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India's Tryst With Tuberculosis: A New Paradigm-BPAL Regime

Tuberculosis (TB) continues to be a major public health challenge in India, which bears the world's highest burden of the disease. Despite several government initiatives and advances in medical technology, managing TB in India is a complex task due to a variety of factors that are unique to the country's social, economic, and healthcare landscape. Here are some of the key challenges that India faces in its fight against TB:

High TB burden and drug-resistant TB

India accounts for over a quarter of the global TB cases. In 2022, there were an estimated 2.8 million TB cases in India. The sheer volume of cases makes it difficult to implement effective surveillance, diagnosis, and treatment programs across the country. Compounding this issue is the rising incidence of drug-resistant TB (DR-TB), including multidrug-resistant (MDR) and extensively drug-resistant (XDR) TB.

MDR-TB in India is increasingly common, with over 130,000 cases estimated annually.

The emergence of XDR-TB adds another layer of complexity, as these strains are resistant to nearly all available anti-TB drugs, making them more challenging and expensive to treat.

Delayed diagnosis and underreporting

Early diagnosis is critical to controlling TB, but India faces significant hurdles in this area:

Access to diagnostics: Many rural and remote areas lack proper healthcare infrastructure, limiting access to advanced diagnostic tools such as GeneXpert machines and other molecular tests that can rapidly detect TB and drug resistance.

Underreporting: Many TB cases remain undiagnosed and unreported, especially in the private healthcare sector, which caters to a large portion of India's population. Patients often go undetected, are misdiagnosed, or do not receive proper follow-up. The stigma associated with TB also discourages people from seeking timely medical attention, further contributing to underreporting.

Poor Treatment Adherence and Completion Rates

The treatment of TB, especially drug-resistant TB, requires prolonged and complex regimens. Standard TB treatment involves taking multiple antibiotics for at least 6 months, while MDR-TB treatment can take up to 18-24 months.

Non-Adherence: Due to the long treatment duration, many patients fail to complete their course of therapy, either due to side effects, social factors, or a lack of understanding of the importance of adhering to the regimen. This non-adherence increases the risk of treatment failure, relapse, and the development of drug resistance.

Healthcare infrastructure and accessibility

India's healthcare system is a blend of public and private sectors, with vast disparities between urban and rural areas. In rural regions, where nearly 70% of the population resides, healthcare facilities are often under-resourced, and access to specialized TB care is limited.

Urban-rural divide: While cities may have better healthcare services, rural areas face a scarcity of diagnostic facilities, skilled healthcare workers, and access to second-line drugs required for treating MDR-TB.

Infrastructure gaps: Many primary healthcare centers are not equipped to handle the complexity of TB management, especially when it comes to managing MDR-TB, leading to diagnostic delays and inappropriate treatments.

Stigma and social barriers

The stigma associated with TB remains one of the most significant challenges to managing the disease in India. TB is often viewed as a disease of the poor, leading to widespread discrimination.

Discrimination: Many patients face stigma in their communities, workplaces, and even within families, which can result in social isolation and reluctance to seek care.

Impact on women: TB carries a disproportionate social burden for women in India, as it affects marriage prospects, family life, and employment opportunities. Many women delay seeking treatment to avoid being stigmatized, exacerbating the spread of the disease.

Co-infection with HIV

HIV co-infection is a significant risk factor for the development of active TB. In India, HIV-TB co-infection is a growing concern, particularly because TB is the leading cause of death among people living with HIV.

Co-infection burden: An estimated 3% of TB patients in India are co-infected with HIV, and this co-morbidity poses diagnostic and therapeutic challenges, as immunocompromised individuals are more likely to progress to active TB and require more complex treatment.

Private sector involvement

A significant proportion of TB patients in India first seek treatment from private healthcare providers, which are not fully integrated into the national TB control programs.

Unregulated treatment: In the private sector, there is often unregulated and inappropriate use of antibiotics, leading to improper treatment, poor adherence, and the development of drug resistance.

Delayed notification: Many private practitioners fail to notify the government about TB cases, leading to gaps in the overall data on the disease burden and treatment outcomes.

Financial constraints

Although the Indian government provides free TB treatment through the National Tuberculosis Elimination Programme (NTEP), the indirect costs of the disease remain a heavy burden on patients, especially those from low-income backgrounds.

Loss of income: Many TB patients, especially those with MDR-TB, are unable to work during treatment, leading to financial hardships that hinder their ability to complete therapy.

Cost of diagnostics and medicines: Although treatment is free in the public sector, many patients initially seek care from the private sector, where they may incur significant costs for diagnosis and treatment.

