Breaking the drug-resistant TB transmission cycle important

GeneXpert

Nearly two months after the Health Ministry set a highly ambitious target of working towards elimination of tuberculosis by 2025, a study published in The Lancet Infectious Diseases indicates that India’s TB crisis is all set to snowball by 2040 when one in 10 cases could be drug-resistant. What is even more alarming is that the increased number of drug-resistant cases — both multidrug-resistant TB (resistant to more than one of the first-line drugs) and extensively drug-resistant TB (additionally resistant to fluoroquinolones and at least one of the second-line injectable drugs) — will come from direct transmission from infected people to others rather than by strains acquiring resistance to TB drugs during treatment due to inappropriate treatment or discontinuation of treatment midway. The study found that “most incident” MDR cases are “not caused” by acquired drug resistance, and that acquired drug resistance will become a “decreasing cause” of drug-resistant TB. The increased availability of drugs to fight drug-sensitive TB has led to the emergence of MDR-TB strains. With increasing number of MDR-TB cases, there has been a shift in the way people get infected with drug-resistant TB — from strains acquiring drug resistance during treatment to direct transmission of MDR-TB strains from an infected person. The same trend is seen in the case of XDR-TB too. As a result, in high MDR-TB burden countries such as India, improved treatment outcomes in people might only reduce and not eliminate drug-resistant TB. Till 2015, only about 93,000 people with MDR-TB have been diagnosed and put on treatment.

The study, based on a mathematical model to forecast how TB is likely to progress in the four most-affected countries (Russia, the Philippines and South Africa, India), suggests that the number of new MDR-TB cases in a year in India will touch 12.4% by 2040, up from 7.9% in 2000. In the case of XDR-TB, the incident cases will rise to 8.9%, up from 0.9% in 2000. In 2015, the four countries accounted for about 40% (more than 230,000) of all drug-resistant TB cases in the world. Besides increasing the number of people who are diagnosed early and successfully treated, India’s TB control programme has come up with enhanced interventions to break the transmission cycle of the bacteria in the community. One of the ways this can be achieved is by carrying out immediate screening of all family members of a patient who has been diagnosed with the disease. Contact screening of family members and preventive treatment of all children below the age of five years who have not developed TB disease are already a part of the Revised National Tuberculosis Control Program (RNTCP) but is rarely done. Another important strategy that has to be adopted is making drug susceptibility testing universal and mandatory. Developing more accurate, cheaper and effective diagnostic tests and improved treatment regimens that are less expensive and of shorter duration will also go a long way in winning the war against the disease.

Published in The Hindu on May 12, 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

About 0.5 million TB patients approaching RNTCP centres are not treated

GeneXpert

In 2013, only 39 per cent of 2.7 million TB patients in India had one year of recurrence-free survival.

In 2013, India had about 2.7 million people with TB, which is 23 per cent of the global burden of TB. India also accounted for 27 per cent (760,000) of the world’s “missing” patients — those may not have received effective TB care or may have received potentially suboptimal TB care in India’s private sector.

According to estimates by a team of researchers, of 2.7 million patients, only 72 per cent were evaluated at RNTCP facilities, about 60 per cent successfully diagnosed, 53 per cent registered for treatment, and 45 per cent completed treatment.  In all, only 39 per cent of 2.7 million patients achieved optimal outcome of one-year recurrence-free survival. The results of study that looked at TB cascade of care at RNTCP were published on October 25 in the journal PLOS Medicine.

“Though most of 27 per cent of “missing” patients are being treated in the private sector; a smaller percentage may not have received any care for TB, though it is hard to know how large this untreated population is. The WHO’s revision of India’s TB burden, released last week, would suggest that this percentage of patients who don’t come into contact with RNTCP TB services is larger than we have estimated,” says Dr. Ramnath Subbaraman from the Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard Medical School, Boston, U.S and the first author of the paper.

The bottom line is that about 500,000 patients (one-fifth of all TB patients) who interfaced with government TB clinics are either not successfully diagnosed or are diagnosed with TB but lost to follow-up before starting treatment.

If only 1.3 per cent of TB smear-positive patients who reached RNTCP diagnostic centres were not correctly diagnosed, 38 per cent of new smear negative patients and 27 per cent of retreatment smear negative patients were not diagnosed. So of all TB patients seeking care at government TB facilities, 16 per cent are not successfully diagnosed.

Soumya Swaminathan. - Photo R. Prasad

We need to know more about how anand where patients seek care, says Dr. Soumya Swaminathan.

