Will advances in TB treatment outweigh the Covid-19 pushback ?

Shobha Shukla *

The impact of the COVID-19 pandemic on TB diagnosis and mortality in 2020 has been frightening, to say the least. Recently released WHO data shows that 1.4 million fewer people got TB care in 2020 as compared to 2019- a 21% decrease. Also over 0.5 million people died from TB in 2020 due to lack of diagnosis.

Latest data by Stop TB Partnership shows that in 9 countries (Bangladesh, India, Indonesia, Myanmar, Pakistan, Philippines, South Africa, Tajikistan, and Ukraine) which together account for 60% of the global TB burden, TB diagnosis and treatment enrolment in 2020 declined by 1 million - a drastic reduction of 23%. Globally, in 2020 there was an estimated drop of at least 1 million in TB treatment enrolment, pushing the TB response to 2008 levels in terms of people diagnosed and treated.

A modelling analysis done in May 2020 found that even short COVID-19 related lockdowns can generate long-lasting setbacks in TB control, due to disruption in routine TB care services. A 3-month lockdown followed by 10-months to restore to normal could lead to an additional 6.3 million cases of TB and an additional 1.4 million TB deaths between 2020 and 2025 globally. In India the disruptions are expected to cause an additional 1.19 million TB cases and 361,000 TB deaths over the next 5 years.

However, while the TB care and control situation is very grim, it is not a lost cause. Even amid the global pandemic, TB treatment innovations have advanced at an unprecedented pace, thanks to the untiring efforts of our scientific community. Encouraging results from some phase-3 clinical studies of new drug regimens provide the much needed hope of better and more patient-friendly treatments for drug-susceptible as well as drug-resistant TB.

Shorter and all oral regimen for XDR and MDR-TB

At CROI 2021, Dr Pauline Howell of the University of the Witwatersrand, South Africa, presented a new analysis based on two years of the Nix-TB study, in which approximately 90% of the patients with highly drug-resistant TB who were treated with a 6-month, all-oral regimen of pretomanid, bedaquiline and linezolid (BPaL) remained free of their disease. Pretomanid, which is used in this regimen, is a new chemical entity developed by TB Alliance.

Nix-TB is an open-label, single-group study that had 65% participants with XDR-TB and 35% patients with unresponsive MDR-TB. At 6 months after the completion of therapy, 90% of the enrolled patients were found to have had a favourable outcome - 89% of those with XDR-TB and 92% of those with MDR-TB.

The study thus shows that XDR-TB and complicated MDR-TB can be treated with a 26 weeks long all oral 3 drug regimen with a 90% success rate, which is similar to that obtained with the standard of care in the treatment for drug-sensitive TB. Currently used regimens have had a success cure rate of only 34% for XDR-TB and 55% for MDR-TB cases. Moreover, they routinely last for two years or longer and are very costly.

In her presentation at CROI, Dr Howell shared that, "Results of this simplified, shortened, and all-oral regimen for highly drug-resistant TB show sustained high efficacy through a 2-year follow-up from end of treatment. A follow-on trial ZeNix that investigates the optimal dose and duration of linezolid in the BPaL regimen, has recently completed enrolment.

The objective of this study is to evaluate if the efficacy of the BPaL drug regimen can be maintained, while reducing toxicity and increasing tolerability through a shorter linezolid duration of 2 months and/or its smaller dose of 600 mg (as compared to the current 1200 mg dosage). We look forward to the primary endpoint 6 months into post treatment results."

Meanwhile, WHO has recommended the BPaL regimen under operational research conditions and it has also been authorised by the European Medicines Agency.

In an exclusive interview given to CNS (Citizen News Service), Dr Howell said,"TB Alliance is studying this regimen in multiple countries. Operational research is now underway in at least 5 countries with many more expected to join this year. Physicians in USA are prescribing the regimen under routine practice conditions. The regimen was approved in India by the Drug Controller General of India (DCGI) last year.

The ZeNix trial is taking place in Russia, Georgia, Moldova and South Africa, evaluating different doses and durations of the drug linezolid as part of this regimen. They have also partnered with MSF to evaluate BPaL-based regimens for all people with DR-TB (at least rifampicin-resistant TB), and not just highly drug-resistant strains."

