Tuberculosis epidemic in India is “larger” than what was previously estimated, the World Health Organisation (WHO) today said while asserting that the country was one of six nations which accounted for 60 per cent of the new cases in 2015.
The Global Tuberculosis Report 2016 which was released today, however, said the number of TB deaths and incidences rate continue to fall globally as well as in India.
“The TB epidemic is larger than previously estimated, reflecting new surveillance and survey data from India. However, the number of TB deaths and the TB incidence rate continue to fall globally and in India,” WHO said.
It said that in 2015, there were an estimated 10.4 million new (incident) TB cases worldwide, of which 5.9 million (56 per cent) were among men, 3.5 million (34 per cent) among women and 1.0 million (10 per cent) among children while people living with HIV accounted for 1.2 million (11 per cent) of all new TB cases.
“Six countries accounted for 60 per cent of the new cases – India, Indonesia, China, Nigeria, Pakistan and South Africa. Global progress depends on major advances in TB prevention and care in these countries,” the global health body said in its report.
It said worldwide, the rate of decline in TB incidence remained at only 1.5 per cent from 2014 to 2015 and stressed the need for it to accelerate to a 4–5 per cent annual decline by 2020 to reach the first milestones of the End TB Strategy.
“In 2015, there were an estimated 480000 new cases of multidrug-resistant TB (MDR-TB) and an additional 100000 people with rifampicin-resistant TB (RR-TB) who were also newly eligible for MDR-TB treatment.
“India, China and the Russian Federation accounted for 45 per cent of the combined total of 580000 cases. There were an estimated 1.4 million TB deaths in 2015, and an additional 0.4 million deaths resulting from TB disease among people living with HIV. Although the number of TB deaths fell by 22 per cent between 2000 and 2015, TB remained one of the top 10 causes of death worldwide in 2015,” it said.
WHO said that in 2015, 6.1 million new TB cases were notified to national authorities and reported to WHO while notified TB cases increased from 2013–2015, mostly due to a 34 per cent increase in notifications in India.
“However, globally there was a 4. 3 million gap between incident and notified cases, with India, Indonesia and Nigeria accounting for almost half of this gap. The crisis of MDR-TB detection and treatment continues.
“In 2015, of the estimated 580000 people newly eligible for MDR-TB treatment, only 125000 (20 per cent) were enrolled.
Five countries accounted for more than 60 per cent of the gap – India, China, the Russian Federation, Indonesia and Nigeria,” it said.
WHO said that the upward revisions to estimates of the burden of TB disease in India for the period 2000–2015 follow accumulating evidence that previous estimates were “too low”.
“This evidence includes household surveys, a state-wide TB prevalence survey, studies of anti-TB drug sales in the private sector, notification data and new analysis of mortality data.
“Since India accounts for more than one quarter of the world’s TB cases and deaths, these revisions have had a major impact on global estimates. Estimates for India are considered interim, pending a national TB prevalence survey scheduled for 2017/2018,” WHO said.
It said that in the African Region where the burden of HIV-associated TB is highest, 81 per cent of notified TB patients had a documented HIV test result.
“The proportion of known HIV-positive TB patients on ART was above 90 per cent in India, Kenya, Malawi, Mozambique, Namibia and Swaziland,” it said.
Giving out details about India, WHO said mortality (HIV+TB only) was 37 per thousand while incidence (HIV+TB only) was 113 per thousand.
Estimated TB incidence in India in 2015 in the age group of 0-14 years for both males and females was 255 per thousand.
Commenting on the report and the disease in the South East Asian Region which also includes India, WHO Regional Director (SEARO) Poonam Khetrapal Singh said TB remains a serious problem across the region and requires the fullest attention and strongest commitment of governments.
“As outlined in WHO’s new global report on TB, a number of countries in the region are among the world’s highest TB burden countries, while revised estimates based on increased case-reporting and enhanced surveillance show that the TB caseload is higher than previously projected.
“TB is the single largest cause of death of any infectious disease in the region, and remains responsible for incalculable suffering, premature mortality, impoverishment and foregone development,” she said.
She said though countries have been making efforts to end TB and the number of TB deaths and its incidence rate continues to fall, at the current trend the region would not be able to achieve the SDG targets.
“A newer and bolder approach is needed to bend the curve faster and sharper to achieve the global targets. This means intensifying measures to ensure early diagnosis and treatment, such as active case-finding and enhancing access to cutting-edge diagnostic tools.
“Adopting newer approaches of case diagnosis, community based treatment and treatment of latent infection. It means integrating TB programmes with existing health systems, thereby amplifying the effect these interventions have,” she said.
Singh also said that funds must be allocated accordingly, while political commitment must be fortified and both must occur at national and international levels.
Research on newer drugs to treat tuberculosis is posing a serious challenge to scientists. This is primarily because the TB bacteria is a formidable pathogen making it tough for researchers to develop effective drugs. However, the only way to counter TB worldwide would be through a vaccine and new drug strategy, said Prof. V Nagaraja, president, JNCASR and head department of microbiology and cell biology, Indian Institute of Science.