“To reach all TB patients and avoid delays in diagnosis, TB services must be available where patients seek care. We need to know more about how and where patients seek care,” says Dr. Soumya Swaminathan, Director-General of ICMR and one of the authors of the paper. “Active case finding in vulnerable populations, use of molecular diagnostics and more suspicion of extrapulmonary TB by doctors are needed to improve TB diagnosis. Attention has to be paid to all steps of cascade.”

Currently, smear-negative TB patients are diagnosed using a multi-step diagnostic workup. As a result, at least 60-80 per cent of patients with negative sputum smear never complete the workup. “While the RNTCP is trying to implement a new diagnostic algorithm for smear-negative TB, the best solution for diagnosing more smear-negative patients would probably be use of new but more expensive diagnostic tests such as Xpert MTB/Rif, which diagnoses a substantially greater percentage of patients with smear-negative TB,” Dr. Subbaraman says.

Ironically, 13 per cent (over 200,000) patients who were diagnosed were lost before the start of treatment — about 16 per cent of smear-positive TB patients and about 10.5 per cent of smear-negative patients.

Pai

Only 11 per cent of MDR-TB patients survived for one year after treatment, says Prof. Madhukar Pai

“There are many reasons why diagnosed TB patients don’t start treatment. But the bottom line is that better record keeping and aggressive tracking of newly diagnosed patients might help to reduce the number of patients who are diagnosed but not enrolled in TB treatment,” says Dr. Subbaraman.

“For patients with MDR-TB, out of the 61,000 who reached government TB clinics, only about 11 per cent completed appropriate treatment and survived for one year after treatment without experiencing disease relapse, ” says Prof. Madhukar Pai, a TB expert from McGill University, Montreal, Canada and one of the authors of the paper.

“The major problem we highlight is not that MDR-TB patients are not seeking care. Rather, a very large percentage of them (59 per cent) were not successfully diagnosed in 2013. I should note that, since 2013, the number of MDR-TB patients diagnosed in the RNTCP has increased a bit in 2014 and 2015, but the percentage of MDR-TB patients successfully diagnosed is still probably abysmally low,” Dr. Subbaraman says.

“There is expansion of Xpert for diagnosing MDR-TB cases. But we need more decentralised rapid MDR diagnostics,” says Dr. Swaminathan.

Published in The Hindu on October 26, 2016

Pharmacies in India may not be causing TB drug-resistance

Pharmacy - Photo R. Prasad

Thirty-seven per cent of 622 pharmacies in Mumbai, Delhi and Patna handed out antibiotics to TB ‘patients’ with symptoms. – Photo: R. Prasad

If an earlier study revealed the tendency of private practitioners to liberally use antibiotics to treat tuberculosis leading to a delay in TB diagnosis and treatment and increase the chances of TB spreading within a community, pharmacies in Delhi, Mumbai and Patna are no better. A study published on August 25, 2016 in the journal The Lancet found that a majority of 622 pharmacies in the three cities dispensed antibiotics to TB patients even when they did not carry a prescription.

According to government guidelines, “pharmacies are required to counsel patients with TB, identify and refer persons with tuberculosis symptoms to the nearest public health facilities for testing” and dispense TB drugs. Much like the private practitioners, pharmacies tend to be the first point of contact for primary care in India.

Srinath Satyanarayana, the first author of the paper from McGill University, Montreal, Canada used standardised TB patients — healthy individuals trained to pose as TB patients and interact with pharmacists — to understand how pharmacies in the three cities treated patients presenting with TB symptoms or microbiological confirmation of pulmonary TB. The other main objective was to determine whether the pharmacies were contributing to the inappropriate use of antibiotics.

The standardised patient 1 presented with 2-3 weeks of cough and fever and was directly seeking drugs from a pharmacy. The standardised patient 2 presented with one month of cough and microbiological confirmation of TB from a sputum test.

Only 13 per cent of simulated patients with TB symptoms and 62 per cent of patients with microbiological confirmation were correctly managed.As expected, liberal dispensation of antibiotics was seen in the case of standardised patient 1. Only 96 of 599 pharmacies (16 per cent) refereed such patients to health-care providers. But ideal case management was in only 13 per cent of the cases as a few pharmacies handed out antibiotics to the patients even while referring them to a physician. Antibiotics (37 per cent), steroids (8 per cent) and fluoroquinolones (10 per cent) were given to standardised patients with symptoms.

“That nearly 37 per cent of the pharmacies are handing our antibiotic to persons presenting with TB symptoms is really worrisome,” says Dr. Satyanarayana in an email to me. But more worrying is the dispensation of fluoroquinolones. “Fluoroquinolones are an essential part of MDR-TB treatment regimen and emerging regimens, so quinolone abuse is a concern,” they write.