Shorter regimen for drug sensitive TB

In the 3rd episode of The Dose Podcast series, that was released on World TB Day 2021, Dr Susan Dorman, an infectious disease expert at the Medical University of South Carolina, shared the exciting results of the US Centers for Disease Control and Prevention (CDC) Tuberculosis Trials Consortium (TBTC) Study 31/A5349, which she has been closely involved with.

This phase-3 study examined the efficacy and safety of two investigational 4-month treatment regimens for the treatment of drug-susceptible pulmonary TB, compared to the currently used standard of care 6-month regimen consisting of rifampicin, isoniazid, pyrazinamide and ethambutol in the control arm. One investigational regimen used rifapentine in place of rifampin and moxifloxacin in place of ethambutol. The other investigational regimen just replaced rifampin with rifapentine.

Giving details of the study, Dr Dorman said, "The study enrolled 2500 participants in 13 countries in the regions of Africa, Asia, South America, and North America. It included adults and adolescents and also people living with HIV. Primary endpoint was the percentage of participants who were cured and remained cured till 12 months after completion of treatment.

The key findings from the study were that the regimen containing both rifapentine and moxifloxacin was as effective as (or non-inferior to) the standard 6 month regimen in curing drug-susceptible pulmonary TB.

While the standard 6 month regimen cured 85% of the participants in the control arm, the new regimen cured 84% of the participants in all its sub groups. In fact the overall efficacy results for HIV positive sub-group were higher at 85% as compared to 78% cure rate for participants who were living with HIV in the standard of care regimen group. We are now going ahead to see if this new regimen is also appropriate for populations that were not included in Study 31- like young children and pregnant women."

The other 4-months regimen (without moxifloxacin) did not meet the non inferiority criterion, although its safety and tolerability was comparable to the 6-months regimen, informed Dr Dorman.

Study 31 clearly demonstrates that a treatment regimen containing rifapentine and moxifloxacin along with isoniazid and pyrazinamide can effectively and safely cure drug susceptible pulmonary TB in 4 months.

What next?

However, translating scientific evidence of clinical studies into public health benefits is not an easy task. The path to global adoption of the scientifically validated shorter and better regimens is not very straight, rightly says Dr Stephen Gillespie, Professor of Medicine at the University of St Andrews. While he was speaking in the context of the shorter regimen for drug-susceptible TB, the same holds true for newer regimens for drug-resistant TB as well.

In Dr Gillespie's opinion, "Next steps are more difficult. First is getting the approval by WHO and regulatory authorities in different countries. Then the Ministries of Health have to come up with the funds to buy the new drugs to adopt the new regimens in their national TB control programmes. We have also to engage with the community and inform TB patients that new and better regimens are available. Also, the one constituency, which we perhaps do not think about, are the physicians themselves who could be very conservative at times. Many might say that a longer regimen is better for TB treatment. So we have to address the issue of physicians' education as well."

These two studies demonstrate the latest breakthrough in global efforts to create shorter and better treatments for drug-resistant as well as drug-sensitive TB, which are urgently needed to treat all patients with TB and achieve the WHO's End TB Strategy targets. Equally important is to ensure that clinically validated shorter TB regimens are made accessible to those in need of them as soon as possible.

Let us not forget that 10 million people are affected with TB every year and 1.4 million die. There are many similarities between TB and COVID-19. Both are airborne infections transmitted through breathing and affecting primarily the respiratory tract. Also, people affected by TB are at a higher risk of adverse COVID-19 outcomes.

And as Dr Howell says, COVID-19 has become a significant challenge for health systems who are also burdened by drug-resistant TB. However, by adopting short, simple TB regimens that are easier to manage, patients have the potential to complete their treatment with fewer chances to contract or spread COVID-19.

But the question that plagues the minds of TB researchers and activists is: Does TB, the top infectious disease killer, not deserve the same political commitments and investments that we have seen in 1 year of COVID-19?

While USD 90 billion has been spent on Covid-19 vaccines (including research and development, procurement and delivery of those that have been rolled out) this year, a mere USD 1 billion has been spent in 10 years of TB vaccine research. Is it because the pandemic has affected the rich and poor alike, but TB still remains largely a poor person’s disease?

