In a breakthrough, a blood test can diagnose TB disease

TB photo-Optimized

This is an animation depicting an active TB infection targeting the lungs. — Jason Drees, Biodesign Institute at Arizona State University

In a marked departure, researchers have used a rapid blood test that relies on two Mycobacterium tuberculosis-specific peptide fragments for diagnosis of TB disease and monitoring treatment. Currently, sputum samples are used for diagnosing TB disease in the case of pulmonary TB and tissue samples in the case of extra-pulmonary TB. The blood test accurately detects minute levels of two biomarkers — CFP-10 and ESAT-6 — that are “actively secreted” by the bacteria when it causes TB disease. Currently, the assay costs less than $10.

In a pilot study, the new blood test was able to diagnose active TB cases with “high sensitivity and specificity”. It was able to diagnose active TB even in people who were coinfected with HIV. The results were published in a paper published today (March 28) in the Proceedings of the National Academy of Sciences (PNAS) by Chang Liu from Houston Methodist Research Institute. Dr. Liu is currently at Arizona State University.

The blood-based assay was able to provide quantitative results that will help in knowing the severity of active TB and in monitoring treatment outcomes. Unlike Xpert, it cannot detect rifampicin resistance.

The blood-based assay was able to diagnose both pulmonary and extra-pulmonary TB cases with high sensitivity — over 91% in the case of culture-positive pulmonary TB (PTB) and above 92% extra-pulmonary TB (EPTB), and 82% in culture-negative PTB and 75% in EPTB in HIV-positive patients. In the case of HIV coinfected cases, the sensitivity was 87.5% for PTB and 85.7% for EPTB cases. It also had high specificity (87-100%) in both healthy and high-risk groups.

“We want to detect only active TB, but not latent TB, so we selected CFP-10 and ESAT-6. However, we believe these two biomarkers are capable of detecting early activation of latent TB, but we are conducting more experiments to confirm that,” says Dr. Liu in response to a question on the choice of the two peptide fragments.

According to a 2014 WHO report, there is a need for a “rapid biomarker based non-sputum-based diagnostic test that uses an easily accessible sample and is able to accurately diagnose pulmonary TB (and ideally also extrapulmonary TB)”.

Obtaining sputum samples is not always easy and is particularly difficult in the case of little children and people who are HIV positive. About 15-25% of all TB cases are extrapulmonary and biopsy samples are needed in such cases. Even Gene Xpert, introduced a few years ago to improve sensitivity and specificity, relies on sputum samples, and as per a 2014 WHO update, Xpert has “very low quality evidence” for EPTB diagnosis. Also, cerebrospinal fluid or other samples are needed for diagnosing EPTB using Xpert.

The blood-based TB diagnostic assay will be go a long way in the war against TB, particularly in diagnosing TB in little children, people with HIV and extra-pulmonary TB cases.

The blood sample is first microwave irradiated for about 20 minutes, and the target peptides are enriched using a nanoparticle enrichment platform and a high-throughput mass spectroscopy for enhancing the detection of Mycobacterium-specific biomarkers. It take some about four hours to prepare a serum sample and 10 minutes to know if the two peptides are present in the blood.

“CFP-10 and ESAT-6 are also expressed by some other mycobacteria, they cause NTM infection, not TB. We discovered peptides in CFP-10 and ESAT-6 that are specific to TB. So we digest the two proteins [using microwave irradiation] before diagnosis,” Dr. Liu, who is the first author of the paper, says in an email. “NanoDisk is functionalized with antibody. Their capture and isolate the peptide targets from patient serum sample. In addition, due to their special material and nanostructure, they can enhance the signal of mass spectrometry during detection.”

“We are particularly excited about the ability of our high-throughput assay to provide rapid quantitative results that can be used to monitor treatment effects, which will give physicians the ability to better treat worldwide TB infections,” said Prof. Ye Hu from the Houston Methodist Research Institute and the Corresponding author of the paper said in a release. Prof. Hu  is currently at Arizona State University. “Furthermore, our technology can be used with standard clinical instruments found in hospitals worldwide.”

