(Focus-India)
In this interview, we are focusing on the ongoing fight against tuberculosis (TB) in India. According to the World Health Organization's Global TB Report 2023, India has made impressive progress in battling TB. Since 2015, TB incidence and mortality have declined by 16 percent and 18 percent, respectively, faster than the decline globally. This shows that India has adopted several approaches to mitigate the impact of TB, ranging from robust public health campaigns to innovative treatment methods. Through widespread education, early detection programs, and advancements in medical research, India aims to not only treat existing cases but also to break the cycle of transmission.
To learn more about it, we engaged in an informative conversation with Dr. Salil Bhargava, a prominent professor in pulmonary medicine with 35+ years of experience. Dr. Salil highlighted the significance of collaboration between healthcare professionals, policymakers, and the broader community in achieving meaningful progress against TB and thereby to eradicate the ailment.
Dr. Salil Bhargava is a Professor of Pulmonary Medicine at Gyanpushp Research Center for Chest & Allergy Diseases, Indore, India.
National Strategic Plan for Tuberculosis Elimination 2017–2025 aims to achieve a rapid decline in the burden of TB, morbidity, and mortality while working towards eliminating TB in India by 2025. [1], [2] What specific measures and strategies have been implemented by this program to prevent and control TB?
Dr. Bhargava - The government is addressing tuberculosis (TB) through various approaches, including the easy detection of patients. This involves the diagnosis of individuals through Passive Case Finding (PCF), where patients voluntarily report to the hospital. At the hospital level, both pulmonary and extrapulmonary patients are identified based on their symptoms. For instance, if a patient presents with a cough, they are subjected to investigations. To facilitate this process, a significant number of hospitals in each district are equipped with Truenat or CB-NAAT machines, which are polymerase-based reaction devices. These machines are provided free of charge to hospitals, along with all other components of the TB control program.
What impact have these interventions had on the incidence and prevalence of TB in India?
Dr. Bhargava - Although there has been a decline in TB cases, it is not declining as quickly as required to reach the desired level. However, substantial efforts are being made to address this issue. In his 'Mann Ki Baat' program, the honorable Prime Minister Narendra Modi mentioned the 'Ni-kshay Mitra Yojana,' as malnourished individuals are more susceptible to severe and widespread TB infections.
It has been more than two decades since India launched the Revised National TB Control Programmer (RNTCP), based on the internationally recommended Directly Observed Treatment Short-course (DOTS) strategy. In your perspective, what measures could be undertaken within the program to meet India’s goal of TB elimination by 2025?
Dr. Bhargava - As we get closer to 2025, if we all put in the same dedication and effort that we showed during the COVID pandemic and utilize the financial resources, energy, and equipment we invested in combating COVID, we can strive towards achieving the elimination of TB in our country. Let us believe in our ability to accomplish this goal.
There are several strategies that can be employed to enhance TB control and achieve the goal of elimination. Firstly, active case finding through mass screening using X-ray machines can enable the detection of undiagnosed patients by screening entire cities. Secondly, the development of effective vaccines, like what we have witnessed with COVID-19, holds great potential in aiding TB control efforts. Thirdly, implementing TB preventive therapy on a broader scale can effectively reduce the future incidence of new cases.
In your opinion, what role do molecular tests play in the future of TB diagnosis and treatment in India?
Dr. Bhargava - Molecular tests possess high sensitivity and are capable of detecting even a very small amount of target molecules. These tests are highly effective in identifying TB patients on a large scale. While they may be slightly more expensive at present, the government's provision for these tests makes them feasible for everyone to use. These tests can be utilized by everyone and are particularly valuable in cases of extrapulmonary testing, where the number of baselines is minimal.
Do you see any recent advancement in the point-of-care test for diagnosis of TB or multidrug-resistant TB?
Dr. Bhargava - In nearly all government healthcare facilities, methods such as line probe assay (LPA), liquid culture techniques, CB-NAAT, and drug susceptibility testing for multidrug-resistant tuberculosis (MDR TB) are available. If a patient requires these tests, they are referred to the government system for access. The objective is to identify cases of drug-resistant TB at the earliest possible stage.
Doctor, I understand that drug-resistant TB remains a challenge to cure. Even though the efficacy of drug regimens has improved, side effects and length of treatment have continued to impact patients negatively. How do you treat and manage your extensively drug-resistant tuberculosis (XDR TB) and pre-extensively drug-resistant tuberculosis (pre-XDR TB) patients?
Dr. Bhargava - Recently, a few newer drugs have been available in the armamentarium of our TB regimes, such as Delamanid, Linezolid, and Bedaquiline. Some of these regimens have been tested and shown to have potential benefits for patients with drug-resistant TB.
Are there any new potential therapies in the pipeline for the treatment of MDR TB?
