India’s political leadership has made tremendous commitment to end tuberculosis in India. But the question remains: Can India end tuberculosis without innovation, new strategies, and technologies backed by evidence?
The National TB Elimination Programme’s efforts to make diagnosis and treatment facilities available across India, though commendable, are undermined by the limitations of the health systems, including access to accurate diagnosis and high-quality care.
Tuberculosis still affects millions of Indians, and if we continue with our current diagnostic and treatment approaches, elimination is unlikely. Why? First, the tests used are unable to detect all cases and all forms of tuberculosis, across age groups. Despite prolonged treatment with multiple drugs, we cannot guarantee cure or stop tuberculosis recurrence or emergence of drug resistant tuberculosis.
Additionally, there are numerous other factors that present challenges in tuberculosis control, including poverty, poor nutrition among a large proportion of the population and gender disparities. Unless there is a multi-pronged, innovative and evidence-based approach, nothing will change, and millions will continue to suffer or die.
Where are the gaps? Lack of investment in innovation and three years of a devastating pandemic have moved India further away from its goal of ending tuberculosis. An average tuberculosis patient’s story is proof of the havoc it can cause and what goes unnoticed is the impact on their families and society.
Often, patients face multiple barriers to access good quality care. Following diagnosis, they may be prescribed varying treatments by doctors. There is little or no monitoring for patients outside the National TB Elimination Programme and the medication costs cause many to discontinue treatment. In many cases, the costs to achieve accurate diagnosis and treatment exhaust not just patient income, but also their savings. Delayed diagnosis results in community spread of the disease.
The healthcare system is ill-prepared to provide prompt diagnosis and assured cure. Common practice has been to diagnose tuberculosis patients as soon as they develop symptoms of lung disease. But we now know that many patients are infectious even before they develop symptoms.
Current technologies available for detecting TB infection are sophisticated, costly, and there are no rapid tests available. Additionally, we still are not able to easily identify who among those with latent infection will develop active disease. We need better diagnostic tests that can be used directly in affected communities, where tuberculosis cases are.
What can be done to change this status quo? First, we could start by investing in emerging and ongoing research and strengthening capacity, particularly research being conducted in India and in collaboration with other countries. For instance, here in India there is ongoing research to identify clinical biomarkers, or physiological signals that happen in the body, that can predict the likelihood that someone who is infected with tuberculosis will develop active TB disease and that can predict treatment failure.
Findings can help inform focused treatment approaches for patients who are likely to have severe disease or for which treatment will likely not be successful, rather than treating everyone infected regardless of whether they are likely to develop disease. Reducing the number of people who are taking medications reduces burdens to patients, costs to families and the government, and the development of drug resistance.
This personalised approach may be developed for the treatment of tuberculosis, tailored to the type of disease. Research in the field of multi drug-resistant-tuberculosis to understand the patterns of progression and transmission will help provide early and accurate diagnosis and treatment for patients as well as protect those around them.
Second, we need to address other diseases and conditions that complicate TB treatment. People who have tuberculosis infection are at much higher risk for other diseases. Covid-19, a disease that also affects the lungs, is a good example, and diabetes and undernutrition are also adversely associated with tuberculosis. It is important to understand the interactions among diseases and factors that contribute to disease, and two-way screening is essential. A harmonised diagnostic strategy for co-infections at the programmatic level will address this.
Third, research findings need to be incorporated into tuberculosis elimination policy and programs. For instance, India needs to pilot and include new diagnostics in its strategy as urgently as possible. There is also a critical need to synthesise evidence and select shorter, more effective regimens for tuberculosis prevention and treatment recommended by the World Health Organization. This would have a transformational impact on the fight against tuberculosis.
All this may seem like a tall order, but as Covid-19 showed us, innovation and research can be brought to bear on disease challenges if we put funding and political will behind it. During Covid-19, we saw the rapid development and deployment of new tests, changes in clinical practice, and new public health policies literally overnight. Now ask – how can India leverage this experience to end tuberculosis?
Similar to the response to Covid-19, elimination of tuberculosis will be founded in research and innovation, and in public health policies and practices that are responsive to new scientific findings that ensure all Indians live healthy, productive, and fulfilling lives.
Sonali Sarkar is Additional Professor and Head of the Department of Preventive and Social Medicine in Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry.
DJ Christopher is Professor, Department of Pulmonary Medicine, Christian Medical College, Vellore.