According to the authors, the NanoDisk-MS assay meets several of the WHO criteria for a noninvasive TB assay — “it uses a small, non-invasive specimen; does not require bacterial isolation; has high sensitivity and specificity for active TB cases in extrapulmonary, culture-negative, and HIV-infected TB patients; and directly quantifies Mtb antigens for rapid monitoring of anti-TB therapy effects”.

The assay was able to detect marked reduction in the peptides levels in both HIV-positive and HIV-negative TB cases that were started on TB treatment. But more studies need to be carried out to evaluate the performance of NanoDisk-MS assay in treatment monitoring as the pilot study was not designed to measure the rate of decline of TB bacteria with treatment.

“We have tested 21 patients (HIV- and HIV+) with multiple longitudinal samples, and were able to see biomarker decrease correlated to treatment in 19 of them. Larger clinical validation is underway [to know treatment resistance and therapeutic efficacy],” he says.

The researchers note that larger, randomised studies are needed to confirm the results of the pilot study.

“Any blood-based, rapid TB diagnostic assay is ideal and has huge potential as it does not depend on sputum samples [for pulmonary TB], and tissue samples in the case of extra-pulmonary TB. But many studies based on blood-based assays have not been successful earlier,” says Dr. Soumya Swaminathan, Director-General of ICMR, Delhi. “High specificity [correctly identify those with the disease] is very important and so large-scale tests have to be carried out in countries like India where a large population has latent TB infection.”

Published in The Hindu on March 28, 2017

Without a magic wand, India cannot eliminate TB by 2025

GeneXpert

Only 93,000 MDR-TB cases have been diagnosed till 2015 in India.

At the end of 50 years of tuberculosis control activities, the disease remains a major health challenge in India. As per new estimates, the number of new cases every year has risen to 2.8 million and mortality is put at 4,80,000 each year. These figures may go up when the national TB prevalence survey is undertaken in 2017-18. Against this backdrop, the Ministry of Health and Family Welfare, in its national strategic plan for tuberculosis elimination (2017-2025), has set a highly ambitious goal of “achieving a rapid decline in burden of TB, morbidity and mortality while working towards elimination of TB by 2025.”

Though the Revised National Tuberculosis Control Programme (RNTCP) has treated 10 million patients, the rate of decline has been slow. Providing universal access to early diagnosis and treatment and improving case detection were the main goals of the national strategic plan 2012-17. But the RNTCP failed on both counts, as the Joint Monitoring Mission report of 2015 pointed out. Going by the current rate of decline, India is far from reaching the 2030 Sustainable Development Goals — reducing the number of deaths by 90% and TB incidence by 80% compared with 2015. Yet, the latest report for TB elimination calls for reducing TB incidence from 217 per 1,00,000 in 2015 to 142 by 2020 and 44 by 2025 and reduce mortality from 32 to 15 by 2020 and 3 per 1,00,000 by 2025.

Incidentally, nearly 50% of people in India are latently infected with TB. According to CDC, 5-10% of infected people will develop TB disease at some time in their lives. “About half of those people who develop TB will do so within the first two years of infection,” the CDC says. With the latently infected people acting as a reservoir, it will be nearly impossible to eliminate TB in India by 2025.

Radical approaches are needed to come anywhere close to reaching these ambitious targets. Most importantly, the TB control programme plans to do away with the strategy of waiting for patients to walk in to get tested and instead engage in detecting more cases, both drug-sensitive and drug-resistant. The emphasis will be on using highly sensitive diagnostic tests, undertaking universal testing for drug-resistant TB, reaching out to TB patients seeking care from private doctors and targeting people belonging to high-risk populations.