BPaL regime

What is MDR-TB?

Multidrug-resistant tuberculosis (MDR-TB) occurs when the bacteria that cause TB develop resistance to the two most powerful anti-TB drugs: isoniazid and rifampicin. This means that standard treatments no longer work, making MDR-TB far more challenging to cure. Patients with MDR-TB must undergo a long and complex treatment involving multiple drugs, often leading to severe side effects and poor adherence.

What is the BPaL regimen?

The BPaL regimen is a newly developed treatment specifically designed to combat MDR-TB. It consists of three drugs:

Bedaquiline (B): A new anti-TB drug that targets the bacteria's energy production, weakening and killing the bacteria.

Pretomanid (Pa): A drug that attacks the bacteria's cell wall and DNA, stopping its growth and leading to cell death.

Linezolid (L): A powerful antibiotic that blocks protein synthesis in the bacteria, preventing them from multiplying.

Together, these drugs work in synergy to provide a highly effective treatment for patients with MDR-TB, including those with extensively drug-resistant TB (XDR-TB).

Why is the BPaL regimen important for India?

India has one of the highest burdens of TB in the world, and drug-resistant TB is a growing challenge. Traditional treatment regimens for MDR-TB are long, lasting up to 24 months, and involve a complex mix of drugs with severe side effects. Many patients struggle to complete these treatments, leading to incomplete cures, further resistance, and spread of the disease.

The BPaL regimen is a game changer for several reasons:

Shorter duration: The BPaL regimen lasts only 6 months, compared to the traditional MDR-TB treatments that take up to 2 years. A shorter treatment duration makes it easier for patients to complete their therapy, increasing the chances of cure.

Fewer drugs: Older MDR-TB regimens require patients to take multiple drugs daily, often leading to difficult side effects such as nausea, hearing loss, and kidney damage. The BPaL regimen involves just three drugs, making it more manageable and less toxic for patients.

Higher cure rates: In clinical trials, the BPaL regimen has demonstrated cure rates of around 90%, which is significantly higher than those seen with older MDR-TB treatments. This means that more patients have a better chance of successfully overcoming MDR-TB.

Addresses XDR-TB: Extensively drug-resistant TB (XDR-TB) is an even more severe form of TB that is resistant to many of the most effective drugs. The BPaL regimen offers a powerful option for treating XDR-TB, a crucial step forward in fighting the disease.

The impact of BPaL on public health in India

Implementing the BPaL regimen widely in India could have a transformative effect on the country's efforts to control TB. By providing a shorter, more effective treatment for MDR-TB, BPaL can help reduce transmission rates, as patients who are cured more quickly are less likely to spread the disease. Moreover, improving treatment outcomes for MDR-TB patients will help prevent the development of more severe forms of drug-resistant TB.

Challenges to overcome

While the BPaL regimen shows great promise, there are challenges that must be addressed for it to have a widespread impact:

Cost: The newer drugs in the BPaL regimen, particularly bedaquiline and pretomanid, are more expensive than traditional TB drugs, posing a barrier to accessibility in low-resource settings.

Access: Ensuring that patients across India, particularly in rural areas, have access to the BPaL regimen will require strong government support, partnerships with health organizations, and an efficient supply chain.

The way forward

For India to make significant progress in the fight against TB, it is critical to embrace innovations like the BPaL regimen. Continued investment in TB control programs, improved diagnostics, and expanded access to effective treatments will be essential. Public awareness campaigns must also educate communities on the importance of completing TB treatment to prevent the spread of drug-resistant strains.

In conclusion, the BPaL regimen offers a vital opportunity to improve the treatment of drug-resistant TB in India. Its shorter duration, higher efficacy, and ability to treat even the most resistant strains of TB make it a crucial tool in the battle against this deadly disease. By making the BPaL regimen widely available, India can take a major step toward controlling and eventually eradicating TB.

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Disclaimer

Views expressed above are the author's own.

END OF ARTICLE

County Reports Three Non-Connected TB Exposures

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The County's Tuberculosis Control Program is working in close collaboration with the University of California San Diego, Sweetwater Union High School District and the San Diego County Sheriff's Office to notify people who have been potentially exposed to tuberculosis (TB) in unrelated potential exposures at different sites during different time periods. 

Tuberculosis rates in San Diego, California, and the United States, have been rising since 2020.  

At UC San Diego, the County is working with university officials to notify students, employees and contractors potentially exposed to TB at UC San Diego's La Jolla campus during the 2023-24 school year. The school is located at 9500 Gilman Drive in La Jolla. The dates of potential exposure are from July 1, 2023 to March 20, 2024.