In stark contrast, in the case of standardised patient 2 who had a microbiological confirmation of TB disease 67 per cent (401 of 601) of pharmacies referred the patient to a health-care provider.  Like in the earlier case, ideal case management was seen in only 62 per cent as the standardised patient did receive antibiotics (16 per cent) or steroids (3 per cent) even while being referred to a health-care provider.

“In case of TB patients with microbiological confirmation of TB disease, antibiotics (without anti-TB properties) will be ineffective and un-necessary, and can delay the initiation of proper therapy for patients. These patients will continue to spread the disease in the community and TB disease will continue to progress in the concerned individual. Steroids reduce body immunity, suppress symptoms temporarily and can worsen the TB disease,” Dr. Satyanarayana says.

Silver lining

The only silver lining is that none of the pharmacies in all the three cities handed out first-line anti-TB drugs to these “patients.” So pharmacies are unlikely sources of irrational drug use that contributes to multidrug-resistant tuberculosis. “Also, pharmacies are not trying out high end antibiotics such as fluoroquinolones when they realise that the patient has some underlying illness such as TB,” he says.

“TB Drug resistance occurs primarily due to incorrect regimens, intake of drugs irregularly or intake of drugs for very short duration of time. From our study, it appears that pharmacies are not playing a role in deciding the anti-TB regimens and are also not dispensing anti-TB drugs over-the-counter, at least in the three cities that we studied. So the drug resistance in India could be due to either patient related factors or provider related factors or due to health system related factors (which has not created a system for all TB patients in country to access quality assured diagnosis and treatment free of cost and seamlessly),” Dr. Satyanarayana says.

One reason why pharmacies did not dispense anti-TB drugs could be because they belong to a more stringent Schedule H1 category of drugs where details of the prescription and name of the doctors and patients have to be documented and the registry has to be retained for two years.

Indian private sector bears 2-3 times higher TB burden than estimated

GeneXpert

A major revision of the TB burden estimates might be required both for India and the world.

A study has found that in 2014 there were 2.2 million TB patients treated in India’s private sector alone. This is 2-3 times higher than current estimates.

In all probability, the higher TB burden in the private sector might still be an underestimation as drug-resistant TB cases were not taken into account. Thus, the private sector is treating an enormous number of patients for TB, appreciably higher than has been previously recognised. In contrast, the State-run Revised National Tuberculosis Control Programme (RNTCP) treated 1.42 million TB patients in 2014.

According to a 2015 WHO report, six million new TB cases were reported to WHO from across the world in 2014. And India’s TB contribution accounted for 26 per cent of these reported cases. But based on the results of the study, a major revision of the TB burden estimates in India and worldwide might be required. Under-reporting of TB cases could be significantly fuelling drug resistance and have implications for patients across the globe.

More importantly, the results of a study published on August 25 in the journal The Lancet suggests that TB incidence is considerably higher than previously recognised, Prof. Nimalan Arinaminpathy, the first author of the paper from the School of Public Health, Imperial College London, says in an email to me.

India has to redouble efforts to reach patients being treated in the private sector.

Lack of systematic data

Despite the private sector treating more patients than the public sector, systematic data on the private sector was lacking. So the study by Prof. Arinaminpathy looked at the sales of anti-TB drugs containing rifampicin by pharmacists across the country in 2013 and 2014. The team then used this figure to calculate the number of cases. The authors adjusted for TB overdiagnosis in the private sector. There was much variance in the number of patients treated in the private and public sector in different States. For instance, the public sector in Orissa had 1.5-2.8 times the volume of TB medicines prescribed than the private sector but Bihar had three times the volume of TB medicines prescribed in the private sector than public sector. But on a national level, there was nearly twice as much TB treatment in the private sector as in public sector in 2013 and 2014.

The 2.2 million cases treated in 2014 in the private sector was arrived at by considering that TB patients underwent four months of treatment on average and only 50 per cent of TB diagnosis in the private sector was correct. The number of patients treated in the private sector increases when higher accuracy of positive TB diagnosis and shorter average treatment duration were considered.

The results of the study have major implications for TB strategy for India. The disorganised private sector poses several challenges to TB control. Since free TB care is assured even to patients opting for private sector, India has to “redouble efforts to reach patients being treated in the private sector and to deliver the highest possible standards of TB care.”

stethoscope

Indians spent $59 million for TB drugs alone in the private sector in 2014.

