India’s TB Problem and the Right to Treatment

Why in News?

• Drug-resistant tuberculosis (DR-TB)is a huge challenge that demands urgent attention.
• With a quarter of the world’s DR-TB cases, India’s response can shape how other countries deal with this growing threat.

 

Drug-Resistant Tuberculosis (DR-TB)

• It occurs when bacteria become resistant to the drugs used to treat TB which means that the drug can no longer kill the TB bacteria. 
• DR-TB is spread the same way that drug-susceptible TB is spread. 
• DR-TB can also occur when the drugs used to treat TB are misused or mismanaged. Examples of misuse or mismanagement include:
  • People do not complete a full course of TB treatment
  • Health care providers prescribe the wrong treatment (the wrong dose or length of time)
  • Drugs for proper treatment are not available
  • Drugs are of poor quality
• DR-TB is more common in people who
  • Do not take their TB drugs regularly
  • Do not take all of their TB drugs
  • Develop TB disease again, after being treated for TB disease in the past
  • Come from areas of the world where DR-TB is common
  • Have spent time with someone known to have DR-TB disease

 

DR-TB Situation in India

• The WHO estimates that 119,000 new cases of multidrug/rifampicin resistant TB (MDR/RR-TB) emerge in India each year.
• However, the Indian TB programme has notified only a little over half the estimate, 64,000 MDR/RR-TB cases in 2022.

 

India’s TB Elimination Programme

• Elimination of Tuberculosis is one of the sustainable development targets to be achieved by 2030 by the world, India has set the target of 2025.
• The national strategic plan 2017-2025 sets the target of India reporting no more than 44 new TB cases or 65 total cases per lakh population by 2025.
• The programme also aims to reduce the mortality to 3 deaths per lakh population by 2025. The estimated TB mortality for the year 2020 stood at 37 per lakh population.
• The plan also aims to reduce catastrophic costs for the affected family to zero. However, the report states that 7 to 32 per cent of those with drug-sensitive TB, and 68 per cent with drug-resistant TB experienced catastrophic costs.
• The goals are in line with the WHO’s End TB strategy that calls for 80% reduction in the number of new cases, 90% reduction in mortality, and zero catastrophic cost by 2030.

 

Major Challenge to India’s TB Elimination Programme: MDR-TB

• Resistance to Rifampicin
  • Rifampicin is the most effective first-line drug and the resistance to it is of greatest concern. Resistance to rifampicin and isoniazid is defined as MDR-TB. 
  • The WHO report mentions that DR-TB continues to be a public health threat in India.
• India’s Insistence on Using Mix Treatment
  • In December 2022, WHO recommended the use of the BPaL(Bedaquiline, Pretomanid, and Linezolid) regimen for DR-TB patients, which offers as much higher success rate of 89 per cent, reduces the pill burden to only three to four pills a day and shortens the treatment duration.
  • However, India continues to use a mix of treatment options, most of which are difficult to adhere to.
  • As per the India TB Report 2023, over 22,000 Indian MDR/RR-TB patients in 2021 were on treatment regimens which contained injectables.
  • The WHO has recommended phasing out injectables in 2019. Only 68 per cent of the MDR/RR-TB patients initiated on treatment in 2020 successfully completed treatment.
  • Moreover, in 2022, only 53 per cent MDR/RR-TB patients (~31,000) were put on the shorter bedaquiline-containing regimen, the preferred drug for DR-TB, recommended by the WHO since 2019.
• Reliance on Old Methods of Detection
  • Recently the WHO released a Standard on Universal Access to Rapid TB Diagnostics, recommending the use of molecular diagnostics as the initial test as these are highly accurate, detect resistance to drugs, are cost-effective, and reduce treatment-related delay.
  • However, last year in India, only about 23 per cent of those presumed with TB underwent these initial diagnostics tests.
  • The traditional sputum smear microscopy was the initial diagnostic investigation for 77 per cent of the suspected patients.
  • Microscopy, a century-old tool, cannot detect drug-resistance, and detects only half of all people with these tests.

 

Some Other Challenges to India’s TB Elimination Programme

• A large proportion of the country’s population is undernourished and this can cause a reactivation of TB because of weakened immunity.
• A large section of those afflicted with the disease leave the treatment mid-way because of poor resources and financial constraints.
• Delay in diagnosis, inadequate treatment, high rates of recurrent TB, drug resistance, diabetes, HIV, undernutrition, urbanisation are important drivers for the persisting TB epidemic.
• Private sector engagement is a challenge. The involvement of the private sector has to be scaled up as they can play a pivotal role in treatment.
• Another major challenge is the high number of DR-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 an inability to implement measures to cap the treatment and drug costs are aiding the spread of the epidemic. 

 

Achievements in TB Treatment

• Improvement in Diagnosis: TB can now be rapidly detected using rapid molecular diagnostics. These tests were extensively used for Covid-19 during the pandemic.
• Shortening the Duration of Treatment of DR-TB
  • Shortening the duration of DR-TB treatment from 24 months to 6 months is a big improvement.
  • Serious form of the disease can now be treated with just oral medications and avoid painful injections.

Way Ahead

• Use of WHO Recommended BPaL regimen for DR-TB patients
  • Instead of using mix treatment option India should start using the BPaL regimen for DR-TB patients which offers a much higher success rate.
  • Studies estimate an annual saving of $740 million globally because of transition to BPaLM/BPaL.
  • With India accounting for a third of the global MDR/RR-TB treated patients this could mean a saving of nearly $250 million per year for the country.
  • Most notably, India is the only global supplier of pretomanid, a key drug within the BPaL regimen.
  • However, only 403 patients in India have so far been administered the pretomanid-containing BPaL regimen through a clinical trial.
• Ensure the Availability of New Tools to All with DR-TB: With the availability of highly accurate tools to detect DR-TB, India can cure DR-TB within six-months with oral medications.

 

Conclusion

• Every individual has the right to access diagnostic and treatment options that offer them the best chances of recovery. 
• Now when highly advanced tools are available, India must make use of them and no one should suffer or die from drug-resistant TB.

 

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Q1) Why are diabetic patients at a risk of developing TB?

Global researches have shown that people living with latent TB along with diabetes are at a much higher risk of developing active TB. It is like a double-edged sword. Studies demonstrated that diabetes predisposes a patient to infections in which cell-mediated immunity has a pivotal role, such as TB. Uncontrolled diabetes is the most concerning health issue as it makes a person immunocompromised. This leads to altered metabolism which reduces T cell immunity and thereby increases the risk of TB.

 

Q2) What has been India’s progress so far in combating TB?

India has managed to scale up basic TB services in the public health system, the rate of TB decline is slow to meet the elimination deadline. While sufficient expertise exists, these resources have often been underutilised for quantitative analysis and improvements in TB control policy and implementation. According to the 2019 Tuberculosis Profile of India collated by the WHO the total TB incidence in the country was 2640000. Total cases notified in India in 2019 was 24,04,815 of which the new and relapses figured at 2162323. For TB financing the 2020 National TB Budget was pegged at $497 million of which 85 percent was domestically funded.

 

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Source: The Indian Express