In spite of access to funding from global foundations and trusts like TB Alliance and Bill-Melinda Gates Foundation along with the efforts by Big Pharma, researchers are still grappling to contain the disease. There is a TB vaccine trial underway in the EU. The need of the hour is a therapeutic pathway with a preventive vaccine or a drug that could shorten the duration of treatment and be able to tackle both multi-drug resistant (MDR) and latent infections, he added.
There is considerable focus and interest to discover drugs that effectively eradicate this infection. But the dormancy factor of the disease with no accurate details makes it impossible to predict the infection. This along nexus of HIV and MDR TB are seen to be a major hindrance for scientists across the world and India to find the right treatment option for this condition, Dr. Nararaja stated in his key note address at the Drug Discovery India 2016 event organised by SelectBio here in Bengaluru.
Speaking on the topic ‘Targeting Topology Modulators to Counter Resurgent Tuberculosis’, he said one-third of the world population is diagnosed from the dreaded disease with 2 million fatalities reported annually. The major impediment to possibly eradicate TB is that the bacteria is difficult to tackle.
In the last 15 years, the emergence of MDR TB is both extensive and total which is impacting both developing and developed countries. The disease is now seen to affect every tissue in the body. In fact, TB of other organs is another serious issue. There is no one drug to treat this condition and the drug combination is proving to be MDR.
The key components for TB control in India are to pursue high quality DOTS (directly observed treatment, short-course), strengthen the primary healthcare system to address this disease onset, enable research to find new chemical entities and novel drug targets, noted Dr. Nagaraja.
Delving on the TB vaccination strategy, he said that BCG was not effective in India and its efficacy was only partially satisfied even in the Caucasian population. The way forward is a vaccine to stall TB infections. Researchers need to focus on sterilising bacteria activity and oral delivery medication with a novel mechanism action.
Pharma research is complicated on the one hand and sophisticated on the other. However, India has attracted the top 50 global pharma companies in the country going by the access to qualified research expertise. Even knowledge-based Ayurveda will bring out the best in research for new drugs. There is need to strengthen partnerships to pursue collaborations, said Rathnam Chaguturu, founder and CEO, iDD Partners, US and conference chair at the Drug Discovery India 2016 event.
The Department of Biotechnology (DBT) in collaboration with Department of Science & Technology, and the Department of Science & Technology, Government of South Africa, and South African Medical Research Council will soon embark on a collaborative research programme on HIV, TB and TB/HIV. The programme would be under the framework of bilateral Science and Technology Cooperation Agreement between the Department of Science and Technology, Ministry of Science and Technology, Governments of India and South Africa.
The thrust areas of the programme would be on development of preventive HIV vaccine by designing immunogens that can elicit potent and broadly neutralizing antibodies; isolation and characterization of neutralizing MAbs effective against clade C HIV-1 viruses for use in combination therapies, passive immunization, and/or for designing preventive vaccines; Creation of cohorts of TB patients with HIV-1 co-infection and formation of national biorepositories (for breath condensates, blood, tissue etc.)to facilitate immunological studies on HIV and TB; and identification of biomarkers and development of novel assays for diagnosis and management of tuberculosis and tuberculosis with HIV co-infection.
The DBT’s initiative in this regard is significant as the human immunodeficiency virus (HIV) and tuberculosis (TB) are the leading causes of death in adults and children in both India and South Africa, and the impact of the converging dual epidemics is one of the major public health challenges of our time. Development of effective biomedical tools and solutions for diagnosis, prevention and treatment of AIDS and tuberculosis is required to address challenges in disease management and control.
Interdisciplinary research in these areas will not only accelerate development of transformational technologies but also help to develop capabilities and solutions for these unconquered diseases. The proposal should be geared towards product development or have clinically useful applications. It should have intra country linkages and a strong collaborative component utilizing complementary expertise of both countries, and addressing regional needs.
Scientists in either country could also submit proposals in case they have an existing product or a proof of concept and they would like to access facilities in either country for a collaborative framework to help facilitate product development in an accelerated manner (e.g. manufacturing, preclinical testing etc.). The programme is aimed to facilitate partnerships between research institutions in India and South Africa. This programme will leverage upon existing scientific capacities, enable technology transfer and catalyze mentorship/training. Thus, this collaboration will synergistically advance discovery efforts towards development of new technologies and products for prevention and management of HIV/AIDS and TB by building scientific leadership capacity, fostering a sustainable environment for translational research and enhancing clinical capability/capacity. In South Africa, this call for proposal is open to researchers residing in South Africa and who are affiliated with a recognized higher educational or research institution such as a university, university of technology or science council. The South African applicant must be in possession of a PhD. Private sector companies are not eligible for this call. In India, the lead Indian applicants should be scientists/faculty members working in regular capacity in universities, academic institutes or national research and development laboratories/institutes. Private sector companies are not eligible for this call.