India has made significant strides in tuberculosis (TB) management, but it will need to develop newer approaches and tools to deliver on our goal of a TB-Mukt Bharat. In fact, India has set herself an ambitious target of eliminating TB by 2025, five years ahead of the international timeline. In 2021, about 10.6 million people were estimated to have fallen ill with TB globally.
First, for the effective management of any public health crisis at the scale of TB, a resilient funding stream needs to be in place to consistently fuel research and innovation in newer technologies.
A December 2022 report (Tuberculosis Research Funding Trends, 2005–2021) revealed that for the first time in history, in 2021, TB research and development funding hit one billion dollars worldwide. However, governments had committed to double of this amount at the 2018 UN General Assembly High-Level Meeting on TB. Here, it gives me much pride to say that the Indian Council of Medical Research (ICMR) has been one out of the three largest funders of TB-related infrastructure and other investments.
The other two are the US NIH and USAID. All three have jointly contributed to 72 percent of total investments in this area. ICMR expenditures have primarily been towards supporting scientific laboratories and health research activities — reflective of the priorities of the organisation.
Furthermore, the report also reaffirmed that the public sector remains the largest source of funding for something critical to eliminating the disease in future — TB vaccines research. Here, too, ICMR was one among the three entities which spent upwards of $1 million on TB vaccines research in 2021.
TB R&D Priorities
Vaccines are undoubtedly the most effective way to insulate people from disease. Again, the pandemic has demonstrated that effective vaccines can be developed in a shorter duration of 1-2 years. There is no reason for countries to still be dependent solely on a 100-year-old BCG vaccine for TB — while it is effective in TB prevention in children, its effectiveness in adolescents and adults is still controversial.
To this end, India must be commended for taking positive strides over the years to arrive at potential vaccines. For instance, there have been research on a recombinant-BCG vaccine which can be administered to both children and adults. Other vaccine candidates are also in the pipeline, which have shown to prevent TB in TB infected, HIV-negative adults. But we still need to have market-ready vaccines and have sharper, structured bench-to-bedside policies in place so we can expect faster availability of these promising vaccines.
In addition to upgrading our preventive capacity, we need to ensure strong curative measures too. More targeted investments and support must be extended towards the development of newer, safer anti-TB drugs and drug regimens. For instance, regimens such as BEAT-TB — which uses Bedaquiline, Delamanid, Linezolid and Clofazimine and can potentially reduce XDR TB treatment to 6 – 9 months from the current duration of 18 months — should be explored on an urgent basis.
While research has been ongoing, mechanisms to fast-track specific research need to be put in place. Here, mention must be made of BPaL (Bedaquiline; Pretomanid and Linezolid) regimen that uses the latest anti-TB drug, Pretomanid. This WHO-approved regimen is undergoing field trials in India currently and can potentially reduce treatment time to around 6 months from 18 months.
Furthermore, the older drug regimen that included nearly 10+ different anti-TB drugs for a patient to take daily. With both BEAT and BPaL, just three to four daily tablets will likely be needed. However, we also need to ensure that trials for life-saving drug regimens are accelerated so they can actually impact lives on the ground. In this context, it may be useful to explore collaborations between developers of drug regimens (like BPaL) and research institutes in India so that the need for bridging studies for new drug regimens comes down. This can ensure new treatment options for the future are introduced in the country effectively without delays.
We already have the experience of expedited roll-outs for Covid-19 therapeutics, diagnostics and vaccines. Building on these learnings, seamless policy mechanisms need to be put in place to expedite the roll-out of new tools for other disease areas. India also has the requisite political will and has made its intention of financial prioritization for TB clear. We simply need to deliberate on the motivations that drove us towards fast-tracking Covid-19 R&D and use the same to further fuel our Jan Andolan against TB.
The writer is the Director, ICMR-National Institute for Research in Tuberculosis. Views are personal.