The other priority is to provide anti-TB treatment — irrespective of where patients seek care from, public or private — and ensure that they complete the treatment. For the first time, the TB control programme talks of having in place patient-friendly systems to provide treatment and social support. It seeks to make the daily regimen universal; currently, the thrice weekly regimen is followed by RNTCP, and the daily regimen has been introduced only in five States. There will be a rapid scale-up of short-course regimens for drug-resistant TB and drug sensitivity testing-guided treatment. In 2013, India “achieved complete geographical coverage” for MDR-TB (multi-drug-resistant tuberculosis) diagnosis and treatment.  Yet, only 93,000 people with MDR-TB had been diagnosed and put on treatment till 2015; several MDR-TB cases are simply not diagnosed.

What next?

Though Bedaquiline, the drug for people who do not respond to any anti-TB medicine, is provided in six sites in the country, the number of beneficiaries is very small. It has been a battle to get the drug for treatment, as in the case of an 18-year-old who had to approach the Supreme Court for help. Yet, the report envisages a countrywide scale-up of Bedaquiline and Delamanid.

In a marked departure, the report underscores the need to prevent the emergence of TB in susceptible populations. One such segment is those in contact with a recently diagnosed pulmonary TB. Incidentally, active-case finding is already a part of the RNTCP programme but rarely implemented. It wants to increase active case finding to 100% by 2020. Since RNTCP expenditure has increased by 27% since 2012 and is inadequately funded, the Ministry proposes to increase funding to ₹16,500 crore.

Acknowledging that the business-as-usual approach will not get the Health Ministry anywhere close to the goals, it has earmarked critical components that will be addressed on priority. These include sending customised SMSes to improve drug compliance, incentivising private doctors to notify cases and providing free medicines to patients approaching the private sector, facilitating nutritional support to TB patients, including financial support, rewarding States performing well in controlling TB, and using management information systems to monitor all aspects of TB control. “The ultimate impact of this national strategic plan will be transformational improvements in the end TB efforts of India,” the report says. It plans to take a “detect-treat-prevent-build approach” in its war against TB.

Published in The Hindu on March 19, 2017

Can health spending of 2.5% of GDP only by 2025 help achieve the goals set by India’s National Health Policy?

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The National Health Policy wants to reduce infant mortality rate to 28 per 1,000 live births by 2019.

The long awaited National Health Policy announced a few days ago proposes to raise public health expenditure as a percentage of GDP from the current 1.15% to 2.5% by 2025. The resource allocation to individual States will be linked with their development indicators, absorptive capacity and financial indicators. “There will be higher weightage given to States with poor health indicators and they will receive more resources. The Policy aims to end inequity between States. But at the same time, States will be incentivised to increase public health expenditure,” says Manoj Jhalani, Joint Secretary — Policy, Ministry of Health and Family Welfare.

The catch

While public health expenditure as a percentage of GDP will reach 2.5% only by 2025, many of the goals listed in the Policy have a deadline of 2025 and some of them even earlier.

The Policy stresses on preventive healthcare by engaging with the private sector to offer healthcare services and drugs that are affordable by all. It wants to reduce out-of-pocket “catastrophic” health expenditure by households by 25% from current levels by 2025.

The focus is on providing free, comprehensive care in primary care for the most prevalent communicable and non-communicable diseases, and increased affordability of care at secondary and tertiary care services by a combination of public and not-for-profit private providers wherever necessary. It wants to increase the utilisation of public health facilities by 50% from the current levels by 2025.

Health card roll out

The Centre is working on introducing a health card — an electronic health record of individuals. “The health card will be for retrieving and sharing health data by lower [PHC] and higher [secondary and tertiary] healthcare facilities. It will be helpful when patients move from primary to secondary or tertiary healthcare facilities,” says Mr. Jhalani. “It will be launched in six months to one year’s time. It will be launched in those States that show interest to roll it out in certain districts or across the State.”

Disease control and elimination

Like the Health Ministry’s National strategic plan for tuberculosis elimination 2017-2025 report, the Policy wants to reduce incidence of new TB cases to reach elimination by 2025. In a similar vein, the policy has set 2017 as the deadline to eliminate kala-azar and lymphatic filariasis in endemic pockets, and 2018 in the case of leprosy. In the case of chronic diseases such as diabetes, cancer, cardiovascular diseases, it envisages a 25% reduction in premature mortality by 2025.

