What is common to Amitabh Bachchan and Nelson Mandela? Both are icons in their respective fields, both have entire nations swearing by them and both are tuberculosis survivors. While one has been talking to one of the worst TB affected populations in the world about the importance of seeking medical attention for prolonged coughs, the other’s famous quote “It always seems impossible before it is done” has all but become the tagline of the 46th Union World Conference on Lung Health in Cape Town — the picturesque South African city often branded the most beautiful city in the world — as speaker after speaker drives home the stiffness of the challenge of eradicating TB and the need to believe that the goal is achievable.
Challenge for India
For India, of course, the goal is far more challenging than the rest of the world, not just because of the fact that an estimated 2.6 million Indians are currently living with the disease but also because like all other social sector programmes, the Revised National TB Control Programme (RNTCP) is critically short of funds and public private partnership remains a dirty word in healthcare. So willing partners in the battle have been scrupulously given the cold shoulder while the government limps along, blaming states for their inability to implement schemes and spend funds. This year RNTCP requested Rs 1358 crore - far less than the Rs 1500 crore estimate drawn up by the Joint Monitoring Mission Report 2015- as the ideal average annual spend for tuberculosis control in India. It got just 52% of the requested budget- Rs 710 crores.
Though health minister J P Nadda has been using every available opportunity to make the point that money is never an impediment for any health initiative, experts working on the ground point out that the fund crunch inevitably has an effect on the implementation. For one India is one of only two countries in the world - the other one is China - that still has an intermittent drug regimen. The Directly Observed Treatment Shortcourse (DOTS) requires patients to visit the DOTS centre on designated days (three times a week) to take their medication. The problem with such a system in a poor country like India that also has very high levels of migration is that many times patients do not complete the full course.
Drug resistant TB
The result is drug resistant TB which essentially means a bacterium that has only had a brief exposure to anti-tubercular drugs but not enough to be killed so that it undergoes genetic mutation to develop resistance to those drugs. India has moved on now from multi drug resistant (MDR) forms of the disease to what is known as extensively drug resistant or XDR TB. According to the Centers for Disease Control and Prevention, “Extensively drug-resistant TB (XDR TB) is a rare type of multidrug-resistant tuberculosis (MDR TB) that is resistant to isoniazid and rifampin, plus any fluoroquinolone and at least one of three injectable second-line drugs (i.e., amikacin, kanamycin, or capreomycin). MDR TB is caused by an organism that is resistant to at least isoniazid and rifampin, the two most potent TB drugs.” The real danger of this though is not just what happens to the individual patient who has a drug resistant form of TB but the fact that this person, when she or he infects others, will also transmit the drug resistant TB. Ballpark estimates say that every TB patient infects 60-70 others.
The government of India is not unaware of these damning statistics. It has recently announced that a daily treatment regimen for TB will be rolled out from February 2016. But this will not be in the entire country but rather only in five states - Maharashtra, Bihar, Kerala, Himachal Pradesh and Sikkim. This is as per recommendations of the World Health Organisation that says that a daily regimen usually means higher rates of compliance and also that a single missed dose has the potential for far less damage than the thrice-a-week regimen.
As India grapples with its formidable challenge of 2.2 million TB cases a year (2014 figure) and 2.2 lakh deaths and the need to ensure compliance in a population that is low on hygiene, literacy and money, interesting pilots are being tested in parts of the country to address exactly these goals with the involvement of the private sector. The Municipal Corporation of Greater Mumbai (MCGM) for example along with PATH has started a programme under which every TB patient is given a unique identification number. When that number is given to the chemist the person walks away with a box of free drugs for the entire month. The unique feature of this programme though is the provision that MCGM is engaged for couriering medicines to a patient’s native village, should the person leave Mumbai during the course of his/her treatment. Till date some 100-odd such parcels have been couriered.
At the other end of the spectrum is a fully government funded initiative in Mehsana Gujarat where empanelled doctors and chemists are similarly handing out medicines to patients free - with the restriction that only first line TB drugs will be given under the scheme - and getting reimbursed by the government. The scheme also has a home visit element so that the family is kept in the loop and future feedback on compliance sought from them. Both Mumbai and Mehsana have a very high TB burden, the first because of a slew of reasons like crowded living conditions and migration, that often results in non-compliance and resistance, and the latter because of high levels of malnutrition.
Meanwhile new findings from clinical studies presented at the world conference at Cape Town show promise for a shorter nine month course for treatment of MDR TB. The standard WHO recommended treatment regimen is for 24 months. A multi country cohort of MDR-TB patients treated using the nine month regimen showed a 80.9% treatment success rate. Participants were from Benin, Burkina Faso, Burundi, Cameroon, Ivory Coast, Niger, Congo, Rwanda and the Central African Republic.
“These preliminary results from using a 9-month MDR-TB treatment regimen are excellent. Implementing the shortened regimen is proving feasible and with improved outcomes compared with the standard MDR-TB treatment regimen,” said Dr Arnaud Trebucq of The Union, lead investigator of the study. Another study, the STREAM trial, sponsored by The Union and implemented together with the Medical Research Council (UK) with support from USAID, is also testing the effectiveness of a 9-month MDR-TB treatment regimen. The first stage of the trial is going on in Ethiopia, in South Africa, at sites in Durban, Sizwe and Pietermaritzburg, Vietnam and Mongolia. STREAM is the first randomised clinical trial of this scope being conducted in Mongolia for any disease.