The omnipresence of tuberculosis (TB) in the pages of history and literature is testimony to how the disease has plagued generations across the world and continues to be a major problem even today. India bears over a quarter of the global TB burden. Political will in India has helped drive a great deal of progress in the fight against the disease. For example, in 2023, addressing the big challenge of ‘missed’ TB cases, 25.1 lakh patients were diagnosed in India as having TB, highlighting strengthened case finding efforts. However, as we work toward the goal of TB elimination — the Prime Minister has urged citizens to work towards TB elimination — we must look to innovate and deploy proven technologies and tools at our disposal.
Regimens and issues
The first low-hanging fruit that I believe must be invested in urgently is new shorter regimens for drug-resistant TB. It has been encouraging to learn that India will soon introduce the World Health Organization (WHO)-recommended shorter regimen for drug-resistant TB. The current regimens on offer are long and arduous, requiring patients to consume nearly 13 to 14 tablets every day if they are on the shorter nine to 11-month regimen, or four to five tablets every day if they have been put on the 18 to 24 month longer regimen. The treatment is physically and psychologically draining and has severe side effects, such as loss of hearing, and even psychosis.
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Moreover, a problem with such an extended treatment regimen that requires regular visits to a TB clinic for nearly two years is loss of employment, driving many families into poverty.
In 2022, WHO recommended the shorter, safer and more effective regimens called BPaL/M for all drug-resistant TB patients, and there is a lot of recent data that show this regimen to be more effective with better compliance. With only three to four tablets every day, patients can complete their treatment within six months, with minimal side effects. The success rates of this regimen are also reported to be higher — 89% as compared to the 68% treatment success rate reported in the country in the 2023 India TB Report. Given its efficacy, close to 80 countries around the world have already procured the BPaL/M regimen and about 20 of the highest burden countries are already rolling it out.
Research indicates that savings from implementing this regimen will be between 40% to 90% of the cost of current treatment regimens, and that an immediate transition to BPaL/M could result in an annual saving of approximately $740 million (or approximately ₹6,180 crore) for health systems globally. This is a more effective and safer solution to treat drug-resistant TB and we must work on expediting access to this regimen to all eligible patients across the country.
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Making the best use of new treatments
The next question is this. How do we go about diagnosing more people with TB so that they can benefit from these game-changing new treatments? The answer lies in making sure that we are screening and testing quickly and efficiently to reduce delays in accurate diagnosis. For this, a proactive approach is essential. It is time we modernised and used health datasets, which include GIS mapping, to identify vulnerable populations such as those with comorbidities (for example, malnutrition, diabetes and HIV), former COVID-19 patients, and at-risk communities in slums, prisons, or those who are homeless. Targeted multi-disease focused screening drives can then be conducted to detect TB cases early, even among those without typical symptoms.
In fact, recent evidence highlights that a significant number of people with pulmonary (i.e., lung) TB may not exhibit recognisable symptoms such as cough, fever, weight loss, or night sweats. The National TB Prevalence Survey (2019-21) highlights the importance of chest X-rays, which detected 42.6% of cases that would have otherwise been missed. Leveraging advancements in technology, portable X-ray machines equipped with AI-driven tools can significantly reduce diagnostic delays, especially in remote and under-resourced areas.
Further, there is a critical need to expand the use of rapid molecular tests over less sensitive microscopy methods for faster detection and drug resistance profiling. This shift is crucial in promptly identifying TB cases and determining appropriate treatment options. In short, by proactively identifying at-risk populations and investing in and leveraging advanced/innovative diagnostic technologies, we can improve TB detection rates, reduce delays, and enhance treatment outcomes.
As we look to eliminate tuberculosis and and make our country TB-free, prioritising these essential areas will be critical as these will be an investment in a healthier future for all of us.
Dr. Randeep Guleria is the Chairman of the Institute of Internal Medicine and Respiratory and Sleep Medicine at Medanta, Gurugram, and a former Director of the All India Institute of Medical Sciences, New Delhi
