Like sand slipping through fingers, anti-TB drug resistance threatens to unwind the progress

Bobby Ramakant *

There is no doubt that groundbreaking progress has been made in fight against tuberculosis (TB) in the past two decades, but it might be prudent to review if we are winning the fight in order to #endTB by 2030. Do we slip backwards when we fail to prevent every single transmission of new TB infection or when a new person becomes resistant to anti-TB drugs? Are we sliding farther away from our #endTB goalpost, when we fail to ensure early diagnosis, effective treatment and successful cure?

Dr Tedros Adhanom Ghebreyesus, the newly elected Director General of the World Health Organization (WHO) had said to AMR Times last month, "Continuing to scale up treatment for HIV and TB – and addressing the growing rates of resistance – should be high on the agenda of our efforts in combating AMR [anti-microbial resistance]. We have made tremendous gains on these diseases in the past few decades, and I'm gravely concerned that resistance will start to unwind that progress. In 2015, for example, the WHO estimated that there were more than half a million new cases of drug-resistant TB cases that require treatment but only 20% of them were treated. Even those treated they have about 50% treatment success rate. We cannot underestimate this crisis and we must do better to identify, track and manage these drug-resistant TB cases as part of our AMR efforts."

According to the WHO, resistance to TB drugs is a formidable obstacle to effective TB care and prevention globally. Multidrug-resistant TB (MDR-TB) is multifactorial and fuelled by improper treatment of patients, poor management of supply and quality of drugs, and airborne transmission of bacteria in public places. Case management becomes difficult and the challenge is compounded by catastrophic economic and social costs that patients incur while seeking help and on treatment.

Undoubtedly, drug resistance is a human-made disaster. Drug resistance not only occurs because of irrational drug use or other social determinants that jeopardize adherence, but also spreads from an infected person to another uninfected person (person to person transmission or primary infection of drug-resistant TB). Failure of ensuring infection control in healthcare settings, communities and homes, is a big stumbling block for fight against TB and other infectious diseases.

In a first-of-its-kind study in South Africa, researchers from the CDC and other institutions found that over two-thirds (69%) of the 404 Extensively Drug Resistant TB (XDR-TB) patients had not been treated for multidrug resistant TB (MDR-TB) before their XDR-TB diagnosis, suggesting that person-to-person contact is the primary driver of XDR-TB in the region.

We are walking but we ought to run!

At the TB Free India Summit which was organized last month, Dr GR Khatri who heads the World Lung Foundation South Asia and was awarded one of the country’s highest civilian honours, Padmashri, said “in India, 2-3% of MDR-TB is primary infection (person to person transmission). We are walking, we have to run!" said Dr GR Khatri calling for urgent measures to ensure TB rates decline fast enough to meet end-TB targets and no further drug-resistance spreads.

Dr Rohit Sarin, Director of National Institute for TB and Respiratory Diseases (NITRD, formerly LRS Insitute for TB and Respiratory Diseases) said that prevention will be the true answer to tackling drug resistant TB – and – that is also why we must treat it best! Diagnosing and successfully treating every case of drug resistant TB, and preventing its further spread from an infected person to uninfected person or via irrational drug therapy, is central to averting a pandemic of drug resistant TB strains. “If we do not act now we might have an epidemic of drug resistant TB and that will be akin to fighting a losing battle” rightly said Dr Sarin.

Dr Srikanth P Tripathy, Director of National Institute for Research in Tuberculosis (NIRT), Indian Council of Medical Research (ICMR) called for having rapid drug resistant testing for newer molecules which are being introduced in country’s TB programmes: Bedaquiline and Delamanid.

Experts voicing out their concern against brewing drug resistance are right. Earlier this month, The Lancet article forecasted increase, not decline, in MDR-TB in high burden nations. It predicted that MDR-TB will increase to 12.4% in India, 8.9% in Philippines, 32.5% in Russia and 5.7% in South Africa by 2040. It also predicted that XDR-TB will increase to 8.9% in India, 9% in Philippines, 9% in Russia and 8.5% in South Africa by 2040. The Lancet article must set off the alarm bells and serve as a final wake up call to gear up to overcome the challenges blocking progress towards ending TB by 2030. Business as usual is clearly not an option if we are committed to end TB.

#WalkTheTalk on social security and UHC

Although TB diagnosis and medicines are provided free of cost in government sector yet there are catastrophic costs which a patient or family incurs and it can be an obstacle to completing treatment and may thwart efforts to get cured. TB survivor and patient advocate Deepti Chavan highlighted that “Surviving TB was not easy, taking 15-20 pills each day, vomiting blood, I could not walk, I was bed ridden, my hearing was affected, my vision was affected, basically I could not do anything, I was almost like a vegetable. The support I got was only from my family. We came from middle class family but they had to take debts for my treatment.”

Championing the cause, Deepti Chavan shared her concerns: “I think about patients who have lesser means. They do not know what they are going to eat in the evening, yet they have to endure such treatment. They cannot go out and earn! I am a patient advocate because I do not want anyone else to suffer the way I have. I know 'Being Human' funds treatment of TB patients, so I will like to thank Sohail sir (film actor, producer and director) and request him to please thank Salman sir (film icon) for me for doing so much for the patients."

Being Human is a NGO run by Sohail and Salman Khan’s family. Sohail Khan, noted Bollywood film actor, producer and director, acknowledged Deepti’s plea and responded that “If there is anything in our personal capacity or family that we can do, where ‘Being Human’ is concerned, we will take this initiative forward.”

Time for policy to drive programmes on the ground

All governments had unanimously approved the WHO End TB Strategy in World Health Assembly 2014, which calls for ending catastrophic costs to TB care. Governments need to scale up efforts to ensure that economic hardships do not impede TB programme outcomes.

Social security and universal health coverage are also promises our governments have made as part of the Sustainable Development Goals (SDGs). Shobha Shukla, Executive Director of CNS (Citizen News Service) rightly said that: “It is high time that we re-engineer our fight against TB so that the rate of TB decline shoots up to the required rate of TB decline for ending TB by 2030. Currently the rate of TB decline is many times lower than the require rate. We cannot afford to let drug resistance unwind the progress made. Translating the SDGs into realities on the ground is a human rights imperative.”