptical and afraid that this may be a dream. I am practically involved in this program, and there is a lot of uncertainty and disturbance. My observation is that there is commitment at an individual level, but there is a problem when it comes to the entire team in toto. Everyone on the field is working with dedication, but suddenly you see a lacuna in the chain for various reasons.
For example, if you don't have a CB-NAAT cartridge, you mobilize your staff and diagnose an MDR case but realize that bedaquiline or delamanid is unavailable. Similarly, the announced incentive to the private practitioner does not reach them in all the cases.
So, this program needs much advertisement to raise awareness and a lot of public discussions. The government needs to ensure the uninterrupted availability of manpower and consumables and update CMEs. There should be extraordinary reach to the stakeholders involved and those not directly affected. So, unless and until we have such a team approach with the same commitment at all levels, I think we cannot reach the goal.
Before we conclude, what is your takeaway message for eliminating TB in India?
Dr. Aleemuddin: Whoever is working in the eliminating TB program must see that the existing infrastructure, investigations, diagnostics, and the availability of drugs go uninterrupted. Commitment and strategies to make uninterrupted access to diagnostics and new TB drugs are also important.
At the government level, I would make the National Tuberculosis Control Program as popular as the pulse polio program. 'Do Boond Zindagi Ke' (Two Drops of Life) is more popular in India than 'TB Harega Desh Jeetega,' (TB Loses Country Wins) which means we have given importance to other things and, unfortunately, found lacking in making the TB control program popular. We must improve the point of care services and the ongoing search for new PoC diagnostics. Vaccine development, treatments for post-exposure contacts, development of drugs for mass prophylaxis, etc., are required.
Thank you so much for the insights.