‘India must fully fund and implement the new National Strategic Plan for TB elimination’

“Without substantial investments, it will be very challenging for a country like India to eliminate TB by 2025. India has a bold new National Strategic Plan (NSP) in place, and government should fund and implement it without delay. It should also focus on making new diagnostics, drugs and vaccines for TB,” says Dr Madhukar Pai, Director McGill Global Health Programs. Dr Madhu Pai also serves on the STAG-TB committee of World Health Organisation

India must fully fund and implement the new National Strategic Plan for TB elimination

India has the highest burden of TB. As many as 2.8 million new TB cases were estimated in India in 2015. In fact, India accounts for 27% of the world’s 10.4 million new TB cases, and 29% of the 1.8 million TB deaths globally. India also accounts for 16% of the estimated 4,80,000 new cases of multidrug-resistant TB. A recent Lancet journal report states that, in 2015, about 2,39,000 children died to TB globally. Out of which, India accounted for the largest number (over 60,000) of childhood TB deaths.

The Indian government has approved a National Strategic Plan to Eliminate TB (2017 – 2025). Is Indian government doing enough? Can India eliminate TB by 2025? My Medical Mantra spoke exclusively to Dr Madhukar Pai. Dr Pai’s research is mainly focused on improving the diagnosis and treatment of tuberculosis, especially in high-burden countries like India and South Africa.

MMM – Do you think that India can eliminate TB by 2025?

Dr Madhu Pai: I don’t think so. Year 2025 is just not realistic. It will be very challenging for India, with a massive TB burden, to eliminate TB in just 8 years. On the other hand, the new National Strategic Plan of the Indian government does show high-level political commitment and a serious intent. If the new NSP is well funded and implemented, then I think by 2025, we would achieve much more progress in eliminating TB.

MMM: What Indian government should do to achieve the TB elimination target?  

Dr Madhu Pai: The best plan has already been put forward — the National Strategic Plan to Eliminate TB (2017 – 2025). The plan is bold, ambitious and quite comprehensive. But, the biggest concern, I have, is will the government of India follow-up on such a good plan, with the budget required, which is substantial. I hope India will implement this plan without much delay, so that we can make good progress towards TB elimination.

MMM: Over 2,39,000 children died globally due to TB in 2015, out of which 80% were under the age of 5. Over 60,000 children in India die due to TB each year. How to tackle this?

Dr Madhu Pai: We know that India has high burden of TB in adults and children are infected by adults suffering with TB. India should improve the diagnosis of TB, both for adults and children. Tests like GeneXpert must be made widely more available than it is today. I don’t think India will eliminate TB with the 100-year-old sputum smear technology; we need much more sensitive tools and need much faster detection of drug resistance.

However, the good news is that, India has started making better TB diagnostics freely accessible to children, in both public and private sectors in 9 major cities of India, supported by RNTCP, FIND and USAID. Data from that project clearly shows that GeneXpert is a far superior test in children than smears, and it also helps pick up substantially higher numbers of children with drug-resistance (which causes deaths).

India must fully fund and implement the new National Strategic Plan for TB elimination
Dr Madhu Pai

MMM: What is your opinion on current TB treatment in India?

Dr Madhu Pai: India needs to quickly shift to daily regimens on a national scale. Fixed dose combinations along with adherence monitoring interventions like 99 DOTS, smart pill boxes, information-communication technology (ICT) and call centres to support patients and help them complete therapy. Also, new drugs like bedaquiline and delamanid are here, but access to them is very poor in India. India needs to conduct clinical trials for new drugs regimens, which are shorter and much better what we have today. I am happy that a new consortium has been formed, the India TB Research Consortium, led by ICMR. The ITRC is very well placed to take on clinical trials of new regimens, and work is already underway to do that.

MMM: Is Poverty and malnutrition is the biggest cause of TB in India?      

Dr Madhu Pai: Malnutrition is the biggest driver of the TB epidemic in India. TB is a disease of poverty. So, the social determinants must be tackled if India has to make serious progress in TB control. Diabetes is one of the emerging risk factors for TB. In the short term, we need to improve diagnose and treatment of TB. In the long term, we need to address the social determinants.

MMM: What is India’s strength? How can we leverage those in fight against TB?

Dr Madhu Pai: India has a good and long history of research in TB. India helped develop the DOTS strategy for TB control. So, India should leverage its research strengths, along with our strengths in the area of IT and pharmaceuticals. India is the world’s largest producer of generic drugs, so India could take a lead in making affordable drugs for TB, and also do R&D for new diagnostics and vaccines.