G20 summit: India's fight against TB will figure in Hamburg meet
Prime Minister Narendra Modi will be in Hamburg this weekend for the G20 Summit 2017.
This year’s G20 summit is special. For the first time ever, global health has made it to its agenda. It will be one of the prime developmental topics to be discussed by world leaders, in addition to economic and political issues.
Ahead of this event, the G20 health ministers had grouped in Berlin in mid-May. India’s health minister JP Nadda met his international counterparts to negotiate and finalise a set of common goals and practices to promote health under the Berlin Declaration. After all, health is now a collective responsibility.
In today’s inter-connected world, it takes a single flight for an infectious disease to be transmitted from one part of the globe to the other. With growing evidence of antibiotic-resistance the situation has turned alarming. The destructive toll of this phenomenon is predicted to grow 14-fold within three decades.
TB, world’s deadliest disease, should finally get the attention
The United Nations has declared antibiotic-resistant superbugs as the biggest threat to our civilisation. In Berlin, the G20 health ministers reaffirmed the seriousness and urgency of the problem, agreeing to collectively tackle it.
For example, the current decade has seen tuberculosis (TB) bacteria manifesting itself in several forms of multi-drug resistant species in patients, elevating the treatment challenge manifolds. Being airborne, the risk of its spread is alarming.
The combat approach against drug-resistance, therefore, would necessarily have to be designed with TB control at the centre of this joint front.
Countries have been too slow in tackling TB
By the time, the G20 leaders would collect at the Convention Centre on Friday (July 7) morning, 900,000 people would have died of TB the world over since the beginning of 2017. And a third of those would be Indians.
What a shame that a disease of ancient times continue its curse on the planet. A disease that is easy to diagnose, is treatable, yet it kills millions year after year. Simply because TB remains undiagnosed among 40 per cent people. In 2014, the World Health Organisation set the year 2030 as a target to end TB. Countries with high prevalence of TB have been working towards it. Yet, the progress is slow.
Two organisations that have been working relentlessly for the cause for years – the Stop TB Partnership and Medecins Sans Frontieres (MSF) – joined hands in 2014 to track performance of high-disease burden countries on TB control policies and implementation effectiveness. Through an extensive annual survey, they have been jointly producing "Out of Step" reports since 2014.
The report presents a rating grid for the participating countries on a series of common parameters, with valuable insights on causal factors of non-performance and inadequacies. The results adjudge the degree of progress on TB control, while highlighting the infrastructural or policy gaps per country.
The Out of Step report for 2017 was released this morning. The results are insightful and grim. "This year, we reviewed TB policies and practices in 29 countries, which account for 82 per cent of the global TB burden. It is clear that countries are still not tackling TB effectively. All of them can do much more to prevent, diagnose, treat and cure people affected by TB," says Dr Lucica Ditiu, executive director of The Stop TB Partnership.
“We’ve released the report two days ahead of the summit to call upon on the G20 leaders to wake up and do something to stop the unnecessary deaths and the spread of TB, including drug-resistant TB. About 54 per cent of the 10.4 million people living with TB in the world reside in countries represented at the G20 summit.”
As an immediate follow-up action to the report release, a campaign is launched by the MSF and the Stop TB Partnership to urge governments to pull their TB policies and practices in line with WHO recommendations. Precise and powerful, it couldn’t have been named better: #StepUpforTB.
India needs to step up
India’s action against TB will have a significant bearing on rest of the world. It carries a disproportionately high share of TB’s global disease burden.
In February this year, finance minister Arun Jaitley advanced India’s resolve to eliminate TB, the new deadline being 2025. This was a welcome announcement, but one that cannot unfortunately be taken at its face value.
Here is how India has fared against other countries in adoption of the WHO-recommended policies and practices across the five main parameters covered by the Out of Step 2017 survey:
TB diagnosis
● Out of Step Rating: Inadequate
● Comparative position: 15 countries have introduced the WHO-recommended test (Xpert MTB/RIF) as the initial test for TB. India is amongst the group that hasn’t. The test is available in India and is selectively recommended for high-risk patients only.
