Solving the challenge of drug-resistant TB in India

During the recent Maharashtra assembly session, questions were raised about the rising tuberculosis (TB) cases. Rightly, the discussion also revolved around the need to counter the mounting challenge of drug-resistant TB. While I am relieved to see this matter being raised among our leaders, as a practicing chest physician, drug-resistant TB admittedly gives me sleepless nights.

The difference between drug-susceptible and drug-resistant TB is in the name: One is susceptible to regular treatment regimens, while, in the other, the bacteria has become resistant and unresponsive to one or more of the commonly used anti-TB drugs. In such a scenario, the patient must be put on different and more potent, and until recently more toxic drugs. Despite TB being a millennia-old problem, while the developed world addressed the social determinants contributing to its spread, people in developing countries like India, continue to fall needlessly prey to the disease and its newer harder to treat forms. The current treatment options available to us in India are limited; many come with severe side effects like severe peripheral neuropathy (i.e., nerve damage affecting mobility), pink to black brown discoloration of skin lasting up to three years, and potentially even psychosis, making it an extremely difficult, and at times hopeless journey for the patient, their families and treating physicians.

After a 50-year dry spell, the scientific community discovered bedaquiline in 2012 which now forms part of several new drug regimens that have greatly improved treatment success rates. The more recent introduction of a new drug, pretomanid has proven to be a game changer and infused hope among millions across the globe. In December 2022, the World Health Organization (WHO) recommended the use of BPaL regimen (bedaquiline, pretomanid, linezolid) (used with a fourth drug, moxifloxacin, for certain cases) in drug-resistant TB patients – considering its high success rates of 89% compared to the 52% success rates with current standard of care regimens. Now, with just three to four daily pills, patients can complete their treatment in just six months as opposed to nine-11 or 18-24 month-long treatment options currently provided in many countries, including in India. BPaL is a much safer, shorter, simpler, and cost-effective regimen that makes it easier for patients to complete their treatment.

In 2022, I was part of a government-run clinical trial to test the efficacy of the BPaL regimen. A young woman with drug-resistant TB visited my clinic then and I was able to provide this new regimen to her under the trial circumstances. To my great relief, in just six months she was disease free. The joy and relief that she and her family felt is something I wish I could give to more people. Compare this to her brother’s ordeal who did not have access to this regimen and took 24 months to recover from the same disease. Based on the evidence at hand, therefore, access to the BPaL regimen needs to be scaled up; it should be included in the national treatment guidelines and implemented in India, like many other countries. The WHO itself stated in 2022 “We now call for urgent action by national TB programmes and partners in rapidly transitioning to the new drug-resistant TB treatment regimen.’’

Last year, the Parliamentary Standing Committee on Health too noted the “significant challenge posed by drug resistant TB” and highlighted the importance of early diagnosis and the need to “expedite the scale up” of newer, safer and shorter regimens for treating various forms of TB. We have made tremendous progress in our fight against this great enemy; however, the battle is far from over. Apart from the new regimens against drug-resistant TB, we clearly need to ensure there is widespread access to modern rapid diagnostic tools, that we invest in developing quick point-of-care tests (we did it for Covid in a matter of months), and that we tackle the socio-determinants that contribute to people falling sick with TB (like undernutrition) more proactively.

Collective efforts from the government, from scientists, from physicians and the community, are the only way we can win our victories on each of these battlefronts, and thus, the only way we can win the war and become TB-free.

This article is authored by Dr Vikas Oswal, pulmonologist and TB specialist, Mumbail.