New technologies also focus on maintaining drug adherence—ensuring patients stay the course of treatment, since failing to do so is the main source of drug resistance.
By Angela Chaudhuri & Rhea John
Tuberculosis (TB) is no ordinary disease. It emanates a level of fear that goes beyond the usual concerns of morbidity. The strong social stigma associated with TB envelopes not only those affected, but their entire family. Getting TB is often connected to factors that themselves create stigma, including HIV, poverty, drug and alcohol misuse, homelessness, and incarceration. However, superstitions also play a role—for instance, women are blamed as the source of TB and abandoned by families or considered unworthy of marriage.
The stigma and myths around TB, which is preventable and treatable, contributes to delays in diagnosis and negatively impacts treatment compliance. When this happens, the country’s burden of disease grows, with severe social and economic impact for all of us.
So, how is India handling the 28 lakh TB-affected people and many thousands more that remain undiagnosed? Health minister JP Nadda launched an ambitious programme on World TB Day 2017 “to eliminate TB deaths” by 2025. This road to elimination is long and fraught with challenges, but technology is being harnessed and leveraged to give the TB response a big boost. “Digital technologies can catapult the TB response to the next level,” suggested Mario Raviglione, who was the Director of the WHO Global TB Programme. India is closer now than ever before towards ending TB.
The TB Innovation Summit in New York on September 24, 2018, created a lot of excitement around the future of TB treatment—“It might actually be over by 2025!”—with news of new drugs, and even possibly the long-awaited TB vaccine. This excitement comes from the experience of the last decade, when a series of innovations revolutionised TB response, including GeneXpert, the new TB drugs bedaquiline and delamanid, and wirelessly observed treatment (like DOTS).
Dr Neerja Arora of the Challenge TB project finds the political will is strong and it has applied a “do what it takes” mindset when it comes to prevention and response to TB, and particularly the dangerous rise of drug-resistant TB. To detect the cases of drug-resistant TB that require this breakthrough treatment, the Indian government has invested in GeneXpert (CB-NAAT) and Line Probe Assay (LPA)—tests that allow different types of drug-resistant TB to be identified quickly and correctly. The government has 1,180 CB-NAAT machines and 51 labs equipped for second-line LPA across the country. In Arora’s words, “The new diagnostics have proved to be a game-changer for promptly picking up the patterns of resistance to different TB drugs and identifying patients who are eligible for different regimens for treatment of drug-resistant TB, with or without use of new drugs, thereby improving chances of better treatment outcomes.”
The team at the Foundation for Innovative New Diagnostics (FIND) showed that the miracle machine GeneXpert might be the solution to diagnosing paediatric TB. This solves a long-standing problem. Dr Sanjay Sarin of FIND noted, “TB diagnosis in children is complicated due to challenges associated with sample collection and poor sensitivity of tests, like the AFB sputum smear. Outcomes from this study facilitated a policy decision from the Revised National Tuberculosis Control Programme (RNTCP) on use of GeneXpert for diagnosing TB in children.” GeneXpert is three times as effective as sputum (phlegm-based) tests, and has a quick turnaround time for receiving results (90% of the results are available in less than 24 hours). This is critical for children, for whom delays in diagnosis are usually longer, and more dangerous, than for adults.
The International Union against Tuberculosis and Lung Disease (The Union) is providing technical assistance on another exciting shift in diagnostics: mobile X-ray van. On average, someone with symptoms of TB takes one-and-a-half months to get diagnosed, mainly because very few smaller primary health centres (PHCs) have X-ray machines, and only half the TB cases are detected through the usual sputum test. The other half (patients who go undiagnosed) can infect others and even succumb to the infection. Under Mission TB-Free Haryana, a collaboration between the Haryana government, Medanta hospital, Central TB Division and The Union, mobile X-ray vans travel the last mile to PHCs, and share X-rays with Medanta radiologists over WhatsApp for a quick diagnosis. So far, with just two vans, this project has identified 1,100 missed cases of TB since 2015.
A challenge in TB diagnosis is that many people are left undiagnosed because their sputum doesn’t even reach the labs. Last month, the health ministry launched a pilot project that uses services of the Department of Posts to transport sputum specimens for diagnosis in Karawal Nagar, Delhi. Once diagnosed, patients are registered and tracked through the Nikshay portal, the government’s web-based portal for registration. The upcoming upgrade of Nikshay is slated to allow treatment outcomes—including recovery, mortality and relapse—to be monitored in real-time.
Drug-resistant TB is on the rise and new drugs like bedaquiline and delamanid are still undergoing clinical trials. Yet, to ensure that access to treatment is not denied in the meantime to patients with drug-resistant TB, a strong drug safety monitoring mechanism is being put in place by RNTCP and Challenge TB. This mechanism allows those administering these drugs to screen for warning signs and prevent adverse reactions. From six sites, the project has scaled up to 21 sites, including in Delhi and Mumbai.
New technologies also focus on maintaining drug adherence—ensuring patients stay the course of treatment, since failing to do so is the main source of drug resistance. Drug side-effects, access to confusing medications, and the long treatment regimen are the causes for patients dropping out from the treatment, making the disease worse. Simple yet innovative tools like 99DOTS are making big waves, where a patient receives a phone number in the blister pack under each pill, and gives a missed call to that number noting that the pill was taken. Free dial-in adherence counsellors are also available through this innovation.
But despite these innovations, technology cannot replace human interface. REACH, a Chennai-based organisation, sees TB survivors as the best voice of what it’s like to have TB, and works to help them become effective advocates and champions. REACH has built networks of survivors across India, to make the survivor’s voice heard from panchayat to ministry level. These ‘TB Champions’ support those undergoing treatment or seeking diagnosis, and tackle stigma head-on by speaking about their experience with their communities. Dr Anupama Srinivasan from REACH tells us the biggest eye-opener is that TB Champions, despite the stigma, are enthusiastic to come forward and help turn the tide on TB.
There are more innovations aiming to end TB in India, some in design phase, others in pilot and a few ready to scale. But with innovation must come investment. Both public and private sectors need to invest and do so wisely to eliminate TB. Delays and inaction will be costly.
Chaudhuri, an international public health expert, is Director, Swasti Health Catalyst. John works on research communications at Swasti Health Catalyst