Second, surveillance of TB in the private sector has to be strengthened. In 2014, as against 2.2 million cases, only a little over 100,000 cases were notified by doctors in the private sector. “But the government has been making strong progress in engaging with providers in the private sector. There has been a rapid increase of private-sector notifications in the last two years (there were essentially zero in 2011). These are encouraging first steps, and our results show the scale of the challenge ahead,” he says.

 Finally, there is a compelling need to find the true TB burden in the country. “TB burden is typically measured through TB prevalence surveys, the most recent of which was in Gujarat. We may soon see the opportunity to conduct these surveys more broadly across the country, which would cast critical light on the TB burden in India as a whole,” says Prof. Arinaminpathy.

There is an economic cost attached to the disease. Since TB treatment in private sector is met primarily by out-of-pocket expenditure, as no medical insurance in India covers treatment cost, a six-month treatment course for first-line TB drugs would cost $20. The 2.2 million patients seeking care in the private sector would have therefore spent $59 million for drugs alone.

Published in The Hindu on August 25, 2016

TB: DOTS therapy offered by RNTCP should be more flexible

tumkur pic 2-Optimized

Indian patients have to travel long distances every alternative day to reach RNTCP’s DOTS centre, had to put up with inconvenient timings and unfavourable attitude of RNTCP staff.

If there is already a long delay before TB patients in India start treatment, the Directly Observed Treatment Short-course (DOTS) strategy offered by India’s TB control programme does not make it easy for patients to access and complete the treatment. In contrast, patients who took DOTS from private practitioners faced fewer barriers and were more likely to complete the treatment. The result were published recently in the journal BMC Health Services Research.

The study interviewed 33 TB patients who had recently completed or were on the verge of completing treatment in Tumkur district, Karnataka. These patients belonged to three groups — 1) those who had reached the public sector directly and took DOTS at Revised National TB Control programme (RNTCP), 2) who were referred by private practitioners to DOTS centres run by RNTCP and 3) those who took DOTS treatment offered by private practitioners after being diagnosed at public sector.

TB patients are left with a choice — either earn their livelihood or take the DOTS therapy.Despite TB treatment being free, patients and their caregivers faced challenges, and these were related to coping with RNTCP’s DOTS strategy, the paper says. Poor patients residing in rural areas faced the greatest difficulty in overcoming the barriers. They had to travel long distances every alternative day to reach a DOTS centre, had to put up with inconvenient timings and “unfavourable attitude” of RNTCP staff.

With the timing of DOTS centres at RNTCP being fixed (between 9 am and 1 pm), patients had to reschedule their daily routine to make the visit possible. Travel plus the long waiting period at DOTS centres meant that patients and their caregivers, who are mostly daily wagers, ended up missing work for at least half a day. “Thus, they were left with a choice — either earn their livelihood or take the DOTS therapy,” Dr. Vijayashree Yellappa the senior author from the Institute of Public Health, Bengaluru writes.

“For people who are daily wagers… work is more important than the tablet and if the authorities refuse to oblige [with the timings], he will quit the tablet and proceed to work,” one patient told the authors.

IMG_8359 (1)

There is a compelling need to decentralize DOTS providers, says Dr. Vijayashree Yellappa.

One way of solving this is by having more number of DOTS centres to increase its proximity to a patient’s residence. But more importantly, there is dire need to bring in more flexibility in terms of timings. In stark contrast to public sector DOTS centres, patients who approached private practitioners for DOTS could tailor their timings to suit their daily schedule. “TB medicines should preferably be taken in the morning. But they can be had at any time of the day after a meal,” says Dr. Yellappa. “So patients seeking care in the private sector can continue seeking treatment without losing their daily wages.”

Besides flexibility in timings, proximity to private practitioners was a huge factor for patients seeking DOTS treatment from private sector. Also, immediate medical attention was provided when patients faced side effects, which was missing in case of patients seeking DOTS therapy offered in the public sector. Unfortunately, all the patients who sought treatment from private doctors lived in urban areas.

Counselling, especially in the initial stages of DOTS therapy when patients needed it the most, was simply missing when patients sought DOTS therapy at the public sector. “RNTCP does not have qualified practitioners to offer counselling,” she says. The competence of health personnel involved in TB care should be strengthened and better communication between providers and patients should be achieved through appropriate training, the paper says.

“There is a compelling need to decentralise DOTS providers. Whoever is closer to the patients, including private doctors, pharmacists, teachers and anganwandi workers should be allowed to provide DOTS therapy,” Dr. Yellappa says. In one case, a patient’s mother who is a DOTS provider herself was not allowed to give DOTS to her daughter.