The Policy “aspires” to provide secondary care right at the district level and reduce the number of patients reaching tertiary hospitals. For the first time, there is any mention of public hospitals and facilities being periodically measured and certified for quality.

Pipe dream

The Policy has sharpened its war on tobacco by indicating a 15% relative reduction in tobacco use prevalence by 2020 and 30% by 2025. But the most ambitious target is providing access to safe water and sanitation by all by 2020. As per January 2016 Ministry of Drinking Water and Sanitation country paper, sanitation coverage was only 48%.

Reducing IMR and MMR

Other challenging targets set by the Policy include reducing infant mortality rate to 28 per 1,000 live births by 2019 and under five mortality to 23 per 1,000 live births by 2025. According to the National family Health Survey 4, IMR was 41 in 2015-16; it took 10 years to reduce IMR from 57 to 41. Similarly, under five mortality was 50 in 2015-16 and it took 10 years to reduce it from 74. Over 38% children under five years were stunted according to the NFHS-4 report. The Health Policy wants to reduce this by 40% by 2025.

Increasing immunisation coverage

As against 62% children 12-23 months old who were fully immunised in 2015-16 according to the NFHS-4 data, the Policy has set a target of 90% by 2025. “Going up to 70% coverage is hugely a challenge of reaching the community. But beyond 70% coverage, other factors come in and it becomes a very big challenge,” says Dr. Pradeep Haldar, Deputy Commissioner — Immunisation, Ministry of Health. According to J.P. Nadda, the Union Health Minister, the Mission Indradhanush has increased the annual increase in full immunisation from 1% to 5-7%.

Published in The Hindu on March 19, 2017

Top health stories of 2016

On the health front, the year 2016 witnessed a few setbacks and but also a few positive developments. Here are the most important health developments of 2016

1. Trial results confirm Ebola vaccine provides high protection

who-ebola-optimizedThe Ebola virus that killed more than 11,300 people in three West African countries — Guinea, Liberia and Sierra Leone has finally met its match.

In December, an Ebola vaccine trial carried out in 2015 in nearly 12,000 people in Guinea was found to be safe and highly protective against the deadly virus.

No Ebola cases were recorded in nearly 6,000 people who received the vaccine, while there were 23 cases in the arm that received the vaccine after a 3-week delay. The trial used an innovative design called a “ring vaccination” approach — the same method that was used to eradicate small pox. In the ring vaccination strategy, whenever a new Ebola case was diagnosed, all the people who may have been in contact with that person were traced and included in the trial.

The vaccine was found to have high efficacy even when the interim results were announced. So everyone included in the trial was offered the vaccine immediately, including children older than 6 years.

A total of 28,616 Ebola cases and 11,310 deaths have been reported in three countries, as on June 2016.

Oraquick2. HIV self-testing gets a shot in the arm

Access to and uptake of HIV diagnosis got a shot in the arm when the WHO in November released new guidelines on HIV self-testing. Lack of an HIV diagnosis has been a major obstacle in the war against HIV.

Today, 40 per cent of all people with HIV (over 14 million) are simply unaware of their status. While more than 18 million people with HIV are currently taking anti-retroviral treatment (ART), and a similar number is still unable to access treatment as many are not aware of their HIV positive status.

Only 30 per cent of men have tested for HIV. As a result, men with HIV are less likely to be diagnosed and more likely to die of HIV-related causes than women.

Testing also remains low among high-risk population such as men who have sex with men, sex workers, transgender people, injection drug users, and people in prisons.  These people comprise nearly 44 per cent of the 1.9 million new adult HIV infections that occur each year.

People can use oral fluid or blood- finger-pricks to discover their status in the comfort of their house with no fear of being subjected to stigma and discrimination. This is bound to encourage more people to get tested.

