TB or no TB is the battle

This week in health: World TB Day, pharma companies’ link to electoral bonds and how microplastics impact heart health.

Updated - March 27, 2024 09:58 am IST

Published - March 26, 2024 02:51 pm IST

Image for representational purpose only.

Image for representational purpose only. | Photo Credit: AP

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With a crucial target for the elimination of Tuberculosis literally round the corner (2025, to be precise), it was no wonder then that World Tuberculosis Day came with the noise and hoopla that a deadline deserves. We had a wide range of stories, covering a spectrum of issues relating to TB across the different columns and pages, the kind of attention that TB, given its magnitude and impact in India, deserves. With a target on our backs, it was appalling that India finds itself once again in the middle of a crucial TB drugs shortage, similar to the one that was witnessed last year. Clearly what was done in 2023 to stave off a further shortage of anti TB drugs was insufficient. Bindu Shajan Perapaddan reports an important story: TB, HIV patients and activists seek PM’s intervention over frequent shortages of anti-TB drugs. In a letter to Prime Minister Narendra Modi ahead of World TB Day, which is observed on March 24, activists, public health experts, tuberculosis survivors, and people living with HIV sought his urgent intervention to halt what they said were frequent shortages of anti-TB drugs. Till February 2024, [these] drugs — Isoniazid, Refampicin, Pyrazinamide and Ethambutol – are falling short. This is as per the limited information received from the community/TB people in the affected areas and records only a fraction of the actual shortages and stock-outs that have occurred, they added. This might be the worst move for a country operating on a deadline: The most severe impact of these persistent stockouts of anti-TB drugs is on people currently on treatment, leading to a situation of treatment interruption and a very high risk of developing resistance. This also affects treatment outcomes, increasing the risk of the disease in the community, and thereby putting an additional burden on the TB programme, the group warned. Taking the drugs to the people is of the utmost urgency, the government departments should not allow themselves to be distracted by the amazonian political exercise ongoing in the country, and instead focus on making sure the drugs are available. 

C. Maya brings up another emerging issue in TB care. Subclinical tuberculosis throws up diagnostic challenges, she writes for Kerala, but the issue remains alive for the other States as well. Patient delays in perceiving the symptoms of tuberculosis and the confounding fact that close to 50% of the people who are tested positive for TB through sputum culture do not have the typical symptoms of the disease are complicating early diagnosis and treatment of TB, she writes. The National TB Prevalence survey (2019-21) reported that the TB diagnosis of 42.6% of survey participants would have been missed if chest X-ray had not been an additional screening tool. Because while their sputum culture was positive, they did not exhibit the typical symptoms of tuberculosis — cough, chest pain, fever, night sweats, or weight loss. “This means that there is a high probability that testing for TB only among those reporting symptoms could result in our missing half of the pulmonary TB cases. Chest X-ray should be roped in as an important modality to screen for TB wherein the persons may have no symptoms suggestive of TB. All cases where X-ray abnormalities are reported should be followed by a confirmatory molecular diagnostic test (NAAT), “ says P.S. Rakesh, senior Technical Advisor, International Union Against TB and Lung Diseases, Southeast Asia.

Sarabjit Chadha further elaborates on the diagnostics aspect, at the moment the most crucial part of the puzzle, here. Globally, diagnosis continues to be the “weakest aspect of TB care”, the author adds. According to the WHO’s ‘Global Tuberculosis Report 2023’, for the first time globally, 7.5 million patients were diagnosed with TB in 2022; yet there remained a large gap of some 3.1 million people who probably fell ill with TB but were not diagnosed and reported to national TB programmes. As the article surmised succinctly, “If we cannot find TB, we cannot treat TB. And if we cannot treat TB, we cannot end TB.” Naturally. The TB diagnostics pipeline is rich with several new innovative tests on the anvil. However, to maximise these tests, their rapid validation and adoption under the programme is critical. To ensure we truly reach the last mile, point-of-care testing and diagnosis is imperative. 

Former WHO chief scientist Soumya Swaminathan and public health activist Chapal Mehra push the envelope further on treatment, calling for person-centred solutions. As India grapples with the complexities of controlling TB, we need a paradigm shift urgently — one that places those affected and their lived experiences at the centre of tackling this ancient disease, they write. At the core of this shift lies a fundamental recognition: the needs and the interests of patients and communities must be prioritised within the care paradigm and the healthcare system. This principle, echoed by survivors, communities, health experts and policymakers, underscores the need for a person-centred approach to TB care and management.