* Shobha Shukla – CNS (Citizen News Service) wrote this article for
The writer is award-winning founding Managing Editor and Executive Director of CNS (Citizen News Service) and is a feminist, health and development justice advocate.
She is a former senior Physics faculty of prestigious Loreto Convent College and current Coordinator of Asia Pacific Regional Media Alliance for Health and Development (APCAT Media).
Follow her on Twitter @shobha1shukla
This article was posted on March 27, 2021.

* Comments posted by users in this discussion thread and other parts of this site are opinions of the individuals posting them (whose user ID is displayed alongside) and not the views of We strongly recommend that users exercise responsibility, sensitivity and caution over language while writing your opinions which will be seen and read by other users. Please read a complete Guideline on using comments on this website.

  • Yaoshang Sports @Laipubam : Gallery
  • COVID-19 Status 10 Apr : Govt of Manipur
  • Of Nambul River & Prof Rajendra Ksh #2
  • Lok Adalat at various places in Manipur
  • Covid-19 Survey : for science community
  • A Slave or A Master ! :: Poem
  • Spiritual flight journey
  • Workshop on NEP at Lilong
  • Old Manipuri Movie #2 : eRang Classic
  • COVID-19 Status 09 Apr : Govt of Manipur
  • Yurreipem, Zingyo, Changton: eMing
  • COVID-19 : Impact in Manipur :: News Timeline
  • can the dignity of menstruation be increased
  • Incentivize vaccination for success
  • Need for Flexible Education in Manipur
  • MoU with Film Heritage Foundation
  • Unwanted deafening silence
  • Hun : Thadou biggest cultural festival
  • COVID-19 Status 08 Apr : Govt of Manipur
  • Licypriya addressed UN Youth Forum 2021
  • Status of women in the 21st century
  • ..we will fail to achieve Health For All
  • Monolith at Manipuri cinema Golden Jubilee
  • Complaint filed to MHRC on Sanaton death
  • Indifference to the fast spread of virus
  • Abridged Translation of Sanamahi Laihui #2
  • COVID-19 Status 07 Apr : Govt of Manipur
  • Ningtham Kummei @JNMDA #2 : Gallery
  • Career in Poultry Science
  • Form independent investigation commission
  • Need of actions to control air pollution
  • Politics surrounding call for ADC polls
  • Nongpok Ningthou Phoudamba #1 : Gallery
  • COVID-19 Status 06 Apr : Govt of Manipur
  • Journalists' Sports Meet #2 : Gallery
  • COVID test a must for all incoming flight
  • World Autism Awareness Day 2021
  • Architects @ Makok Technologies, Keinou
  • Bridge :: Poem
  • Second wave spreading swiftly
  • Yaoshang: Cooking Competition : Gallery
  • COVID-19 Status 05 Apr : Govt of Manipur
  • World Veterinary Day, 2021
  • What is it in the name? Famous 'Michaels'
  • The Last Night :: Poem
  • Rehabilitating drug users
  • When Money matters, sincerity is out
  • Cultural Fest of Manipur #1: Gallery
  • COVID-19 Status 04 Apr : Govt of Manipur
  • Mai-Own : Produces from Manipur #3: Gallery
  • 'Manipur Model' of Homestays gets booster
  • Manipur Lokayukta: Today's Imperative
  • Second wave could delay economic recovery
  • Give teeth to war on drugs
  • Thabal Chongba @Bamon Leikai #2: Gallery
  • COVID-19 Status 03 Apr : Govt of Manipur
  • The Joy of Easter Sunday
  • What's happening in Myanmar
  • Easter : A strange & unique celebration
  • For One To Faithful :: Poem
  • Executive member : Physics Academy NE
  • Abridged Translation of Sanamahi Laihui #1
  • COVID-19 Status 02 Apr : Govt of Manipur
  • Relief @ Rajaimei, Senapati : Gallery
  • The Ultimate Sacrifice