The County is also working with Sweetwater Union High School District to notify residents, employees, and volunteers potentially exposed to TB at Chula Vista High School at 820 Fourth Ave. In Chula Vista. The dates of potential exposure are from Feb. 23, 2024, to May 22, 2024.   

At the East Mesa Reentry Facility, the County Tuberculosis Control Program is working with San Diego County Sheriff's Office to notify people potentially exposed from Jan. 2, 2024 to June 5, 2024. 

The diagnosis of tuberculosis can be difficult to establish, and people with TB may be sick for many months before they are diagnosed. As such, periods of exposure can be long. Exposures can be complex and require extensive planning and coordination between sites of exposure and the County TB program. 

TB is an airborne disease that is transmitted from person-to-person through inhalation of the bacteria from the air. The bacteria are spread when someone sick with TB coughs, speaks, sings or breathes. People with frequent and prolonged indoor exposure to a person who is sick with TB should get tested.  

Effective treatments are available to cure people who are sick from active TB. It is especially important for people with symptoms of active TB and those who are immune compromised to see a medical provider to rule out active TB disease and to discuss treatment.  

"Symptoms of active TB include persistent cough, fever, night sweats, and unexplained weight loss," said Ankita Kadakia, M.D., County Interim Public Health Officer. "Most people who become infected after exposure to tuberculosis do not get sick right away. This is called latent TB infection. Some who become infected with tuberculosis will become ill in the future, sometimes even years later, if their latent TB infection is not treated. For people who think they may have been exposed, blood tests and skin tests are an effective way to determine an infection." 

People who test positive for TB but who don't have symptoms of an active disease should get a chest x-ray and talk to a medical provider, as they most likely have a latent TB infection. People in this situation are infected with TB, but the infection is essentially dormant or "sleeping." Taking medicines for latent TB infection can cure the infection and keep these people from getting sick later.  

The number of people diagnosed with active TB in San Diego County had decreased since the early 1990s when more than 400 cases were reported annually. After decades of declining, TB cases have begun to rise since 2020. 

In 2020, there were 193 TB cases, 201 in 2021 and 208 in 2022. In 2023, a total of 243 people were reported with active TB disease in San Diego County. The 17 percent increase in 2023 brought the County back to pre-pandemic levels.  

An estimated 175,000 people in San Diego County have latent TB infection. Of these, 5 to 10 percent are at risk for developing active TB disease if they go without preventive treatment.   

People who would like more information on this potential exposure should call the County Tuberculosis Control Program at (619) 692-8621. 

Expert Calls For Gender-sensitive Approach To Tackle Tuberculosis

Nigeria's struggle with tuberculosis (TB) continues, with the country ranking among the top 10 globally in terms of TB burden.

Expert at a 2-day capacity-strengthening workshop noted that a gender-sensitive approach is crucial to addressing the disease's disproportionate impact on men.

The workshop which concentrated on health reporting, with a special focus on Tuberculosis in Nigeria, was organised by The Light Consortium with support from other partners

"The TB burden in Nigeria is a complex issue, and we need to tackle it from multiple angles," said Toyosi Adekeye, Associate Professor in the Department of Community Medicine and Primary Health Care at Bingham University, Zankli Research Centre, Karu, Nasarawa state.

Adekeye who is also a Research Uptake Manager at the Light Consortium, said the research shows that men are more likely to be affected by TB, but they are also less likely to seek care.

"We need to design policies and programs that take into account men's health-seeking behavior and address the social determinants of health that affect them."

Adekeye emphasized the importance of understanding the gender dynamics of TB in Nigeria. "Men's health-seeking behavior is shaped by societal norms and expectations, leading them to prioritize work and income over health. We need to develop innovative strategies to reach men and encourage them to seek TB care."

The Light Consortium, a research organization focused on addressing health disparities, has been working closely with the Nigerian government to develop gender-sensitive TB policies and programs.

"We are committed to supporting the Nigerian government in its efforts to reduce the TB burden," said Adekeye. "By working together, we can make a significant impact and improve the health and well-being of all Nigerians."

The Nigerian government has acknowledged the need for a gender-sensitive approach to TB and has begun to implement policies and programs aimed at increasing men's access to TB care. However, experts say more needs to be done to address the root causes of the disease.

As Nigeria continues to grapple with the challenges of TB, experts like Adekeye remain hopeful that a gender-sensitive approach can make a difference.

"We have the knowledge and expertise to tackle TB in Nigeria. Now, we need the political will and commitment to make it happen," Adekeye said.

NIGERIAN TRIBUNE

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