Over the years, strong TB survivor advocates have emerged who have stridently worked to put the needs of affected communities on the table. They have sought change in key areas and governments have listened and modified their own approach to meet community needs. A case in point is nutritional support, which while limited, is an important step. Further, the growing focus on patient support, addressing stigma, and gendered aspects of TB has also been important. Additionally, we need to focus on efforts to make care more humane. Hence, mental health support and gender responsive care become critically important. Efforts are also needed to strengthen community-based TB care models, empowering frontline health-care workers to deliver comprehensive care which addresses not just treatment but also social, economic and mental health needs and is closer to where patients live.

For an overview of the TB scenario in India, read Aruna Bhattacharya’s actionable ideas for TB control as she provides a summary of the situation until now, and what needs to be done in the future. 

There is some news, positive, on the treatment side. N. Ravi Kumar reports that clinical trials of Spanish tuberculosis vaccine MTBVAC began in India. Bharat Biotech is conducting the trials in partnership with Spanish biopharmaceutical company Biofabri that is responsible for clinical and industrial development of the vaccine developed in the laboratory of the University of Zaragoza with Brigitte Gicquel of the Pasteur Institute, Paris. MTBVAC is the only vaccine against tuberculosis in clinical trials based on a genetically modified form of the pathogen isolated from humans Mycobacterium tuberculosis which, unlike the BCG vaccine, contains all the antigens present in strains that infect humans. While the trials to evaluate the safety and immunogenicity of MTBVAC in India have begun, a pivotal safety, immunogenicity and efficacy trial is planned in 2025, Bharat Biotech said in an announcement coinciding with World Tuberculosis Day on March 24.

Meanwhile, an official in the State said a pilot of BCG vaccination programme for adults is to be launched in Andhra Pradesh in 12 districts this year.

As is usual, various States did their bit to observe TB day…

K. Umashanker writes on the awareness rally in Chittoor, while here is a report about how Chennai airport’s terminals lit up to raise awareness on TB.

Chennai International Airport’s terminals lit up to raise awareness for TB on March 24, 2024.

Chennai International Airport’s terminals lit up to raise awareness for TB on March 24, 2024. | Photo Credit: Velankanni Raj B.

For more news on the pharma sector, which seems to be constantly buzzing of late, let’s start with a small follow-up to the electoral bonds all the rage last week. We mentioned that some pharma companies had also been listed as benefactors for political parties, here is an elaborate story, by Vignesh Radhakrishnan and Mukunth VasudevanPharma companies that bought poll bonds faced regulatory action.

In other significant pharma news, IVI starts tech transfer of simplified oral cholera vaccine to Hyderabad-based Biological E. Seoul-headquartered non-profit organisation International Vaccine Institute (IVI) has commenced technology transfer of simplified Oral Cholera Vaccine (OCV-S) to Hyderabad-based vaccine maker Biological E. This follows a technology license agreement in November 2023. IVI said it has begun providing the technical information, know-how and materials to produce OCV-S at BE facilities. It will continue to support necessary clinical development and regulatory approvals.IVI and BE said they entered into the partnership during an unprecedented surge of cholera outbreaks worldwide and aim to increase the volume of low-cost cholera vaccine in India as well as the global public market. The technology transfer will be completed by 2025 and Biological E. will manufacture the vaccine for India and international markets, they said in a joint statement issued on March 20, 2024.

V. Geetanath also reports that the Hyderabad-based NIAB developed an indigenously made diagnostic kit to detect parasite infecting both humans and animals. Scientists at the National Institute of Animal Biotechnology (NIAB) in Gachibowli have developed a first indigenously made point-of-care diagnostic kit to detect ‘Toxoplasma gondii’ infecting both humans and animals causing chronic illness.This single test uses a chimera protein to detect T. gondii antibodies in humans and animals, and is a significant scientific breakthrough because Toxoplasma gondii is a “highly successful” intracellular parasite causing lifelong infections in humans, severe disease in foetuses and immunocompromised individuals. An infection not only results in significant reproductive losses in farm animals but also has public health implications since consumption of infected meat can facilitate zoonotic transmission, explained senior scientist Abhijit S. Deshmukh, who led the research project. The prevalence of Toxoplasma infection in farm animals like goat, sheep, cattle, and pig is estimated to be around 30-40%. For humans, the prevalence could be about 20% and if infected during pregnancy, leads to abortion, stillbirth and neonatal mortality. The disease is also fatal for immunocompromised HIV/AIDS patients. It also causes severe ocular infection at times leading to permanent vision impairment or blindness, said the scientist.