The study found that only two patients who had approached the public sector were directed to private doctors for DOTS treatment. “But it happened only because the patients initiated it,” she clarifies.

With stigma and discrimination already being rampant, the national TB control programme has done little to reduce it. In fact, RNTCP is programmed to cause stigma and discrimination. “Whenever patients start treatment, RNTCP staff visit their homes. Since they don’t keep the intent of their visit subtle, everyone comes to know of the patient’s TB status,” says Dr. Yellappa. “The programme staff should be more sensitive when they approach patients.”

Currently, the emphasis is more on achieving targets than being patient-friendly. This should change and RNTCP should seriously consider a “patient-centred approach to TB control, delivered with dignity and compassion” as its priority if it intends to provide “universal access to quality assured free diagnosis and treatment to patients”.

Published in The Hindu on August 21, 2016

TB: Social media campaign launched to get Indian government to act

In a desperate bid to urge the Indian government to gets its act together on TB diagnosis and treatment, the Treatment Action Group (TAG) today launched a social media campaign using Twitter called #BrokenTBPromises. The campaign urges the government to live up to promises it has made but has failed to keep in nine areas of TB programme.  TAG is an independent AIDS research and policy think tank fighting for better treatment, a vaccine, and a cure for AIDS. The nine policies have been “delayed time and again” or have been rolled out only in a limited way, the TAG blogs says. “People with and vulnerable to TB in India cannot bear anymore broken promises from their government.”

“It’s clear that without intensified public scrutiny and outside pressure, chronic delays will continue to undermine the drive toward a ‘TB-Free India,’ announced with much fanfare but little follow-through last year,” says a mail sent by TAG to people working in the field of TB, both in India and abroad. The campaign started today with two tweets tagging @PMOIndia. TAG will be tweeting every day at 9 am Indian time and the focus will initially be on the introduction of daily Fixed-dose Combination (FDC) TB drugs.

“In December 2014, the RNTCP [Revised National Tuberculosis Control Programme] announced that it would provide FDCs to people with HIV starting in 104 districts in five States. As of August 1, 2016 — 579 days since the announcement in late 2014 — the roll-out of FDCs is yet to occur,” it says. It is not just the delay but also the government’s attitude to deliver on its promise, particularly the FDCs, that has ticked the NGO. “Each time Indian civil society groups, lead by networks of people living with HIV/AIDS, have written to the RNTCP, the deadline for procuring and delivering FDCs gets pushed farther and farther back. This happened again just last week,” the mail reads. To begin with, TAG is urging the government to fix the #BrokenTBPromises by starting the provision of daily FDCs drugs to people with HIV and children.

“Starting tomorrow [August 1], Treatment Action Group will publicly count up each day that passes without daily FDCs. We will only stop the count when daily FDCs are available to people with HIV and children with TB nationwide,” the mail says.

The NGO plans to exert pressure on the government by tweeting on other delayed TB projects in the second and third week of the campaign.

Ensuring FDCs are provided to needy people is not the only promise the government has not kept. “As the count goes on, we will call on Prime Minister Modi to make good on several other TB programmes and policies,” the blog says.

These programmes include: the national roll out of TB diagnostic test GeneXpert; the scale-up of drug-susceptibility testing; the roll-out of bedaquiline, a new generation drug for MDR-TB patients; the provision of isoniazid preventive therapy for people with HIV and children under five years who have come in contact with people with TB; the provision of rifabutin  for treatment of HIV-associated TB and; the phase out of the category II retreatment regimen.

“Until these programs and policies are in place, people affected by TB in India will be left waiting on the platform, staring down the empty tracks, for a TB elimination campaign that never arrived.”

“Join our count by following and re-tweeting messages from @TAGteam_tweets using the hash tag #BrokenTBPromises and tagging @PMOIndia, the official twitter account of Prime Minister Narendra Modi. You can also write to Narendra Modi directly by filling out the short formWrite your own message, or use the template provided under the tab “Take Action,” found at the top of this page,” the blog urges all concerned people.

The reason why TAG has taken this unusual route to exert pressure on the Indian government is because the way India responds to the TB epidemic will have a telling global impact.

It may be recalled that the Union Health Minister had on April 23, 2015 launched the TB Free India Campaign to much fanfare. But even a year later the campaign has all but not taken off. As a result, many programmes — from diagnosis to prevention — essential to stop TB on its track are yet to be implemented.

Every year, about 2.2 million people in India are diagnosed with TB disease and about 250,000 die from this disease which can be easily prevented, treated and cured. “Every death due to TB is avoidable and represents the failure of India’s government to uphold the human rights of its citizens,” the TAG blog says.