Transforming India from TB Hot Zone to TB Hot Shot

As a clinical researcher working to ease the burden of tuberculosis in India, I know first-hand how deadly and miserable tuberculosis can be. Best known for its cruel toll on the lungs, TB can spread to just about every part of the body, leaving destroyed tissue in its wake. Drug resistance is rendering our go-to cures useless. TB kills an astounding 50% of untreated patients.India is the global TB hot zone—one in four people with TB in the world lives in India. While we know the nation leads in number of cases, it’s hard to get a handle on just how many that is, because people can have TB without showing symptoms. While global disease statistics for 2016 reported approximately 2.8 million cases of tuberculosis in India, it is estimated that 40% of the population is infected with the latent form of the disease. It’s difficult to predict how, when, or whether latent TB will become active and contagious. Simply finding the cases is not enough to eliminate TB in India, because people who have the disease infect between 10 and 15 other people before starting treatment.TB is costly by a variety of measures. It’s socially devastating—the stigma associated with TB causes isolation and distrust within families and throughout communities, and it can prevent people from seeking medical care. TB illness and the months-long course of treatment has substantial effects on worker productivity and household income, and financial costs associated with extended care can push families into poverty quite readily. The implications for the country’s financial health are not surprising. Between 2006 and 2014, TB cost the Indian economy USD 340 billion.Recognizing the magnitude of the problem, in 2016, Prime Minister Modi called for a comprehensive review of TB control strategies and issued a directive for drug-resistant TB diagnostic tests to be available in all districts. He also addressed the Indian people directly, calling for citizens to be proactive in seeking diagnosis and treatment. During the World Health Organization’s (WHO) Southeast Asia Regional Meeting in spring 2017, JP Nadda, India Minister of Health, reported that a strategy was being finalized for aggressively tackling TB and ending the epidemic by the year 2025.I was encouraged by these declarations, which represent the first very public assurances by the Indian government for proactively addressing TB. This same level of commitment was echoed globally at a November 2017 meeting of United Nations organizations, development organizations, national health ministers and other delegates from 114 countries who gathered for a Global Ministerial Conference in Moscow to step up the pace of and investment in the WHO End TB Strategy. Set forth by the World Health Assembly and the United Nations, and part of the Sustainable Development Goals, the strategy seeks to reduce TB by 90% by 2030. It’s bold and ambitious and long overdue.Do I think it’s achievable? With sustained commitment and scientific investment, it is. I have proudly watched India’s achievements across sectors in less time. In the global economy, India ranks #7 and is projected to climb to #2 by 2050. The country comes in at #4 in number of billionaires, behind the US, China, and Germany. And India is garnering increasing recognition for health innovation. Pharma ranks #3 for volume, and the world’s largest vaccine manufacturer is in India. As of 2015, India is #5 among US sources for pharmaceutical imports. The economic resources and scientific expertise are there for meeting the WHO goal.While we have yet to see India’s strategy, there are critical components the global TB research and response community will be looking for:

• Commitment to novel therapeutics and vaccine development. For example, there is one licensed TB vaccine—it was developed in 1921 and it is weak.
• Development of reliable and affordable diagnostic tests. The latest tests are an improvement, but still require expensive equipment and are far from perfect.
• Clinical training and practice standards for healthcare workers. We must protect providers, patients, and their families and keep them from spreading disease in the healthcare setting.
• Expanded community-based health and social services. Support is needed for patients and their families so that social stigma doesn’t prevent them from seeking treatment, and so they are not forced into poverty by doing so.
• Disease reporting, surveillance, contact tracing. To get a handle on the TB epidemic, we need to map hot zones and strategically allocate resources to areas where we can treat people with TB, and offer preventive therapy to people who do not yet have TB.

Government backing alone will not get this job done. NRI and India-based philanthropy have an important role to play in supporting the public–private partnerships that will have the greatest impact. Clinical and basic science research in Indian populations led by collaborative, multidisciplinary teams comprising industry, the laboratory bench, the clinic, and the community will propel big changes. My hope is that the commitment from Indian leadership and the global declaration from the Moscow conference precipitate India’s finest achievement yet. The people deserve a sustained commitment, and the world waits for India to lead—not in the number of TB cases, but in the effort to stop this miserable disease.To learn more:Visit Johns Hopkins Center for Clinical Global Health Education: https://ccghe.netWorld Health Organization Website. Global Ministerial Conference on Ending TB in the Sustainable Development Era. 16–17 November 2017. Moscow, Russian Federation. https://www.who.int/conferences/tb-global-ministerial-conference/en/Amita Gupta, MD, MHS, is Associate Professor of Medicine and International Health, and Deputy Director of the Center for Clinical Global Health Education, at the Johns Hopkins University, in Baltimore, MD. She leads Johns Hopkins’ infectious disease research partnerships with four medical institutions in southwest India. She serves in leadership positions for the RePORT consortium for TB research, funded by the US National Institutes of Health (NIH) and the government of India, including on the RePORT International Executive Committee, as US Chair of RePORT India, and is Principal Investigator of the multi-site C-TRIUMPH research consortium. She is a member of the AIDS Clinical Trials TB Transformative Science Group, which now has the largest portfolio of TB trials in the world, and is the Vice Chair of the NIH-funded International Maternal Pediatric Adolescent AIDS Clinical Trials Network TB Scientific Committee. Her Indo-US team is leading multi-country studies assessing novel interventions for TB treatment and prevention. Dr. Gupta is a practicing infectious disease physician at Johns Hopkins Hospital.