The scientists at JNCASR develop pancreas-mimicking system for responsive insulin delivery in diabetes treatment. What this means is they have developed a new silk-based hydrogel system that mimics the pancreas, notably, offering a potential breakthrough in insulin delivery for diabetes treatment. This is expected to provide a more efficient and responsive method for insulin release, addressing the challenges faced by individuals with both Type 1 and advanced stage Type 2 diabetes.

There’s no ignoring the rather massive non-communicable diseases epidemic, and now is the time to dive in. This study created quite a flutter when it was published, and for the right reasons too: a study takes a closer look at the association between MNPs and cardiovascular events. It linked microplastics with heart attacks and strokes. In a recent study published in the New England Journal of Medicine - Microplastics and Nanoplastics (MNP) in Atheromas and Cardiovascular Events, of more than 200 persons undergoing carotid endarterectomy (surgery to remove blockages in the carotid artery), 58% had a detectable amount of polyethylene in the excised carotid plaque, and 12% also had a measurable amount of polyvinyl chloride (PVC). While polyethylene is widely present as a part of food containers, bags and wrappers, PVC is commonly used to make pipes and other structural materials. While an association by no means proves causality, it is certainly very concerning that plastics are winding up in parts of your body where they certainly have no business to be present,” Sanjay Rajagopala, one of the authors of the study pointed out.

Earlier this month, the world also observed World Kidney Day, faithfully observed with rallies and meetings and awareness generation events. Here, Latha A. Kumaraswarmi and Georgi Abraham provide an extensive overview of what the situation is in India today, what is being done, and what needs to be done, in terms of diagnostics, and care. In Self love: focus on prevention to preserve and protect your kidney function. The authors first lay out the facts: As India faces innumerable challenges in providing healthcare to its 1.44 billion people, kidney disease is emerging as an illness to reckon with. The diversity of India especially with regard to socio-economic status, literacy, food habits, cultural beliefs, and access to healthcare are all important and complex issues facing the State and central governments. A total of 2,200 kidney specialists, skewed in distribution with a majority in the four (advanced) southern States and metropolitan cities leaves a critical gap in providing timely care to kidney disease patients. They also go on to discuss the multifarious causes, lack of compliance to treatments, high costs (Advancing Equitable Access to Care and Optimal Medication Practice is this year’s World Kidney Day theme), self-monitoring, and of course the message that kidney disease is common, harmful and treatable.

Primary on the list of causes that cause kidney disease is hypertension. Did you know that prehypertension affects 33.7% of the population, with varying prevalence across districts? A recent study published in the International Journal of Public Health analysed data from the National Family Health Survey (NFHS-5), on 743,067 adults aged 18–54 years. The sample consisted of 87.6% females and 12.4% males. The study indicated that prehypertension prevalence varied widely across India’s districts, with an overall rate of 33.7%, and ranging from 15.6% to 63.4%. In a sense, this also offers opportunities for the national and state NCD control programmes to pick up these people in order to initiate lifestyle changes to control and manage hypertension, in order that the country does not keep on aggrandising its already heavy NCD treatment and care burden. 

Getting on to mental health, the IMA launched a mental health helpline app for doctors and medicos. The Kerala branch of the Indian Medical Association (IMA) recently launched ‘Helping Hands’, a free help line. Expert psychiatrists will address calls between 8 a.m. and 8 p.m. every day. The contact number is 8136996048.

AI chatbots are here to help with your mental health, despite limited evidence they work. And here’s what we thought was the future, but in our present. Download the mental health chatbot Earkick and you’re greeted by a bandana-wearing panda who could easily fit into a kids’ cartoon. Start talking or typing about anxiety and the app generates the kind of comforting, sympathetic statements therapists are trained to deliver. The panda might then suggest a guided breathing exercise, ways to reframe negative thoughts or stress-management tips. It’s all part of a well-established approach used by therapists, but please don’t call it therapy, says Earkick’s co-founder Karin Andrea Stephan.

