By Invitation. TB: An old foe, but new hope lies in the treatment pipeline

With over 2.6 million dead, Covid-19 has become the world’s leading infectious killer. Thankfully, scientific breakthroughs show that a post-lockdown world is in reach. When that time comes, a familiar and ancient foe is poised to return to the top of the list: Tuberculosis.

TB is also known as kshaya rog (wasting disease) in Hindi. It is a leading global health threat that has been with us for millennia. It kills about 1.4 million people each year. Like Covid-19, this disease is transmitted through the air and often attacks the lungs. Unlike Covid-19, it is a bacterial infection that must be treated with antibiotics.

Tragically, India has been mired in the fight against TB for generations. It leads the world in TB infections, accounting for over one in four of the 10 million people who get sick each year. It also is a leading country for people with drug-resistant forms of TB (DR-TB), which do not respond to commonly used medicines.

DR-TB has continued to grow in the shadow of today’s lockdowns. TB patients around the world have faced disruption of their lengthy antibiotic treatments, increasing the risk that their infections stop responding to treatment and the disease is transmitted to loved ones in close quarters.

According to the World Health Organization, 124,000 of the 2.7 million TB cases in India in 2019 were drug resistant. Despite representing a smaller pool of patients, DR-TB places immense burdens on the health system and patients alike. These forms of TB can take much longer to cure (18-24 months instead of six), usually require 5-7 different medicines in the form of thousands of pills and cost over 30 times that of standard care. Worse, the treatment is only successful in about 50 per cent of patients. Those who survive may still face debilitating health consequences such as hearing loss due to the toxicity of the few last-resort medicines that are available.

TB and its drug-resistant forms are a crisis that cannot be ignored. They must be fought with the same spirit of innovation that we have seen in the response to Covid-19.

It takes a potent combination of political will, funding, and vision to tackle public health problems of this scale. In 2003, then Health Minister (late) Sushma Swaraj demonstrated strong leadership by announcing large-scale HIV treatment with drugs manufactured by the Indian pharmaceutical industry. That move catalysed one of the largest HIV treatment programmes in the world and has resulted in great strides against HIV.

There are signs of hope for the fight against TB. Prime Minister Narendra Modi has set an ambitious goal of TB eradication in India by 2025, far ahead of the 2030 target of the Sustainable Development Goals. This bold commitment may face headwinds in the context of the unforeseen challenges posed by Covid-19, as well as the low success rates of current DR-TB treatments, which limit the potential of expanding TB services. Short, simple and standardised treatments are urgently needed to change the game. The global TB drug pipeline shows promise with over 30 compounds under active development — more than ever before.

One such treatment regimen that was recently approved by Drugs Controller General of India is a combination of two novel drugs, bedaquiline and pretomanid, with the existing drug linezolid (BPaL). The New England Journal of Medicine reports that this six-month, all-oral regimen has an approximately 90 per cent efficacy rate for the most difficult-to-treat forms of TB. Earlier this month, an update on those results presented at CROI (Conference on Retroviruses and Opportunistic Infections) found that, excepting one relapse, all patients who completed treatment remained free of disease two years later.

About 12 countries across Africa, Central Asia, Eastern Europe and the far East are beginning to implement this treatment regimen at a record-setting pace, reaching patients in less than six months since the WHO recommended pretomanid’s use as part of operational research and a little over one year since the first approval by the US Food and Drug Administration (FDA).

To put this in perspective, HIV medicines have taken an average of six years from when they were first approved by a stringent regulatory authority to reach patients in developing countries.

It is noteworthy that the newest of these drugs — pretomanid, developed by the non-profit TB Alliance — is being manufactured in India. This is an inspiring example of how India’s manufacturing prowess in healthcare can save lives: From new medicines for TB to vaccines for Covid-19.

Innovations in treatment could allow India to help those who are facing the worst of the TB pandemic. We have seen demonstrations of political will and scientific breakthroughs. Now is the time to seize the moment and bring this devastating disease under control.

The writer is Senior Vice President (Market Access), TB Alliance. Views are personal

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