The international public health community wants India to act urgently to tackle TB resistance, currently spreading at an alarming rate in the country

Eighteen months after the Indian government launched the “TB Free India” campaign, nine policy changes under the Revised National Tuberculosis Control Program (RNTCP) are yet to be implemented. The delay has raised concerns among the international public health community which believes that drug resistant TB (DR-TB) — currently spreading at an alarming rate in India — will not remain confined with the borders if the Indian government does not show urgency.

The main gaps are regarding the government’s failure to roll-out Fixed Dose Combinations (FDCs) for tuberculosis(TB) patients living with HIV; the failure to provide A child-friendly TB regimen and the glacially slow pace of scaling up availability of a new drug Bedaquiline, which can treat multidrug-resistant TB (MDR-TB).

According to the World Health Organization’s (WHO) latest annual report on TB, India shoulders the maximum number of TB patients — 2.84 million Indians contracted the disease in 2015 alone. “India has more patients living with drug resistant TB than any other country in the world — with an estimated 79,000 persons becoming sick with this disease each year. Furthermore, there is evidence that India is home to the most serious “hotspots of MDR-TB transmission, especially in cities like Mumbai. The resistant form of TB is spreading in India at alarming levels, but since TB is airborne, it is not confined within the borders of the country, and the high rates of MDR-TB in India spell trouble for the entire Southeast Asian region and beyond. In fact, even in low burden countries like the U.S., there have been documented cases of people who have travelled to the India and brought extensively drug-resistant TB (XDR-TB) back to the U.S. India must do whatever it can to stop the transmission of TB both within and beyond its borders, and this can best be accomplished with early diagnosis and effective treatment. The continued unwillingness of the Indian government to provide adequate diagnosis, treatment, and prevention of all forms of TB tarnishes India’s reputation on the international stage,” said Prof. Jennifer J. Furin, lecturer on Global Health and Social Medicine at Harvard Medical School.

India has been listed among the High Burden Countries along with Afghanistan, Bangladesh, Brazil, China, Indonesia, Philippines, the Russian Federation and South Africa but in sheer numbers India is home to maximum number of TB patients, patients with TB and HIV, patients with extreme form of drug resistance called XDR TB. Lack of Indian delegates at the 47th Union World Conference on Lung Health in Liverpool, U.K., has raised further questions about India’s commitment to meet global TB targets. Dr. Mario Raviglione, Director of the Global Tuberculosis Programme, WHO, said, “If India does not move, the world does not move. We cannot do much without India as they have nearly 30 per cent of the TB cases there.”

With an objective to send an “urgent” message to Indian Prime Minister Narendra Modi, activists interrupted the only session attended by an Indian Health Ministry official at the conference reading out a list of demands to address the gaps in implementation. The delay has resulted in a campaign called #BrokenTBPromises- which essentially counts each day until Mr. Modi fixes the 9 promises.

However, Dr. Jagdish Prasad, Director General of Health Services, Health Ministry, stunned the international delegates by calling protesting activists ‘mentally unstable’ during the session. When probed about the delay in rolling out TB drugs, he said, “In India, when a son wants to marry someone’s daughter, it takes over 6 months to arrange the marriage. It is [the] same with policies. We do not want to discuss our internal problems in a foreign country.”

While modern TN care tools like Gene Xpert (to rapidly and accurately detect TB) and new drugs like Bedaquiline and Delamanid (that treat drug resistant TB) are available, the Indian government has not been able to scale up treatment options in the public sector in the last year. The roll-out of bedaquiline has been slow with only 36 patients being enrolled in the Delhi hospitals nearly six months after the launch of Bedaquiline in the national programme. Additionally, the government has not made FDCs available in the government programme yet.

The situation in India is very troubling for us in the international community, added Dr. Furin. “Thousands of people have extreme form of DR TB, for which an effective new therapy is available for over 3.5 years. That fewer than 100 people in India have been able to access this treatment is appalling,” added Dr. Furin, who was one of the protesters. “We are respectful of our colleagues in India who are working hard within the system but when they don’t come to conferences like these, it seems like they don’t want to acknowledge the reality of the disaster that TB and DR-TB is in India. I think it is time for the international community to stop being polite with India because the news that comes out of India is worse and worse every time,” she added.

The nine gaps identified by the activists include:

1. Roll-out of daily FDC drugs for people with HIV (PLHIV);

2. Roll-out of appropriately dosed paediatric drugs for children;

3. The scale-up of GeneXpert, a test that can diagnoses drug resistance in less than two hours;

4. The scale-up of drug susceptibility testing;

5. Roll-out of TB drug Bedaquiline to treat drug-resistant TB

6. Isoniazid preventive therapy (IPT) for PLHIV to treat latent TB infection;

7. Isoniazid preventive therapy (IPT) for children under five who are in close contact with people living with TB;

8. The provision of Rifabutin for treatment of TB co-infection with HIV; and

9. The immediate end to use of the category II retreatment regimen.