Take a note of this story by Dr. Rajeev SadanandanEliminating diseases, one region at a time, starting with the most recent, encouraging response from the guinea worm disease front. The Carter Center, a leader in the global elimination and eradication of diseases, recently reported that guinea worm disease was close to eradication. From 3.5 million cases a year in 21 countries in 1986, the number had come down to 13 in five countries in 2023, a reduction of 99.99%. This would be the second disease after smallpox to be eradicated and the first one with no known medicines or vaccines. This has created increased attention to disease elimination, the first step in eradication. Ending the epidemics of malaria, tuberculosis and Neglected Tropical Diseases by 2030 is one of the Sustainable Development Goals set by the United Nations. Elimination of transmission is challenging and resource intensive. It imposes an onerous load on the system and could lead to the neglect of other important health functions, especially for weak health systems. Therefore, disease elimination should be planned only after careful analysis of the costs and benefits and with informed political support to generate the best outcomes with the least adverse impact, the author warns.

For our tail piece section this week, well, who would have thunk so. Sneha Khedkar reports researchers who say: The way we name cancers could affect access to treatment. Traditional approaches to treating cancer – including surgery and radiation – target the organs in which the tumour is present. This practice formed the basis of classifying cancers after the organ in which they originate. But most deaths due to cancer are the result of the disease metastasising beyond the organ of origin; individuals with metastatic cancer are almost always treated systemically with drugs that enter the blood. Is there a need for change now? Experts say that oncologists spend a lot of time testing new drugs in clinical trials in a sequential manner, leading to “delay in treatment access”. With technological improvements, doctors are also able to find which genetic mutations are responsible for a tumour in many cases, and target them with drugs. All cancers from the same organ don’t always share the same mutations, and these mutations aren’t limited to cancers of a single organ.

From the Health page

If you have a few extra moments this week, do also read:

S. Vijay Kumar reports: To curb illegal trade, Health Ministry tells States to plug gaps in compiling data of organ donors.

Serena Josephine M. says :‘Timely treatment can limit disability in children with Juvenile Arthritis’

NEET PG rescheduled to June 23 due to Lok Sabha elections.

Man with rare autoimmune disorder undergoes brain bypass surgery.

Brazil’s Bolsonaro is indicted for first time over alleged falsification of his own vaccination data.

New Zealand will ban disposable e-cigarettes in a bid to prevent minors from taking up the habit.

IMA flags ‘brain drain’ of specialists to Britain’s NHS.

Centre seeks report from Punjab Government on alleged violation of IVF age limit by Sidhu Moosewala’s parents.

NASA touts space research in anti-cancer fight.

As usual, here is a collection of reports from our regional bureaus on health…

Andhra Pradesh

Nellore Sravani writes about an app that helps take care of mental health.

B. Madhu Gopal writes:Providing proper care early on can improve quality of life of Down Syndrome patients, says expert.

Karnataka

Karnataka will safeguard medical students’ interests, says official.

Shilpa Elizabeth reports: Bengaluru start-up strives to make image-guided surgeries accessible to smaller cities and towns.

Sharath S. Srivatsa explains why Karnataka has banned certain colouring agents.

Kerala

Kerala Health department withdraws circular banning doctors from indulging in social media.

C. Maya explains the resurgence of mumps in Kerala.

Attacks on healthcare professionals: Staff of Thripunithura taluk hospital in Kerala up in arms over lack of safety.

Tamil Nadu

Now, T.N. public can report infectious disease outbreaks on web portal for rapid response.

RGGGH strengthens intensive care services, adds speciality ICUs in the last few years.

Madurai Railway hospital insists on declaration from staff seeking sick leave.

Telangana

Siddharth Kumar Singh writes:Doctors sound caution over spread of scarlet fever among children in Hyderabad.

Over 17,000 National Health Mission contract employees receive overdue salaries.

Public Health Foundation of India ranked second best public health institution globally.

As always, do put us on your radar, as we bring more health content your way. Get more of The Hindu’s health coverage here.

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