Dr. Bhargava - In addition to the aforementioned drugs, there have been attempts to use a few second-line drugs, such as amoxyclav and high doses of isoniazid. However, other drugs have proven ineffective. While I am uncertain about any new drug currently in development, it is worth noting that diagnosing and treating drug-sensitive patients remains a crucial approach that should be explored and implemented as an important tool.
What are the other potential future developments in the treatment of TB, including novel drugs and vaccines, and how could they impact global efforts to end the TB epidemic by 2030 [3], [4]?
Dr. Bhargava - There are several strategies that can be employed to enhance TB control and achieve the goal of elimination. Firstly, active case finding through mass screening using X-ray machines can enable the detection of undiagnosed patients by screening entire cities. Secondly, the development of effective vaccines, like what we have witnessed with COVID-19, holds great potential in aiding TB control efforts. Thirdly, implementing TB preventive therapy on a broader scale can effectively reduce the future incidence of new cases. Additionally, improving treatment regimens, early detection methods, enhancing overall quality of life, and addressing nutritional factors such as increasing body mass index can contribute to better patient outcomes and support the objective of TB elimination.
Our TB program involves multiple stakeholders, including NGOs, social workers, government agencies, and private funders, all working towards reducing TB incidences to the greatest extent possible. As an NGO, our primary focus is to decrease the occurrence of TB cases swiftly. We strive to strengthen the team in any possible way, whether through increasing awareness, adopting scientific tools, leveraging artificial intelligence, or utilizing tools like Predict TB, to improve our efforts in combating TB.
Do you face any challenges or limitations in the treatment and management of TB?
Dr. Bhargava - The detection of TB cases still remains relatively low. It is crucial to identify individuals who are early suspects within society. Even if the initial symptoms of TB may not make someone severely ill, such as a persistent cough, they can unknowingly spread the infection to others while interacting in the community. As a result, not only the index patients but also the new individuals infected by them (approximately 10 to 15 patients) would require treatment in the coming months or years.
Another significant concern is that India is witnessing a rise in diabetes cases, making it a prominent risk factor. Patients with diabetes, HIV, those undergoing immunosuppression therapy, organ transplant recipients, and individuals receiving steroid therapy are particularly vulnerable to TB infection or progression to TB disease. These high-risk individuals should be detected early and receive special attention and appropriate treatment to ensure their well-being.
Predict TB, a five-year project supported by a variety of international funders, aims to use individualized therapy to shorten the time needed to treat TB in drug-sensitive patients. [5] What are your thoughts on the same? How do you think the success of this project changes the treatment landscape of drug-sensitive TB strains?
Dr. Bhargava - I believe any effective treatment for drug-sensitive TB patients can play a crucial role in preventing the emergence of drug-resistant cases and reducing the incidence of future patients. Currently, we rely on fixed durations of therapy, ranging from six to twelve months. However, if we can accurately predict the optimal duration of treatment and gain deeper insights into this aspect, it would greatly enhance our understanding of the situation. Introducing new treatment approaches that are effective, do not contribute to drug resistance, facilitate prompt diagnosis, and do not impede the management of existing patients would be highly beneficial.
Our TB program involves multiple stakeholders, including NGOs, social workers, government agencies, and private funders, all working towards reducing TB incidences to the greatest extent possible. As an NGO, our primary focus is to decrease the occurrence of TB cases swiftly. We strive to strengthen the team in any possible way, whether through increasing awareness, adopting scientific tools, leveraging artificial intelligence, or utilizing tools like Predict TB, to improve our efforts in combating TB.
Finally, what is your suggestion for anyone who wants to contribute to eliminating TB in India?
Dr. Bhargava - There are several areas to consider, and I would like to discuss a few possibilities for collaboration. As a significant funder, your support can greatly contribute to TB research. Additionally, your funding can be utilized to provide portable X-ray machines, ranging from 100 to 1000 units, along with mobile vans. You can also invest in TB diagnostics and vaccine research, as well as contribute to the nutrition aspect. Moreover, individuals with expertise in business management can join the program and establish a corporate-focused TB initiative with the aim of reducing the burden of TB patients in the country and society. There are numerous locations where these contributions can be made, depending on the available funds and the specific areas you wish to prioritize.
To ensure the most effective use of resources, it is essential to identify the areas requiring research and development. For example, if I am working in two cities and require 10 to 15 X-ray machines for each city, costing 20 lakh rupees per machine, I would need a budget of 200 crore rupees. By conducting comprehensive screenings of the entire population within two to three months, I can significantly reduce the TB incidents in these two districts. Considering the budget and goals, we have been training district TB officers in quality improvement cycles and plan to conduct a study on different activities and support required within these cycles. The key is to integrate all these efforts into a unified framework to ensure efficient utilization of funds and maximize their impact.
Thank you so much for your insights!
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