Exclusive interview with Dr. Madhukar Pai, MD, PhD

TB kills more people today than HIV and malaria combined. In 2015, there were an estimated 10 million new TB cases worldwide and 1.8 million TB deaths. And India is the epicenter of this global epidemic!

India accounts for 27% of the world’s 10.4 million new TB cases, and 29% of the 1 million TB deaths globally. India also accounts for 16% of the estimated 480,000 new cases of multidrug-resistant TB. So, yes, we should all be worried about TB. It is, after all, an airborne infection that anyone can contract. Increasingly resistant patterns of TB have been reported, especially it seems, from Maharashtra.

Since the results of the national drug-resistance survey is not yet available, nobody knows the actual number of drug-resistant TB cases in India. WHO estimates that India had about 80,000 cases of drug-resistance TB during 2015.

But there are clear signs that severe forms of drug resistance have emerged, at least in some hot spots such as Mumbai. The most common form of drug-resistant TB in India is multi-drug resistant TB (MDR-TB), which refers to TB that is resistant to isoniazid and rifampicin, two of the most important first-line antibiotics. While MDR-TB is severe enough, hospitals in Mumbai have reported even worse forms of drug-resistance – what they called ‘totally drug-resistant tuberculosis’ (TDR-TB) – suggesting that this form of TB was incurable because of resistance to all the TB drugs tested.

Drug-resistance is a sign that quality of TB care is suboptimal. Indeed, several studies show complex care seeking pathways, long delays in diagnosis, under-use of microbiological tests widespread empirical management, and poor adherence to TB standards. Thus, poor quality of care, in both public and private sectors, increases the risk of drug-resistance and mortality. Persons with TB must take medications without stopping. Otherwise, TB bacteria can become resistant to the common, first-line drugs that are used. This usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs. Drug-resistance can also emerge when the supply of drugs is not continuous; or when poor quality drugs are used.

It is worth comparing China’s TB situation with that of India. China had 0.9 million TB cases in 2015, while India had over 2.8 million. The number of drug-resistant TB cases in China was 57,000 while India was estimated to have over 79,000. TB is no longer a major killer of people in China and does not make the top 10 most important causes of death.

It is remarkable that China more than halved its TB prevalence over the last 20 years. Marked improvement in quality of TB treatment, driven by a major shift in treatment from hospitals to the China CDC public health centers (that implemented the DOTS strategy) was likely responsible for this effect, which has been demonstrated by repeated national TB prevalence surveys.

India needs to go beyond ‘coverage’ of TB services, and work hard to improve ‘quality’ of TB care, in both public and private sectors.

Enormous quantities of anti-TB drugs are used in the private sector, underscoring their importance and scale. India’s TB control program must begin to recognize the role of the private sector and start engaging with it more meaningfully.

Although implementation of the RNTCP resulted in an increase in patients seeking care in public facilities, several patients still initially seek care in the private and/or informal sector or get bounced between the private and public sectors. India is conducting pilot projects with Private Provider Interface Agencies in Mehsana, Mumbai and Patna and have shown that notifications from the private sector can be dramatically increased, with improvements in quality and patient outcomes.

So, lessons from these projects can be used to develop a comprehensive plan to engage with the private sector to improve quality of care, and better regulate this sector. The new NSP does a great job of outlining such a vision. I hope funding will follow.

We recently published the first simulated patient (mystery client) study to understand how pharmacies in three Indian cities treated patients presenting with TB symptoms or diagnoses and to determine whether these pharmacies were contributing to the inappropriate use of antibiotics.

We showed that pharmacies frequently dispensed antibiotics to simulated patients who presented with typical TB symptoms, and they rarely referred persons with classic TB symptoms to doctors (and this can delay the diagnosis of TB). However, none of the pharmacies dispensed first-line anti-tuberculosis drugs (which is good news).

The use of all antibiotics and steroids (which can be harmful to individuals who actually have TB), as well as the total number of medicines given, decreased sharply when the pharmacy staff decided to refer the patient to a doctor, which was far more commonly done when the patient presented with a lab test confirming TB, thus making the diagnosis apparent to the pharmacist. These findings can inform interventions to engage pharmacies in TB control and initiatives to improve protect antibiotics from misuse. With nearly 800,000 chemists in every corner of India, we absolutely must harness them for identifying people with suspected TB and get them linked to testing.

The Government of India announced its plan to eliminate tuberculosis (TB) by 2025 during the Union Budget address last month. The declaration is extraordinarily ambitious. Last month, the RNTCP also published a draft of a new National Strategic Plan (NSP) for TB Elimination 2017-2025.

This plan is very bold, progressive and comprehensive. There are clear plans to address gaps in the cascade of care. While I am excited to see the high-level political commitment and an ambitious NSP, my biggest concern is how India can go from rhetoric to real progress? Historically, India has promised a lot in this area, but not delivered because of poor investment and weak implementation. The best summary of this is in Sujatha Rao’s new book “Do we care?”.

The new NSP, if approved, funded, and fully implemented might be a game change in the fight against TB in India. It is extraordinarily ambitious and quite comprehensive. But the price tag is steep – The cost of implementing the new NSP is estimated at USD 2.5 billion, a steep increase over the current budget. Historically, despite being a highly cost-effective program, and despite having a high absorptive capacity, RNTCP has struggled to receive funding that is commensurate with the scale of India’s epidemic.

This simply cannot continue. India has to start backing its ambitions with dollars. Only then can India realize its potential to take the lead on TB elimination.

I am sure patients with pulmonary TB struggle to breathe in highly polluted cities, but I don’t have a clear answer on the type or magnitude of the effect. We know smoking and indoor air pollution are both associated with TB. But there is not a lot of evidence on how outdoor air pollution affects TB. I think this is a great area for research.

There is definitely great potential for mHealth and ICT tools to leap-frog some big traditional barriers. We are already seeing signs of this in the private sector pilot projects in India.