Results are ready within 20 minutes or less. Those with positive results are advised to seek confirmatory tests at health clinics. Twenty three countries currently have national policies that support HIV self-testing. India is yet to approve HIV self-testing.

zika-microcephaly - Photo WHO3. Zika virus and public health emergency of international concern

On November 18, the World Health Organisation declared that Zika virus is no longer a public health emergency of international concern. It was in February that the WHO declared the Zika outbreak and congenital malformations and neurological disorders in newborns believed to be caused by the virus as a global public health emergency. Brazil has been the worst affected by the virus.

A distinct pattern of birth defects caused by Zika infection during pregnancy is now officially known as congenital Zika syndrome.

In November, a study showed that a small group of Zika-infected babies in Brazil who were born with normal-size heads had developed microcephaly five months to a year after birth.

The virus that has caused about 2,300 confirmed cases of microcephaly (a congenital disorder where babies are born with a small head) since May 2015. The link between Zika virus and microcephaly was established in May this year. After the initial spread to 67 countries, including countries in Southeast Asia, the spread has since slowed down.

While Aedes species of mosquitoes is the primary vector that transmits the virus, it can also be transmitted though semen, blood, tears and other blood fluids. Unlike in the case Ebola, scientists are yet to find an efficacious vaccine against Zika virus. And we are yet to fully understand the entire spectrum of neurological problems that may show up in children born with microcephaly. Meanwhile, the WHO has advised that pregnant women refrain from travelling to countries where local transmission of Zika virus is still prevalent.

GeneXpert4. Incidence of TB in India increases sharply

Although global TB deaths dropped by 22 per cent between 2000 and 2015, TB is still one of the top 10 causes of death worldwide. It kills more people than HIV and malaria.

Of the estimated 10.4 million new cases worldwide, the estimated number of new cases in India alone has increased sharply from 2.2 in 2014 to 2.8 million in 2015. The true incidence in India will be known once the national TB prevalence survey scheduled to begin next year is completed. Besides the uptick in incidence, the number of estimated deaths caused by TB has also more than doubled from 220,000 in 2014 to 483,000 in 2015.

The sudden increase in TB incidence in India is due to 34 per cent increase in case notification between 2013 and 2015 by doctors in the private sector. Yet, in 2015, notification by private-sector doctors was only 16 per cent of the total case notification. Of the 2.8 million estimated cases each year in India, only 1.7 million cases both in the public and private sector were notified in 2015. So the remaining 1.1 million cases are simply not known.

anopheles-gambiae-mosquito-james-gathany-cdc5. Sri Lanka becomes malaria-free

In September, Sri Lanka achieved a huge public health success when the WHO declared it as malaria-free. There has been no local transmission nation-wide in Sri Lanka since October 2012. The WHO certifies a country as malaria-free when the chain of local transmission has been interrupted nationwide for at least three years. With this, Sri Lanka joins the ranks of 34 countries that have been certified as malaria-free since 1960s.

With no local transmission currently, Sri Lanka’s focus is on preventing the re-introduction of malaria from outside, particularly countries such as India, which are malaria-endemic. There were 95 re-introduced cased in 2013, 49 cases in 2014 and 36 cases in 2015.

Sri Lanka was able to win the war against malaria by targeting both the vector and the parasite. This was achieved by active detection of cases and targeting parasite carriers by screening people whether they had malaria symptoms or not.

It came to eliminating malaria in 1963 when it reported just 17 cases including six that were due to local transmission.

Zika - antenatal-care. Photo WHO6. Thailand ends vertical transmission of HIV

In June, Thailand became the first country in the Asia-Pacific region to end vertical transmission of HIV from mother to child.

In 2000, an estimated 1,000 children in Thailand were infected with HIV due to vertical transmission. But in 2015, the numbers dropped dramatically to just 85, a decline of more than 90 per cent. The rate of mother-to-child transmission of HIV has been reduced to less than 2 per cent.

Thailand achieved this feat by ensuring that 98 per cent of all pregnant women with HIV had access to antiretroviral therapy. Women with HIV have a 15-45 per cent chance of transmitting the virus to their children during pregnancy, labour, delivery or breastfeeding if they are not on treatment during pregnancy. But the risk drops to just over 1 per cent if antiretroviral medicines are given to both mothers and children throughout the stages when infection can occur.

