What Happened
- An economic evaluation by ICMR's National Institute for Research in Tuberculosis (NIRT), published in the Indian Journal of Medical Research (IJMR), found that six-month all-oral treatment regimens for multidrug-resistant and rifampicin-resistant tuberculosis (MDR/RR-TB) are cost-effective and offer improved health outcomes.
- The study assessed the cost-effectiveness of shorter bedaquiline-based regimens -- BPaL (bedaquiline, pretomanid, and linezolid) and BPaLM (with added moxifloxacin) -- compared to the 9-11 month and 18-20 month regimens currently used under the National TB Elimination Programme (NTEP).
- The BPaL regimen was found to be both more effective and more economical than the standard longer regimen.
- The BPaLM regimen was found to be highly cost-effective, with an additional expenditure of only Rs 37 per patient per additional Quality-Adjusted Life Year (QALY) gained compared to the standard regimen.
Static Topic Bridges
BPaL and BPaLM Regimens: A New Era in TB Treatment
The BPaL regimen (bedaquiline, pretomanid, and linezolid) represents a paradigm shift in drug-resistant TB treatment. Pretomanid received FDA approval in August 2019 as part of the BPaL combination. WHO guidelines now recommend the 6-month BPaLM regimen (adding moxifloxacin) as the preferred treatment for MDR/RR-TB, replacing the previous 9-18 month injectable-containing regimens that had severe side effects and poor adherence rates.
- BPaLM demonstrated the highest treatment success rate (89%) in the TB-PRACTECAL trial, compared to 52-75% for standard regimens
- The standard linezolid dose is 600 mg once daily for both BPaL and BPaLM
- BPaL is recommended for patients without fluoroquinolone resistance and with less than one month of prior bedaquiline/linezolid exposure
- All-oral regimens eliminate the need for painful injections (e.g., kanamycin, amikacin) that previously caused hearing loss in patients
Connection to this news: The ICMR study provides India-specific cost-effectiveness evidence for these WHO-recommended regimens, strengthening the case for their wider adoption under the NTEP and potentially accelerating India's TB elimination efforts.
India's TB Burden and the National TB Elimination Programme (NTEP)
India bears the world's highest TB burden, accounting for approximately 27% of global incidence (2.8 million estimated cases in 2022 out of 10.6 million globally). India also accounts for 32% of global MDR-TB and rifampicin-resistant TB cases. The NTEP, formerly the Revised National Tuberculosis Control Programme (RNTCP), aims to eliminate TB by 2025, five years ahead of the UN Sustainable Development Goal target of 2030.
- TB incidence in India fell 21% between 2015 and 2024 (from 237 to 187 cases per lakh population)
- India reported 63,929 diagnosed MDR-TB cases in 2023
- Treatment success rates for MDR-TB have improved to 87%, and 72% for pre-XDR-TB
- The Ni-kshay portal tracks all TB patients digitally across India
- India's TB spending remains below WHO-recommended levels, with concerns about erratic drug supply
Connection to this news: The study's finding that shorter all-oral regimens are both cheaper and more effective directly addresses two critical challenges in India's TB programme: the high cost of treating drug-resistant TB and the poor adherence rates associated with longer, injectable-containing regimens.
Cost-Effectiveness Analysis in Public Health Decision-Making
Cost-effectiveness analysis (CEA) is a standard health economics tool used to compare the relative costs and outcomes of different interventions, typically measured in cost per QALY (Quality-Adjusted Life Year) or cost per DALY (Disability-Adjusted Life Year) averted. In resource-constrained settings like India, CEA provides evidence-based justification for treatment policy changes and resource allocation decisions.
- WHO considers an intervention "very cost-effective" if it costs less than one times the per capita GDP per DALY averted
- India's per capita GDP is approximately Rs 2.1 lakh, making the Rs 37/QALY additional cost of BPaLM exceptionally cost-effective
- Shorter regimens reduce not only direct drug costs but also indirect costs (lost wages, travel, caregiver burden)
- CEA evidence is increasingly required by India's Health Technology Assessment in India (HTAIn) body for policy recommendations
Connection to this news: The ICMR study's finding of Rs 37 additional expenditure per QALY for BPaLM makes it one of the most cost-effective interventions available, providing strong evidence for NTEP to transition to these shorter regimens nationwide.
Key Facts & Data
- India accounts for 27% of global TB cases and 32% of global MDR/RR-TB cases
- BPaLM treatment success rate: 89% (vs. 52-75% for standard regimens)
- BPaLM adds only Rs 37 per patient per additional QALY gained
- Standard MDR-TB treatment: 9-20 months; BPaL/BPaLM: 6 months
- TB incidence in India fell 21% between 2015 and 2024 (237 to 187 per lakh)
- 63,929 diagnosed MDR-TB cases in India in 2023
- Study conducted by ICMR-NIRT, published in IJMR