Topic : Paradigm shift for TB control
Topic in Syllabus: General Studies Paper 1: Indian Society
Tuberculosis (TB) remains the biggest killer disease in India, outnumbering all other infectious diseases put together this despite of battle against it from 1962, when the National TB Programme (NTP) was launched.
- In 1978, the Expanded Programme on Immunisation (EPI) began, giving BCG to all babies soon after birth and achieving more than 90% coverage.
- Yet, when evaluated in 1990, the NTP and the EPI had not reduced India’s TB burden.
- In 1993, the Revised National TB Control Programme (RNTCP) was launched, offering free diagnosis and treatment for patients, rescuing them from otherwise sure death.
- However, treatment is not prevention. Prevention is essential for control.
- The number of people becoming ill with TB each year has declined by just 1.5% annually over the past 15 years.
- This rate of decline is unacceptably slow for a preventable, curable disease, and must increase dramatically by 2020 to put the world on track to end TB.
- It kills more than 300,000 people in India every year.
- Between 2006 and 2014, the disease cost Indian economy USD 340 billion.
- India is the highest TB burden country with World Health Organization (WHO) statistics for 2011 giving an estimated incidence figure of 2.2 million cases of TB for India out of a global incidence of 9.6 million cases.
- Tuberculosis (TB) is an infectious disease caused by a bacterium, Mycobacterium tuberculosis. TB is one of the leading causes of mortality in India.
- It has the unique character of mimicking other diseases and hence confuses doctors, which delays diagnosis and further treatment.
- Notably, the common symptom associated with Cough and blood in sputum occurs only in lung TB and there are others like Brain TB, Pelvic TB etc…
- TB can affect the lungs, brain, bones, joints, the liver, intestines or for that matter any organ and can progress slowly or kill in weeks.
- There are 3 distinct stages in TB – infection, progression, transmission.
- TB is spread through the air by a person suffering from TB. A single patient can infect 10 or more people in a year.
Common symptoms of TB are:
- Cough for three weeks or more, sometimes with blood-streaked sputum
- Fever, especially at night
- Weight loss
- Loss of appetite
Those most vulnerable to falling ill with TB include very poor and/or malnourished/ undernourished people, people living with HIV/AIDS, children and women, contacts of people with TB including health workers, migrants, refugees and internally displaced persons, miners and mining-affected persons, persons with diabetes, elderly, ethnic minorities, indigenous populations, substance users and homeless persons.
Tuberculosis in children:
- Children account for an estimated half a million new TB annually and 74,000 deaths (among HIV negative children) in the world.
- In 2012, only around 300, 000 cases were notified to National TB Programmes.
- TB in children is often missed or overlooked due to non-specific symptoms and limitation of diagnostic tools.
- Children at greater risk for Tuberculosis.
Some groups of children are at greater risk for tuberculosis than others. These include:
- Children living in a household with an adult who has active tuberculosis
- Children living in a household with an adult who is at high risk for contracting TB
- Children infected with HIV or another immuno compromising condition
- Children born in a country that has a high prevalence of tuberculosis
- Children from communities that are medically under served
Under Revised National Tuberculosis Control Programme (RNTCP) the following methods are used to diagnose various forms of Tuberculosis:
- Culture (Solid, Liquid)
- Molecular tests Line Probe Assay (LPA),
- Cartridge Based Nucleic Acid Amplification Test (CBNAAT)
- Mantoux Test
- X-ray and other imaging techniques
- Directly Observed Treatment Short-course (DOTS) is the strategy followed for treatment of TB. Tuberculosis treatment requires at least 6 months of treatment.
- Vaccination – The TB vaccine, BCG, addresses the tuberculosis problem in children to some extent.
- TB treatment with DOTS reduces the morbidity and mortality among people living with HIV.
- Extra-pulmonary tuberculosis (EPTB) refers to disease outside the lungs.
- Extra-pulmonary TB may be characterized by swelling of the particular site infected (lymph node), mobility impairment (spine), or severe headache and neurological dysfunction (TB meningitis) etc. Extra-pulmonary TB is not accompanied by a cough because it does not occur in the lungs.
Development of the disease
- Primary infection occurs through blood or lymphatic spread of bacteria to parts of the body outside the lung may occur.