Treatment to prevent vertical transmission is not 100 per cent certain.  So vertical transmission is considered to be eliminated when a country successfully achieves a reduction in transmission to such a low level that it no longer constitutes a public health problem.

Besides treating pregnant women with HIV with antiretroviral medicines, Thailand witnessed a sharp drop in the number of women in the child-bearing age becoming infected with HIV. Between 2000 and 2014, the annual number of women newly infected with HIV fell from 15,000 to 1,900 — an 87 per cent reduction.

polio7. Polio end game starts across the world

In April, 155 countries including India switch from using a trivalent oral polio vaccine that contains type 1, type 2 and type 3 strains to a bivalent oral polio vaccine that contains only type 1 and type 3 strains. The global vaccine switch took place between April 17 and May 1.

The reason for removing the type 2 strain from the vaccine was to confer better protection against polio. The oral polio vaccine contains live, weakened virus, which on rare occasions can turn virulent and cause vaccine-derived poliovirus. Though wild poliovirus type 2 was eradicated in 1999, all type 2 polio cases have been caused only by vaccine-derived polioviruses.  The type 2 strain in the trivalent OPV had caused over 90 per cent of vaccine-derived poliovirus cases in the world in the last 10 years.

Polio, including vaccine-derived polio, can be eradicated only when oral polio vaccine is eventually withdrawn after wild polio transmission has been stopped. Removing type 2 strain from the vaccine and switching over to a bivalent vaccine is the “first major step” of this withdrawal process.

Published in The Hindu on December 28, 2016

Nandita: Deaf but not out

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Nandita Venkatesan lost her hearing in the blink of an eye due to TB injection. – Photo: R. Prasad

When she woke up after a short afternoon nap on November 22, 2013, two days after her 24th birthday, Nandita Venkatesan could see her mother and brother talking to her but could understand nothing; she could hear sounds but could not comprehend them. The noisy world around her almost fell silent. Her hearing loss was 80 per cent in the left ear and 50-60 per cent in the right ear. It has since deteriorated to over 90 per cent in both ears. The villain was the second-line anti-tuberculosis injection kanamycin that she had had for about three months.

Venkatesan’s first tryst with tuberculosis (TB) was in August 2007 when she was diagnosed with intestinal tuberculosis just a month after starting college in Mumbai. Popping 10-15 pills a day for 15 months and battling with the side effects of medication left her with little time to enjoy the pleasures of college life.

As if once was not enough, TB came to haunt her again; she suffered a severe reinfection in 2013. “The memories of the first bout came back to haunt me,” she says in an email. But what she did not realise was that the bacteria were intent on striking a body blow.

The TB infection was severe and medicines alone were ineffective the second time around. “The gnawing abdominal pain was far more severe than the first time and continued despite the medication. I convulsed with acute pain and it started hampering my day-to-day activities. Anything I ate immediately hurt my stomach and passed out undigested,” Venkatesan recalls. The only option left was to undergo a surgery to remove the infected portion of her intestine.

As she was wheeled in to the operation theatre, she reassured herself that things couldn’t get out of hand and she would be on the road to recovery very soon. But that was not to be. Normal life after surgery was short-lived; in a week, she was back in a bigger hospital as her condition had turned critical. Days stretched to months and one surgery turned to four as the infection spread. She underwent three major operations back to back and began second-line drugs after the second surgery when doctors found TB had spread beyond the intestine and she was not responding to first-line drugs. But the culture test result revealed that she was not infected with drug-resistant TB.

Walking skeleton

Solid food was ruled out and only small sips of water every hour were allowed. Nutrition plays a crucial role in recovering from TB but she had to subsist on IV fluids alone and this took a huge toll on her body. She became a walking skeleton after losing 23 kg. Her hair started to fall out. “I vividly remember going for a small walk in the hospital and seeing a reflection of myself in a glass window — with bald patches. I couldn’t recognise myself,” Venkatesan says.

