NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

Friday, August 16, 2013

Tuberculosis is very much in the news, but for all the wrong reasons — a shortage of drugs; increasing multi-drug and extensive drug resistance (MDR, XDR), making treatment both cumbersome and expensive; total drug resistance (TDR) as a veritable death warrant; popularly used serological tests for diagnosis being declared worse than useless, and a government order for mandatory case notification. Private practitioners are legally authorised to treat TB, but without quality check mechanisms. They often bypass the prescribed treatment protocol, while MDR, XDR and TDR result from non-protocol drug treatment.

India pioneered TB control among developing nations. A national TB control project was launched in 1962. With BCG vaccination as the main intervention, there was an air of expectancy that it would protect against TB. Free TB treatment was included to create goodwill in the community, with public-private partnership (PPP). When “directly observed treatment, short course” (DOTS) became popular, PPP was neglected — a fatal flaw in TB control. In 2012, India’s golden jubilee year of TB control, the World Health Organization (WHO) named India the worst performer among developing nations, with 17 per cent of the global population carrying 26 per cent of the global TB burden.

BCG vaccination

India’s TB control pioneers P.V. Benjamin and Frimodt-Moller introduced the mass BCG vaccination in the hope that it would protect against infection by TB bacilli. Preventing infection is key to disease control. BCG manufacturing began in Chennai and an extensive vaccine trial was launched in Chengalpattu district, Tamil Nadu, to measure its protective efficacy. In 1978, the Expanded Programme on Immunisation took over BCG vaccination. In 1979, preliminary results of a 15-year-long BCG trial showed no protection against infection by TB bacilli. The disappointing results were much debated, and ignored by the then TB control leadership. In 1999, the final results, which were published in the Indian Journal of Medical Research, confirmed that the TB control project had lost the tool of primary prevention.

In 2000, the Indian Academy of Pediatrics called for a major redesign of TB control, with alternative tactics to prevent infection and treat infection before it caused disease. WHO’s 2012 Annual Report on TB confirmed India’s failure. DOTS saves lives from TB mortality, but has failed to control TB.