- Bacteria may be coughed from the lungs and swallowed. By this route they may enter the lymph nodes of the neck or parts of the gastro-intestinal (GI) tract.
- Infected milk from cattle infected with M. bovis, could pass disease to humans.
- Multi-drug-resistant tuberculosis (MDR TB) is caused by strains of the tuberculosis bacteria resistant to the two most effective anti-tuberculosis drugs available – isoniazid and rifampicin.
- MDR TB can only be diagnosed in a specialized laboratory.
- Worldwide, only 94, 000 of the 450, 000 people estimated to have developed multidrug-resistant TB (MDR-TB) in 2012 were detected.
- The lowest proportions of new MDR-TB patients reached were in the South-East Asia region (21%) and Western Pacific Region (6%), though they carry over 50% of the global burden of MDR-TB.
- Multi-drug-resistant Tuberculosis requires at least 18-24 months of treatment with medicines which are 100 times more expensive and often highly toxic.
Evaluations of previous programmes:
- When evaluated in 1990, the NTP and the EPI had not reduced India’s TB burden.
- Visionary leaders had initiated a BCG vaccine clinical trial in 1964 in Chingelpet district, Tamil Nadu.
- Its final report (published in the Indian Journal of Medical Research in 1999) was: BCG did not protect against TB infection or adult pulmonary TB, the ‘infectious’ form.
- BCG immunization does prevent severe multi-organ TB disease in young children, and must be continued but will not control TB.
Revised National TB Control Programme (RNTCP)
- By 2014-15, the RNTCP was found to be very successful in reducing mortality, but failing to control TB.
- From when a person becomes infectious to when he/she turns non-infectious by treatment, there is a gap of several weeks during which the infection saturates contacts in the vicinity.
- Delays in care seeking and diagnosis are the result of lack of universal primary health care.
Tamil Nadu pilot model:
- Tamil Nadu is planning to implement new strategy in one revenue district, Tiruvannamalai.
- To ensure public participation — a missing element in the RNTCP — the new model will be in public-private participation mode.
- The Rotary movement, having demonstrated its social mobilization strengths in polio eradication, will partner with the State government in the TB control demonstration project.
- Tiruvannamalai, a pioneer district in health management, was the first in India (1988-90) to eliminate polio using the inactivated polio vaccine (IPV).
- The Directorate of Public Health and Preventive Medicine and the National Health Mission will lead all national, State and district health agencies, district and local administration, departments of education, social welfare and public relations and government medical college.
- The Rotary will ensure the participation of all players (health and non-health) in the private sector.
The paradigm shift essential to ending TB:
- A change in mindset
- Changed and more inclusive leadership
- Innovative TB programmes equipped to end TB
- New, innovative and optimized approach to funding TB care
- A human rights and gender-based approach to TB
- Community- and patient-driven approach
- Integrated health systems fit for purpose
- Investment in socioeconomic actions
The urgent need for new tools to fight TB:
- A VACCINE that protects people of all ages against TB;
- Highly sensitive RAPID DIAGNOSTIC TESTS that can be implemented at the point of care;
- DRUG REGIMENS (including for drug-resistant TB) that are highly effective, faster-acting and non-toxic.
- Dealing with TB requires mass initiatives – health professionals, policy planners and administrators and the public must come together to solve it.
- TB cases can be greatly reduced if basic health sensitiveness of not spitting in public and “mouth covered cough and sneeze practices” are adopted.
- Treatment of latent TB will prevent its progression to active TB and consequently bring down the “Annual Risk of Tuberculous Infection” (ARTI)
- It is important to address the social conditions and factors which contribute to and increase vulnerability to tuberculosis. Concerted efforts should be made to address the issues of undernourishment, diabetes, alcohol and tobacco use.
- Private sector engagement in combating TB needs to be strengthened. The private sector should also be incentivized to report TB cases.
- There is an urgent need for cost-effective point-of-care devices that can be deployed for TB diagnosis in different settings across India.
- It is important to invest more in R&D to come up with new drug regimens for responding to the spread of drug-resistant strains. Further, there is an urgent need to research on an effective vaccine to prevent TB in adults.
- The India TB Research and Development Corporation must play a pivotal role in accelerating the efforts.
- Service delivery should be optimized so that the diagnostics and drugs reach to people who need them the most.
“Ending TB by 2025 is impossible but sustaining its decline is in the realm of reality” discuss