  • ST demand may become redundant
  • Addiction to drugs & alcohol
  • NHPC visit 510 MW Teesta-V
  • Creating space for super spreader
  • Day 3: Yaoshang Sports Meet : Gallery
  • COVID-19 Status 01 Apr : Govt of Manipur
  • Journalists' Sports Meet #1 : Gallery
  • World Autism Awareness Day 2021
  • Cut Money: The Virus of Illfare in Welfare
  • Vigyan Vidushi : Physics for women students
  • Mulling over the absolute
  • Arrest of former Salai Chairman
  • Yaoshang Nakatheng Chatpa : Gallery
  • COVID-19 Status 31 Mar : Govt of Manipur
  • Manipur Champion in Natl Thang-Ta C'ship
  • Yaoshang Pichakari : Gallery
  • Eyek Tamba :: Learn the Manipuri script
  • We are all Human ! :: Poem
  • Adequate nutrition for productive society
  • ADC elections assured, but when? ATSUM
  • Thabal Chongba @Bamon Leikai #1: Gallery
  • COVID-19 Status 30 Mar : Govt of Manipur
  • April Calendar for Year 2021 : Tools
  • Marathon Race- Kanglei Sports: Gallery
  • Paradise found. Paradise made.
  • AR organises anti drug awareness campaign
  • Fire @ Shirui, Ukhrul [Mar 29] : Gallery
  • COVID-19 Status 29 Mar : Govt of Manipur
  • Yaoshang MeiThaba @Kwakeithel: Gallery
  • Relief at Rajaimei & Tumuyon Khullen
  • Mask up to beat the second Covid wave
  • Yaoshang MeiThaba @Bamon Leikai: Gallery
  • COVID-19 Status 28 Mar : Govt of Manipur
  • Promotion of science @Senapati : Gallery
  • In need of a savior: the wailing of Myanmar
  • Science Awareness Programme at Senapati
  • World Sleep Day 2021 #2
  • AR interacts with ex-servicemen
  • Journalists' Sports Meet- Opening : Gallery
  • COVID-19 Status 27 Mar : Govt of Manipur
  • Film Preservation & Archiving Workshop
  • Fullmoon :: Poem
  • Appeal for assistance to Myanmar victims
  • Holi colour can cause dangerous side-effect
  • Training Program on Mushroom Cultivation
  • On Equality
  • Saroi Khangba @Imphal #2: Gallery
  • COVID-19 Status 26 Mar : Govt of Manipur
  • Mai-Own : Produces from Manipur #2: Gallery
  • War on drugs & sports movement
  • Yaoshang (Holi) Festival :: Book
  • Will advances in TB outweigh Covid-19 ?
  • Expecting Rs 14567 crore from the Centre
  • Still making waves in the the year 2021
  • War on Drugs: The uncheck loopholes
  • Junior Men & Women Hockey : Gallery
  • COVID-19 Status 25 Mar : Govt of Manipur
  • Account Assistant @ Amber & Arthur, Imphal
  • Principle of Self Determination & Peace
  • A Poem's Story
  • NDPP delegation visited Assam
  • Climbing cases in the last few days
  • Human Rights issues & Tangkhul Women #4
  • COVID-19 Status 24 Mar : Govt of Manipur
  • World Water Day Water
  • The Night :: Poem
  • Demand to book Lamhainamdi incident
  • Five Films for Freedom, LGBTIQ+ campaign
  • Touch stance with look at past 'mistakes'
  • For a little bit more
  • Mai-Own : Produces from Manipur #1: Gallery
  • COVID-19 Status 23 Mar : Govt of Manipur
  • Lamjing Meira Episode 1 - AMAND Ladies
  • World Sleep Day 2021 #1
  • Science Awareness Program at Wabagai
  • Towards Special Agricultural Zone in Manipur
  • Office Bearers- Manipur Soccer Futsal Assn
  • Of forest and water in the world
  • Chingu Paokhollei Leirang - Ingellei
  • COVID-19 Status 22 Mar : Govt of Manipur
  • Manipur: Team champion, Natl Bodybuilding
  • One Midsummer Dream :: Poem
  • Public auction theory & policy
  • BJP likely to retain Assam
  • Imagination: Not a child's play
  • Climbing cases across the country
  • TAPASYA Foundation day #1: Gallery
  • COVID-19 Status 21 Mar : Govt of Manipur
  • Of Nambul River & Prof Rajendra Ksh #1