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Nandita at the hospital.

“I was in hospital for two months. Since TB had started to spread to other parts of my body, it led to serious complications. Honestly, I didn’t know if I would survive, all I knew was that I was not going to give up,” she says.

After the surgeries, Venkatesan thought she was done with her quota of pain. Little did she realise that the worst was yet to come: her ordeal had just begun with permanent hearing loss. Soon she was hurtling from one problem to another — low BP, low sugar leading to memory loss on five occasions, and elevated creatinine levels.

“It felt like I would never be able to laugh again in my life,” she says. “But I soon realised I had to make the best of the worst situation. I could not sit and feel sorry for myself. In concentrating too much on the closed doors, I forgot to pay attention to the small windows of opportunity and hope. The way out, I felt, was to accept the situation and learn from it. Acceptance helps you move on and find solutions rather than wallowing in self-pity.”

nan-1-optimized

Despite being profoundly deaf, she still dances.

Surviving two bouts of TB infection has taught her to be a fighter and never give up even when pushed to the edge. The inner strength that once turned her into a warrior while in hospital emerged once again. She went back to dancing, her first love, but this time without the luxury of hearing the music. “I took to dance as a way to emerge from my closet and as a means to regain my shattered confidence. I saw it as a means to channel my pent-up energy and exasperation,” Venkatesan says. When she learnt that her dance school was organising a programme, she embraced the opportunity.

Determination, perseverance and imagination have been her strengths. Though profoundly deaf (she can only hear sounds as loud as the bursting of crackers), she slowly learnt to grasp dance steps and co-ordinate with her partners. The dancer in front of her acted as a cue and she memorised the beats, lyrics and steps. She could also feel the vibrations of the rhythm with the help of a hearing aid. “I also use number counts to grasp the beats. For example, if the beats are: Tai…Ta Ka Ki Ta, I convert them to numbers 1…1-2-3-4,” Venkatesan says. “Dance has proved to be incredibly cathartic. It has helped me embrace this ‘rebirth’ and the next stage of my life with more conviction. I guess, ultimately, the desire to dance won against the instinct to flee!”

Battle ready

It may not be an exaggeration to say that Venkatesan has mastered the art of adaptability. Having learnt to lip-read quite well, she has now started learning sign language. She has also learnt to handle everyday challenges like crossing the road by following a person. Venkatesan has been working in a financial newspaper in Mumbai since April this year. “I took a big step towards conquering my disability and kicking TB out of my life,” she says about her decision to work.

Besides actively participating in several programmes to raise awareness about TB as a survivor, Venkatesan is thinking big. She will be participating in the international group action.org’s TB R&D media and public speaking programme to be held in Berlin in January 2017. She also intends to pursue a doctorate in a few years.

“I am far more comfortable in my skin than before. The deafness does bother me sometimes but I have understood what I am capable of,” she says. As a message to other TB survivors, Venkatesan says: “The key is this: be brave; be determined. Take it as a second chance at life. Besides, when life pushes you over, you ought to push back harder!”

Published in The Hindu on December 10, 2016

Time India got serious about fighting TB

GeneXpert

The number of estimated TB deaths in India shot up from 220,000 in 2014 to 483,000 in 2015

Pushed to a corner owing to lack of political will on the part of countries with a high burden of tuberculosis, the World Health Organisation has called for the first United Nations General Assembly session on the disease. The fight against TB cannot be won as long as the high-burden countries, particularly India which has the highest TB burden in the world, do not galvanise their government machinery effectively. While the number of deaths caused by TB and the incidence rate had been consistently dropping from the historical highs globally, there has been a recent uptick that is much larger than previously estimated. The primary reason is the sharp increase in the incidence estimate from India — from 2.2 million cases in 2014 to 2.8 million in 2015. Ironically, the revised disease burden estimate for India is an “interim” one; the actual burden, which could be much higher, will be known only when the national TB prevalence survey that is scheduled to begin next year is completed. The number of estimated deaths caused by TB more than doubled from 220,000 in 2014 to 483,000 in 2015. As in the case of incidence, the revised estimate for deaths could also be an underestimation.

