Evolution and diagnosis of drug resistance will remain a focus of the Foundation’s interest for the next 5 years. The cutting edge technology of whole genome sequencing will be used to determine the repertoire of drug mutations in 10,000 Indian strains. Attempts will be made to get the widest representation of strains from India. This information will be contributed to a global dataset and will help in the development of geographically relevant point of care test for rapid diagnosis of drug resistant TB. Proposals to fund these studies have been submitted to the Bill and Melinda Gates Foundation and The Wellcome Trust by the lead investigator team led by Prof. Derrick Crook, Dept. Of Clinical Medicine, University of Oxford. Capacity building in post sequencing analysis is also being proposed by FMR for Indian scientists so that India can contribute to global knowledge and new developments in this field.
We also propose to harness whole genome sequencing for tracking transmission in communities without the use of conventional field epidemiology. Advocacy is intended for the public health system (RNTCP) to incorporate this technology for routine surveillance in combination with visual epidemiology
Host modification of bacterial (TB) gene expression is also being developed as a key line of study using in vitro models of murine and thereafter human macrophages. These studies are expected to provide mechanisms of bacterial modulation by host factors such as malnutrition, comorbidities/coinfections, drug availability etc. The studies will offer understanding as to why TB becomes a serious virulent disease in deprived and vulnerable populations.
The hypothesis that environmental pollution is a driving force for the spread of both communicable (TB) and non communicable (Type 2 diabetes) disease is proposed for testing using differentially polluted locations in the city. The central inflammasome pathway has been selected for study to verify the hypothesis. Pilot studies have been initiated for measurement of biological and chemical pollution in collaboration with Dr. Ka Man Lai, Baptist University, Hong Kong.
The mix of biomedical and field studies in TB will continue at the Foundation. There may be opportunities to evaluate access to TB care in Public Private Interface models set up by the BMGF in Mumbai and Patna. Their effect on pathways of care accessed by DR TB patients will be of particular interest to the Foundation.
Our previous studies on the status of TB diagnosis and care in multiple congregate settings (old age homes, beggars homes orphanages, prisons etc.) are expected to enter a phase where linkages with the local TB control system will be forged for confirmation of diagnosis, treatment and follow-up. Institutions will be trained for suspicion of TB, infrastructural and administrative aspects of airborne infection control and facilitating tracking of a patient post release from the institution. Such inputs into congregate setting institutions are likely to decrease the transmission of TB in hyperendemic TB areas like Mumbai.
Reduction of TB transmission in healthcare facilities of the public health system in Mumbai has drawn much attention in the recent past due to deaths from TB in healthcare staff. The Foundation has been responsible for prioritizing air borne infection control (AIC) in control efforts with the Municipal Corporation of greater Mumbai from 2009 onwards and has contributed to local capacity building and institution of a cadre dedicated to AIC in the MCGM. It is currently looking for 2 candidates from the field of medicine and environmental engineering to serve as monitors of AIC implementation in the peripheral hospitals and municipal health posts in the city. Their training and monitoring will be undertaken in conjunction with the Centre for Disease Control, USA
A separate effort is also being made to introduce the use of germicidal lamp technology for upper room sterilization of locations such as operation theatres, closed laboratories and TB wards where air exchange through natural ventilation is not possible. A close interaction is ongoing with Prof. Edward Nardell Harvard School of Public Health, USA, a pioneer in the use of this technology in TB AIC
The studies described in this section address key issues of public health insofar as they relate to infectious disease transmission and the threats that are posed to the public from virulent drug resistant strains for TB. We have striven not only to examine new biological paradigms eg. Rapid acquisition of drug resistance by the TB germ but also attempted to implement remedial measures to minimize TB transmission in the city. The emphasis on genomics is additionally being used to develop point-of-care technologies for rapid testing of drug resistance which poses a severe threat to TB control in India. We continue to actively engage with the media for transmitting the findings and the implications of our studies and have facilitated an active citizens group keen to engage with policy making for the control of tuberculosis. Our belief, that attention to non-medical determinants of health like nutrition, environment, housing and education are crucial for eventual eradication of TB, continues to be our guiding principle.
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