  • Khengjang-Yangoulen Fish Conservation
  • Workshop on NEP 2020 at Manipur Univ
  • Cyclist Philem Rohan reached Bengaluru
  • Delhi Citizens extend solidarity with Myanmar
  • Create ADCs first ultimatum
  • Saroi Khangba @Imphal #1: Gallery
  • COVID-19 Status 20 Mar : Govt of Manipur
  • Measures to contain COVID-19 in Yaoshang
  • Science Education @ Chandel : Gallery
  • Consultants @ The Property Geo, Imphal
  • The Myanmar crisis & our options
  • Whither Homeland... :: Poem
  • Course in Kinanthropometry
  • Awareness of science education in SC school
  • Understanding value of 'Time' & 'Money'
  • Human Rights issues & Tangkhul Women #3
  • Book- 'Critics forum Manipur' : Gallery
  • Realization in the dark :: Poem
  • 39th Orientation Program at MU
  • Gauri Healthy Heart Mission at Kakching
  • State of democracy in Thailand : Discussion
  • Disturbing reports of deaths
  • Stop sand mining from River bank
  • Sharungbam Rameshor: Yuva Puraskar
  • COVID-19 Status 18 Mar : Govt of Manipur
  • Brewing Bio Entrepreneurships in Manipur
  • Mayasvi festival of the Tsou of Taiwan
  • Accountants at R-Square Design
  • Myanmar Memories
  • Staring at second wave of the virus
  • Inauguration and Launching Galore
  • Shopping List for Shivaratri #2: Gallery
  • Causes & solutions of unemployment
  • Where Fate Leads :: Poem
  • 'Dry fish' from Chittagong
  • Education for CWSN
  • ST demand: Gearing up for stir
  • Gadgets matters
  • Houses @Yangkhullen, Senapati : Gallery
  • World War II, INA & Manipuri Literature #3
  • Is there a perfect referee in football ?
  • Naga Peace Process :: News Timeline
  • The way to equal future
  • The magic of Coriander in skincare
  • From a high of 426 to zero
  • So far so good
  • My memories of Imphal from 1941 #20
  • COVID-19 Status 15 Mar : Govt of Manipur
  • Mushroom training @MayangImphal: Gallery
  • Periodic, free & fair elections #2
  • Hinges and his beloved :: Poem
  • Meetei tribe wont grab land of hill tribes
  • Four years in office & looking ahead
  • 4 years of citizen centric govt
  • Human Rights issues & Tangkhul Women #2
  • COVID-19 Status 14 Mar : Govt of Manipur
  • COVID-19 Status 13 Mar : Govt of Manipur
  • Eco-Tourism @CheiraoChing : Gallery
  • International Day of Action for Rivers
  • Save Myanmar, Save Humanism
  • 6th webinar 'Career opportunity in IT Industry'
  • Civil Services Examination 2021
  • Stand of others on ATSUM's demand?
  • Rih-Ngai Fest @Kakhulong : Gallery
  • Solution to surging congestion in Imphal
  • The paper once I valued most :: Poem
  • Jobs at Trueblue Taxi Imphal
  • Twelve profits of office
  • Kerala could repeat electoral history
  • ADC election should not be undermined
  • Shopping List for Shivaratri #1: Gallery
  • COVID-19 Status 12 Mar : Govt of Manipur
  • Shivaratri - The night of blissful awareness
  • Aries Haoneo Kuki - new song release
  • Moreh : India's Gateway to ASEAN
  • Career option as makeup artist
  • Webinar on 75 Years of India's Independence
  • Training Program on Mushroom Cultivation
  • Need to save environment: Green Manipur
  • Banning of Thabal Chongba
  • Imphal City from Nongmai Ching #2: Gallery
  • Aries Haoneo Kuki : Singer Profile :: eRang
  • Mega Book Sales @MU : Gallery
  • Featured Front Page Photo 2021 #1: Gallery
  • Karanjid Ahongshangbam: JEE Mains Topper
  • Mova Cave @ Hunpung, Ukhrul #1: Gallery
  • Bongbal Kholen, Kpi District #1: Gallery
  • COVID-19 vaccination [Jan 16] #2 : Gallery
  • Downloadable Manipuri Calendar :: 2021
  • 'Zehara' - Manipuri Movie :: eRang Classic