Drugs, Diagnosis And Disease Management: India’s Fight to Eliminate TB by 2025

India aims to eliminate Tuberculosis by 2025 - 5 years ahead of the global target. Covid has reversed the progress.

XDR-TB patient Hanif, during his weekly consultation with Dr. Joan, at MSF’s clinic in Mumbai.

Courtesy - Atul Loke/Panos Pictures

Covid-19 has severely set back the fight against other infectious diseases like HIV, Tuberculosis (TB), and Malaria. TB is one of the major public health challenges that India is facing today. It carries the burden of nearly a third of TB cases reported globally. It had aimed to eliminate the disease by 2025 – 5 years ahead of the global target. However, the pandemic had disrupted care and disease diagnoses as hospitals focussed on Covid-care.

“The health system is not designed to do early screening for infectious or non-communicable diseases in vulnerable populations in India,” said Leena Meghaney, South Asian Head-Access Campaign, Medecins Sans Frontieres.

TB is caused by Mycobacterium tuberculosis, which usually attacks the lungs. When people suffering from lung TB cough or sneeze they propel TB bacteria into the air and carry them in tiny droplets called aerosols. A person can get infected by inhaling only a few of these germs. It is the world’s deadliest infectious disease after Covid-19. TB is curable and preventable if diagnosed accurately and as early as possible. But misdiagnoses remain a massive problem.

Although the tools for TB detection and diagnoses have improved in recent decades, many get diagnosed through clinical suspicion.

The mental and physical trauma of misdiagnosis

When Yasmeen Chaudhary visited her doctor complaining of fever, cough, and fatigue, they told her that she had typhoid. Yasmeen did not recover despite being on typhoid medication for a month.

So, she decided to take a second opinion and visited the local clinic, where the doctor advised her to get an X-ray. The reports concluded that she was suffering from TB and not typhoid. The doctor recommended that she must consult a specialist at a government hospital in Mumbai. There, she learned that she was suffering from Multi-Drug Resistant TB (MDR-TB) and was given treatment accordingly. Six months into her treatment, they informed her that she was now suffering from Extensively Drug-Resistant TB (XDR TB).

By then, Yasmeen had completely broken down. She was the worse for wear physically, mentally, and emotionally.

“It was the darkest period of my life. I used to vomit every day. It was difficult to breathe and I had grown so weak that I would need support even while using the washroom. To make matters worse, TB also took away my job. I was tired. I did not know how to pay my bills. The pain of the injections and medication was so excruciating that I simply did not want any treatment.”

Drug resistance occurs when anti-TB medicines are used inappropriately. It can also happen if poor quality drugs are prescribed or when patients prematurely stop their treatment. MDR-TB is a form of TB caused by bacteria that do not respond to the first-line of anti-TB drugs. According to the WHO, it is still treatable and curable by using a second-line of treatment drugs.

XDR-TB patient Nischaya, at home in the Ambedkar Nagar area of Mumbai, with her TB medication.

Early diagnosis and access to TB drugs

Early and accurate diagnosis of TB is only one of the multiple challenges that healthcare professionals face. Ensuring affordable care and treatment is accessible to all, particularly in the underprivileged communities, is a bigger problem. Leena Meghaney shed insight into the sourcing, pricing, and distribution concerns around drugs and injectables for TB.

She said, “Availability of paediatric formulations of Drug-Resistant (DR) TB drugs that are exported is a challenge. Tenders of the TB program receive no bids from drug manufacturers. While currently, the National TB Elimination Programme (NTEP) has started procuring drugs through the Global Drug Facility, it needs to fix this problem for the future. Pooled procurement, incentives, and early payments to manufacturers are essential to solve the problem.”

She continues, “We need new TB medicines like Bedaquiline and Delamanid to replace the injectables and increase cure rates to 70% for M/XDR TB patients. Delamanid is patented, expensive, and not readily available to DR-TB patients. NTEP procures just 7000 treatments, which is a tenth of what it needs to meet the needs of M/XDR patients across the country.”

MSF treats patients diagnosed with DRTB

The MSF clinic in Mumbai provides free, comprehensive, and individualised treatment to people with severe forms of DRTB. They focus on delivering patient-centred care whereby some patients seen by MSF have previously been treated with ineffective regimens for several years by public and private practitioners. Some, like Yasmeen, have been directly infected by XDR strains in the community. MSF’s model of care focuses on reducing DR-TB mortality by increasing timely access to diagnostics and the most effective drug regimens in the Mumbai-East ward, the TB hotspot of Mumbai.

After being let down by various hospitals, Yasmeen’s sister helped her access TB treatment at MSF’s Mumbai clinic. It has been 18 months been since she has been cured of TB now.

Symptoms of TB and Coronavirus

TB has similar symptoms to coronavirus. They include coughing, chest pain, fatigue, fever, night sweats, chills, and loss of appetite. Thus, it is easier for people to often mistake TB for Covid-19 and resist diagnosis or treatment with the false assumption that it shall pass.

India is determined to set the record straight and meet the initial targets around early detection and elimination of TB. Last month, the national task force on coronavirus disease management revised their Covid-19 guidelines. They advised Covid-19 positive patients to undergo a TB test if the cough persisted for over two to three weeks.

Hailing the Indian government’s announcement, Elin Hoffman Dahl, Infectious Disease Medical Advisor at MSF Oslo, said, “If acute onset cough and fever persists, then it is important that we rule out other causes of disease. In the current climate of Covid-19, most of us might rule out the possibility of contracting something like TB. So, it is a good recommendation by the Indian government to get tested for TB if the above symptoms persist.”

According to the latest report by the WHO, in 2020, TB claimed more than 1.5 million lives globally, recording the first-ever increase in a decade. The WHO further estimates that Covid-19 related disruptions in access to TB treatment could cause an additional half a million TB deaths.

Most people, even today, are unaware of the scale of the TB outbreak. For India to truly eliminate TB by 2025, epidemiologists advocate ramping up early detection through affordable tests. Most importantly, people from underprivileged communities should have access to free medicines, counseling, and care to get rid of TB.