The Global TB Report 2016, recently released, has revised the estimates for the tuberculosis (TB) burden in India upwards. The country has 27 per cent of the global burden of incident tuberculosis and 34 per cent of global TB deaths. For the year 2015, the updated estimate of incidence (new and relapse TB cases per year) is 2.8 million cases. India diagnosed and notified 1.7 million incident TB patients in 2015, leaving approximately 1.1 million presumptive patients whose fate was unknown. The actual burden of TB will be known only after the completion of a national TB prevalence survey scheduled for 2017-2018; the numbers could be even higher. Worryingly, the 2015 estimate of the number of TB deaths is 4,78,000 — making TB one of the leading causes of death in India. Further, of the estimated 79,000 cases of multidrug resistant (MDR) TB, about 31,000 were diagnosed and the majority put on treatment.
There is strong political commitment at the moment to tackle TB head-on and achieve the 90-90-90 targets by 2035 (90 per cent reductions in incidence, mortality and catastrophic health expenditures due to TB). In order to do this, our policies must be driven by data and evidence, as well as be responsive to patient needs and expectations. Unlike polio, we do not have an effective vaccine to prevent TB, so our strategy must be based on finding all cases, treating them appropriately, reducing risk factors and preventing further transmission. For this, we need better and more efficient diagnostics, shorter treatment courses, a better vaccine (BCG protects only young children from severe forms of TB) and better preventive strategies.
Hope with research There is hope on all these fronts. The Indian Council of Medical Research (ICMR) and Department of Biotechnology (DBT) have a joint programme to evaluate indigenous TB diagnostics and have evaluated a couple of very promising products which could potentially replace imported tests. Two new drugs for TB (Bedaquiline and Delamanid) were introduced globally in 2013 and can now be tested in combination trials to see if shorter and more effective treatment regimens can be created.
Indian scientists working in laboratories of the Council of Scientific & Industrial Research (CSIR), the DBT and the Indian Institute of Science as well as some new start-up companies have identified several targets and compounds, which need further work (pre-clinical, toxicology and clinical trials), to see if a new drug for TB can be developed. A modified, recombinant BCG vaccine developed by German scientists and to be manufactured at the Serum Institute of India, will soon be tested at many centres in India to try and reduce recurrences of TB in treated patients.
Focus on nutrition Of the many risk factors for TB, the one that we need to pay most attention to is undernutrition. Malnutrition (low body weight) is responsible for 50 per cent of TB in India and also leads to higher death rate, because of the low capacity of the body to mount an immune response. Reports from tribal areas of our country show that the average body weight of men and women with TB is 30-35 kg! Prevalence rates of TB are directly correlated with socio-economic status, with people in the lowest economic quintile having 3-4 times the rate of TB than those in the highest.
We have decades of experience dealing with TB and the knowledge, capacity and resources to tackle the problem. We cannot let the TB bacteria get the better of us. With analysis of the available data, we can plan appropriate strategies to prevent, diagnose and treat it. Researchers, academics, government and private sector doctors, corporate sector and industry, non-governmental organisations, TB programme staff, treated TB patients, students and all citizens can contribute to this effort. We have a window of opportunity now — TB can be history by 2050 if we try.
Dr. Soumya Swaminathan is Director-General, Indian Council of Medical Research.
