“Shorter regimens to treat tuberculosis should be made available to everyone in India. In particular, it is amazing to have a 6-month, oral treatment for drug-resistant TB. This means, we can put an end to painful, toxic 24-month regimens for DR-TB which include injectable drugs. I would like to see all injectable drug regimens phased out,” Prof Madhukar Pai, Canada Research Chair in Epidemiology and Global Health at McGill University, Montreal, who is one of the key speakers at the virtual 53rd Union World Conference on Lung Health that began on Tuesday, told The Indian Express.
The world conference on lung health (Nov 8-11) is taking place against the backdrop of global TB and Covid-19 pandemic. What are your major concerns?
Until the Covid-19 pandemic, tuberculosis was the world’s leading infectious killer. In the past two years, Covid-19 took over the number one spot. Now, both TB and Covid-19 are syndemic, respiratory infections and pose a huge threat together. The 2022 WHO Global TB Report, released last month, shows that both TB deaths and TB incidence increased during 2021. To make matters worse, the burden of drug-resistant TB (DR-TB) also increased by 3% between 2020 and 2021. So, I expect this year’s TB conference to have a lot of content on how the Covid-19 pandemic has eroded many years of progress in TB control, and what we can do to reverse the negative trend.
Covid pandemic has been challenging especially as India has set a goal to end TB. What actions are required?
India has set ambitious goals to end TB and there is a lot of political commitment from the Indian government. According to the WHO report, in 2021, an estimated 10.6 million people fell ill with TB. India accounted for 28% of the 10.6 million new TB cases. The incidence rate globally rose by 3.6% between 2020 and 2021, reversing declines of about 2% per year for most of the past two decades. During the pandemic, TB case notifications decreased globally and India had the highest decline in TB case notifications during 2020 and 2021, compared to 2019 and previous years. This is worrisome, because undiagnosed people will transmit the infection in the community and that will push up the TB incidence. It already has, according to WHO. Another worrisome trend is worsening poverty and food insecurity. Poverty and under-nutrition are critical drivers of the TB epidemic and we should expect a worsening of the TB problem in India, where malnutrition alone accounts for nearly half of TB incidence. So, poverty reduction and social benefits (e.g. rations for people with TB, direct cash payments) are key.
Omicron and its sub-variants are fast moving viruses though symptoms are mild. Should we also be worried about long Covid effects?
I would not dismiss Omicron sub-variants as ‘mild.’ Among elderly and those with comorbidities, it is killing many people globally. Also, if people have not had their booster doses, re-infections can occur and can be severe. We are learning that long Covid is a big issue and the virus can cause fatigue, brain fog, shortness of breath and other symptoms. So, it is important to ensure wider and easier access to Covid-19 vaccines and booster shots, as well as access to anti-viral treatments such as Paxlovid.
What are the latest tools that can help with active TB case findings?
During the pandemic, all countries, including India, scaled up PCR-testing and genetic sequencing capacity for Covid-19 and this expanded capacity could be used for TB testing and surveillance. I would like to see India phase out sputum smear microscopy and offer molecular TB testing to all people with suspected TB. India already has a big network of GeneXpert systems and is lucky to have a WHO-endorsed molecular TB platform called TrueNAT by Molbio Diagnostics. This technology needs to be scaled up widely for TB. India also has a WHO-endorsed digital X-ray AI solution by Qure.AI, and this could help with active case finding and community-based screening. During the pandemic, huge advances have been made in digital health tools (e.g. mobile apps), tele-health, use of digital adherence technologies, and home delivery of medicines. All of these could help with the recovery of TB.
How safe are shorter TB treatment regimens?
With regards to treatment, safer, shorter cures recommended by WHO for nearly all forms of TB are: three-month regimens for TB prevention (3HP, isoniazid and rifapentine), four-month regimens for drug-sensitive TB, and six-month, all-oral regimens for drug-resistant TB (based on bedaquiline, linezolid and pretomanid). These shorter regimens should be made available to everyone in India. In particular, it is amazing to have a 6-month, oral treatment for drug-resistant TB. This means, we can put an end to painful, toxic 24-month regimens for DR-TB which include injectable drugs. I would like to see all injectable drug regimens phased out.