The increase in incidence owes to a 34 per cent rise in case notifications by health-care providers in the private sector between 2013 and 2015. Yet, in 2015 notifications by doctors in the private sector comprised only 16 per cent of the total. Though notification was made mandatory in 2012, only 1.7 million incident TB cases in the public and private sectors were notified in 2015. Thus the fate of 1.1 million patients is simply not known: they have fallen off the radar. For an effective fight against TB, the control programme needs to be aware of every single patient diagnosed, and offer treatment to all. If there are only about 50 per cent of the patients approaching the private sector who successfully complete treatment, a recent study has shown that in 2013 only about 65 per cent of the 1.9 million who approached the public sector completed the treatment regime. The crisis has been aggravated with the disease becoming more expensive and difficult to treat and the number of people with drug-resistant forms increasing. The national TB control programme is behind schedule with respect to critical programmes including the expansion of the GeneXpert pilot programme, scaling up of drug sensitivity testing, and the introduction of a child-friendly paediatric TB drug. Only sustained action on several fronts can help bring TB under check. The global war will not be successful till India wins the battle within its own boundaries first.

Can The Union think out of the box to hold the Lung Health conference in India? 

GeneXpert

The venue of the Union Conference on Lung Health is chosen based on who wins the bidding process.

“The Union World Conference on Lung Health is the largest annual meeting focusing on the issues as they relate to low- and middle-income countries and populations,” says The Union website.  Tuberculosis is one of the important topics covered during the conference held every year in different countries. This year’s venue was Liverpool.

But why Liverpool, I wonder. Is United Kingdom one of the TB high burden countries in the world? Far from it. Last year the conference was held in Cape Town, South Africa. But the Union Conefernce on Lung Health in 2014 was held in Barcelona, Spain. The 2013 conference was in Paris, the 2012 conference was in Kuala Lumpur, Malaysia, 2011 conference was in Lille, France and the 2010 conference was in Berlin, Germany.

Except South Africa, which is one of the high-burden countries like India, none of the other countries where the conference was held is anywhere close to being a high-burden country.

India has the highest TB burden in the world. The data released two weeks ago by the World Health Organisation (WHO) has revealed that India’s TB burden estimate shot up from 2.2 million in 2014 to 2.8 million in 2015. And this upward revision is only “interim” we are told. The true burden will be known only when India completes the national survey that will begin next year. The number of TB deaths more than doubled from 220,000 in 2014 to 483,000 in 2015.

Yet, it’s a long time since the conference was held in India, if at all. If the global war against TB can be won only when TB incidence in India is reined in, the first thing The Union should do is to hold the 2017 conference in India. But sadly, that is surely not going to happen. That is because the selection is based on a bidding process. And the bidding for the 2017 conference has already been completed. Given the dubious distinction of being the world’s capital in terms of number of TB patients, India will surely not bid for the conference anytime in the future.

But the conference, which brings in some 4,000 experts from about 130 countries, will be an ideal opportunity to turn the spotlight on the inadequate steps taken by India to fight the infectious disease. Many reporters from English and language newspapers, magazines and online only websites will be able to attend the meetings and cover the event in great detail. Instead of a couple of news items carried by a handful of newspapers, we would see many articles written by almost every newspaper, magazine and online only websites. TV channels in India would also carry at least the highlights. The conference will act like a pressure point for India.

It will also provide an excellent opportunity for TB activists in India and NGOs to turn the heat on the government. There surely will be a handful of TB survivors who will be willing to highlight problems that the government and international experts are not aware of.  And it will be very difficult for the Union health minister and other senior health ministry officials not to attend the conference.

Since there are so many advantages of holding the conference in India, and knowing that India on its own will not bid for holding the conference, can The Union think out of the box to find a way of holding it in India?

Fighting TB in India needs a lot of imagination and novel approaches, besides willingness and determination. The Union too should exhibit some novelty in its approach.