Short Anti-TB Regimen (BPaL)


    In News

    • Recently, a short tuberculosis treatment regimen of six months called BPaL as against the usual 18-month protocols has won the scientific vote with trials in multiple countries showing it had favourable outcomes in 84% to 94% of the sickest TB patients

    About BPaL

    • BPaL is a combination of three newer antibiotics: bedaquiline, pretomanid and linezolid.
      • In India the three-antibiotic combination is still under clinical trials and the regimen could be included in the national TB programme.
    • Three doses: While two components pretomanid and bedaquiline are novel drugs developed by TB Alliance and Johnson & Johnson. Linezolid is an old generic drug. 
      • The three drugs are approved in India. 
    • Mode of BPaL: It is an oral regimen. 
    • WHO: the WHO has approved regimens containing pretomanid for all forms of drug-resistant TB. 

    Data/ Facts

    • India has the world’s highest TB burden: 2.6 million active cases and close to 450,000 deaths each year from the infectious bacterial disease.
      • Mumbai is often called the capital of drug-resistant TB cases. 
        • It has the largest number of TB patients on the newer short which is injectionless BPaL in India.
    • TB Alliance: It is the New York-based non-profit that discovers and offers drugs to fight tuberculosis (TB). 
    • XDR-TB: Extensively drug-resistant tuberculosis (XDR-TB) is a rare type of multidrug-resistant tuberculosis (MDR-TB) in which several of the most effective and core anti-TB drugs fail to work against microbial activity.


    Issue with BPaL 

    • Side-effects: the right proportion of these three drugs is a big worry as some patients developed side-effects affecting the nervous system and vision to BPaL.

    Significance of BPaL

    • There has been no mortality among BPaL trial patients even though most had advanced disease.
    • BPaL regimen is approved by the U.S. Food and Drug Administration (FDA) for the treatment of adults with pulmonary extensively drug-resistant tuberculosis (XDR-TB) or multidrug-resistant TB (MDR-TB) that is treatment-intolerant or non-responsive.
    • Oral treatment: Patients no longer have to undergo painful daily injections for months.


    • Cause:
      • It is caused by Mycobacterium tuberculosis (bacteria) and it most often affects the lungs.
    • Transmission:
      • TB is spread through the air when people with lung TB cough, sneeze or spit. 
      • A person needs to inhale only a few germs to become infected.
      • With TB infection, a person gets infected with TB bacteria that lie inactive in the body. This infection can develop into TB disease if their immune system weakens. 
    • Symptoms:
      • Prolonged cough, chest pain, weakness/fatigue, weight loss, fever, etc.
      • Often, these symptoms will be mild for many months, thus leading to delays in seeking care and increasing the risk of spreading the infection to others.
    • Diagnosis:
      • In the case of suspected lung TB disease, a sputum sample is collected for testing for TB bacteria.
      • For non-lung TB disease, samples of affected body fluids and tissue can be tested.
      • WHO recommends rapid molecular diagnostic tests as initial tests for people showing signs and symptoms of TB
      • Other diagnostic tools can include sputum smear microscopy and chest X-rays.
    • Treatment:
      • Both TB infection and disease are curable using antibiotics.
      • It is treated by the standard 6-month course of 4 antibiotics. Common drugs include rifampicin and isoniazid.
      • In drug-resistant TB, the TB bacteria do not respond to the standard drugs. Its treatment is longer and more complex. It is treated by Bedaquiline.
      • In case of infection (where the patient is infected with TB bacteria but not ill), TB preventive treatment can be given to stop the onset of disease. This treatment uses the same drugs for a shorter time.

    Efforts Taken

    • Global Efforts
      • Global Tuberculosis Programme and Report, 1+1 initiative & Multisectoral Accountability Framework for TB by WHO.
      • Ending the TB epidemic by 2030 under UN SDG target 3.3.
      • Moscow Declaration, 2017 to End TB.
    • Indian Efforts
      • The government aims to have a TB-free India by 2025, five years ahead of the global target of 2030.
      • National Tuberculosis Elimination Programme: National Strategic Plan to end TB by 2025 under pillars of Detect-Treat-Prevent-Build (DTPB).
      • Universal Immunisation Programme.
      • Revised National TB Control Programme under the National Health Mission.
      • NIKSHAY portal and TB Sample Transport Network.
      • Development of National Framework for Gender-Responsive approach to TB.

    Challenges associated with TB

    • The redirection of human resources within the health system during the three COVID waves has left TB facilities understaffed leading to poorer quality and delayed care.
    • Studies have suggested that COVID may trigger pathways leading to reactivation of dormant TB bacilli.
      • Historically, turmoil in society (such as wars), food insecurity, poverty and malnutrition have resulted in surges in the incidence of TB.
      • We could, therefore, witness an increase in TB in the coming years.
    • Malnutrition, poverty and immuno-compromising conditions such as diabetes are some of the factors strongly associated with TB.
      • Over a hundred million Indians smoke tobacco which is a strong risk factor for both developing TB, and dying from it.

    India specific suggestions

    • India needs to triple the funding not just for TB but for health, nutrition and preventive services.
    • India needs to invest in state-of-the-art technologies, build capacity, expand its health workforce and strengthen its primary care facilities.
    • It also needs to consider telemedicine and remote support as important aspects of health services.
    • Open and collaborative forum: Most importantly, before embarking on any of this, it needs to build an open and collaborative forum where all stakeholders, especially affected communities and independent experts, take a lead role.
    • COVID has been a stellar example of how investments and actions can be swift and public education can transform behaviour.
      • Similar aspirations for TB can help turn this crisis into an opportunity to re-imagine our overburdened and underfunded systems.
    • We need to actively engage the private sector, build bridges and partnerships as we did in the case of COVID.

    Way Forward

    • Shorter regimens are the need of the hour in TB treatment especially in crowded places such as metro cities.
    • Acceptability and feasibility of the BPaL regimen is high among TB stakeholders in Indonesia, Kyrgyzstan, and Nigeria.  

    Source: TOI