● Gap: In common practice, symptomatic diagnosis or that by the age-old technique of blood-smear microscopy prevail as the basis to establish TB in India. Patients suspected for drug-resistance are referred to specialised laboratories using culture techniques, but not widely. India has an expansive lab network, enough to cover three-fourths of the population. There is still a long way to upgrade them to house the Xpert MTB/RIFmachines that detect drug-resistant forms of TB within two hours. Currently, India has 735 planned installations, and a committed increase to take the number up to 1019.
● Challenge: Diagnosis is the weakest link in India’s TB scenario. As Dr Madhukar Pai, a passionate TB activist and associate director, McGill International TB Centre of Canada, puts it, “The Out of Step report clearly shows that India is not doing well on TB diagnosis with major issues in both public and private sectors. In the public sector, India is still relying too heavily on the antiquated smear microscopy (which can miss half of all TB cases and not detect drug-resistance)."
In the private sector, she goes on to say, healthcare providers manage empirically with broad-spectrum antibiotics and rarely test for TB, even when patients present with classic symptoms. All of this means that patients are diagnosed after nearly a delay of two months, and after having seen at least three different care providers. India must urgently upgrade its TB testing services in the RNTCP, rapidly scale-up the use of molecular tests, and engage the private sector to ensure better care of patients via public-private models.
TB Treatment
● Out of Step Rating: Inadequate
● Comparative position: Of the two modern drugs recommended by the WHO — bedaquiline and delamanid, India is not among the 11 countries, who have approved both options. India’s national guideline includes bedaquiline only. Also, India is not among the list of 13, which have adopted the shortened treatment regimen for multi-drug resistant TB (MDR-TB). Child-and caregiver-friendly pediatric fixed dose combinations are approved in India.
● Gap: A high level of inconsistency exists in the prescription behaviour of doctors across India. Also, India still follows the intermittent-dosing regimen instead of the recommended daily-dose regimen. Access to bedaquiline is restricted and limited, as was evident in the recent case of a teen-aged TB patient.
● Challenge: A very tiny fraction of doctors in India is trained to prescribe the standard of care treatment for TB, as shown in a 2010 study led by Dr Zarir Udwadia in Mumbai. In a group of 106 general practitioners, the study landed with 63 different types of drug prescriptions, revealing a strong tendency to "over-treat". This has led to the emergence of Tb superbugs — from being multi-drug resistant (MDR) to becoming extensively drug resistant (XDR), and now totally drug resistant (TDR) species.
Models of Care
● Out of Step Rating: Meets policy requirements
● Comparative position: India is in the list of 20 countries, wherein treatment for TB (both drug-resistant and drug-sensitive type) is accessible to patient at a primary health care centre.
Medicines regulatory environment
● Out of Step Rating: Inadequate
● Comparative position: India is one of the 21 countries that allow accelerated regulatory approvals. However, 100 per cent quality assurance is not guaranteed as unregistered medicine is legally available.
● Gap and challenge: Sub-optimal quality of medicines will break the treatment drive. In a study, it was found that 10 per cent of TB medicines dispensed through pharmacies were spurious.
I had earlier detailed the enormity and complexity of TB’s burden in India, and raised alarm at the consistent trend of India’s TB control budget being slashed by 40-50 per cent since 2013.
Worryingly, the 2017 budget for India’s revised action plan for TB control (National Strategic Plan) was slashed yet again, by 25 per cent in May. India urgently needs Xpert machine installations for improved and fool-proof diagnosis. The budget cuts may have an impact on procurement of these expensive machines and test cartridges.
Another process layer was introduced for the patients — having an Aadhaar card has been made mandatory for patients to claim cash assistance sanctioned under the National Strategic Plan.
Looking at the above results of the Out of Step 2017 survey, will the ruling government have a change of mind on the above? Well, only time will tell.
When asked what message would the Stop TB Partnership like to pass on to India’s prime minister to step up India's TB control programme, Dr Lucica Ditiu said, "India’s strong vision and commitment to end TB is commendable. The government must continue to support it with adequate resources and support, and keep it on utmost priority. The world is waiting for the most inspirational case study on TB elimination to emerge — let India be that shining example."