Still a serious concern

By Ramesh Raja
In Health
April 4, 2016
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To tackle the menace of TB, the Government must ensure access to quality, affordable diagnosis and treatment, regardless of where an individual seeks care

tb-indiaThe prevalence of tuberculosis (TB), one of the world’s deadliest diseases, has been a major health concern of India for centuries. It is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent. According to the health ministry, 40 per cent of Indians are affected with TB. India, in fact, is the world’s ground zero of this curable disease (if treated in time). The World Health Organization has cited the country to have the highest burden of TB accounting a quarter of the world’s annual incidence of the disease. In 2014, 2.2 lakh Indians succumbed to the bacterial ailment. Furthermore, the threat of drug resistant TB is larger than ever and needs to be urgently tackled.

Although TB is close to being eradicated in the developed world, it is a serious concern in developing countries, where the high prevalence of the disease is mainly due to malnutrition, crowded living conditions and poor tuberculosis control infrastructure. In India, undiagnosed and mistreated cases of TB continue to drive the grave scenario. Early diagnosis, correct treatment and completion of treatment are absolute necessities, if we are to bring down the incidence, prevent relapse and emergence of drug resistance. Doctors stress that greater awareness can prevent a large number of tuberculosis deaths, many of which happen due to lack of reach of proper treatment and drug resistance.

The risk of developing active tuberculosis is a two-step process, beginning with initial exposure to and infection by Mycobacterium tuberculosis followed by subsequent progression to disease.  “In India, the rates of infection are actually so high that the bacteria are prevalent in the air. This is why a large number of people in India have latent bacteria. This means the bacteria remains passive inside the body because the body has strong resistance against it. This latent infection becomes active when the body’s immunity levels plummet due to any reason. This is why people with weakened immune systems have a much greater risk of falling ill from TB. Notably, a person living with HIV is about 26 to 31 times more likely to develop active TB because HIV destroys the body’s immunity. This explains why TB is a leading killer of HIV-positive people causing one fourth of all HIV-related deaths.

Another hurdle to the treatment is that within a short time of commencing treatment the patient begins to feel well and symptoms are relieved to a great extent. This is equated with cure, which is not so. Patients tend to discontinue treatment and relapse with multi-drug resistant TB, which is more virulent, difficult to treat and expensive,” says Dr Piyush Goel, consultant pulmonology and critical care medicine at Columbia Asia Hospital, Gurgaon.

The good part is that TB is curable. Although a contagious infection that starts usually from the lungs but may spread to other organs of the body, it can be treated with a 6-9 months treatment. A failure to complete treatment results in a more dreadful problem associated with TB today – that of drug resistance. “Anti-tuberculosis drug resistance arises due to improper use of drugs in drug-susceptible TB patients. Improper or irrational use often implies failure to ensure that patients complete the whole course of treatment. Once the patient takes the drug for a period of time and then skips it without completing the course, the bacteria in his or her body develop resistance to this particular drug. This drug will now have no impact of the infection when consumed again,” adds Dr Goel.

Essentially, drug resistance arises in areas with weak TB control programs and this is today a major problem in India where the medical fraternity is struggling to deal with the problem of multi-drug resistant TB. Recently, Union Health and Family Welfare Minister JP Nadda and several Indian parliamentarians from the Global Coalition Against TB acknowledged the need to prioritize TB control and pledged their support towards achieving the Sustainable Development Goal for the disease. The minister further emphasized that the Revised National Tuberculosis Control Program (RNTCP), the government agency responsible for TB control, needs restructuring to make it more meaningful and private players need to be involved. “If implemented at scale, the government’s commitment to increase private sector engagement to encourage standard TB care practices across the spectrum of healthcare providers can give a much needed boost to the country’s TB control efforts,” feels Madhukar Pai, Canada Research chair in epidemiology and global health at McGill University, Montreal.

At the same time, the health ministry must increase its budget for the RNTCP. While delays at the state level in the release of allocated funds have hindered effective functioning of the national program, the RNTCP has a history of being significantly under-funded. The allocation towards the RNTCP has consistently shown a trend of being lower than the required and requested amount. This is not surprising, given the overall under-investment in health by the government. According to Pai, who was a member of the Joint Monitoring Mission of 2015, a group of technical experts that reviewed the RNTCP’s performance in April last year, “The findings by the mission reveal that while the country has made progress in reducing the TB burden, a minimum of Rs 1,500 crore were needed by the RNTCP to execute its own National Strategic Plan 2012-2017. In 2014, the allocated amount toward the RNTCP was Rs 640 crore while the requested amount was Rs 1,358 crore – a shortfall of 53 per cent.”

Another key scheme is the Initiative for Promoting Affordable, Quality TB tests (IPAQT), a private lab network that has increased access to accurate diagnostics at lower costs. The government could evaluate these projects, and scale up aspects that have worked well. Clear guidelines can be established to rope in the private sector in such public-private partnership projects. “With the introduction of new diagnostics (e.g. GeneXpert), new TB drugs (bedaquiline and delamanid), and new adherence monitoring solutions and ICT platforms, India is well placed to design a comprehensive strategy to incorporate these into the RNTCP, and modernize DOTS services. These new tools will need to be made more affordable for the Indian public, in both public and private sectors,” observes Pai.

Last but not least, strong activism is of great importance to enhance public awareness, and to stimulate political leadership for the cause. Although TB advocacy has received a remarkable boost in the recent past via print and electronic campaigns, it needs to reach all Indians. Empanelment of superstar Amitabh Bachchan as an ambassador for TB control is a welcome step in this regard. It may be noted that the legendary actor himself is a TB survivor, who contracted the disease in 2000 on the day he was going to start famous TV show, ‘Kaun Banega Crorepati (KBC)’. He had to go through a very rigorous treatment for almost a year.

In order to protect people from the spread of endemic and reach the missing million cases, the government must guarantee access to quality, affordable TB diagnosis and treatment, regardless of where an individual seeks care. Furthermore, we must make a practice to commemorate the World Tuberculosis Day on March 24 to highlight our efforts in eliminating the disease.

How to minimize risk and prevent infection

Those with pulmonary TB are contagious for 2-3 weeks after starting treatment. The patient is advised to wear a mask for this period

Eat healthy

Eating a balanced diet full of vegetables and fruits to keep the supply of vitamins and minerals abundant is important to keep the body healthy and immunity good.

Live healthy lifestyle

A growing number of our present day concerns stem from lifestyle disorders. Living a sedentary life, lack of sun exposure and absence of physical exercise weakens the body and makes it prone to illness. Proper control of diabetes is essential to prevent lowering of immune status.

Never ignore symptoms

Always report any symptoms that may indicate an infection. Persistent cough, recurrent fever, fatigue, weakness, and loss of appetite or weight are symptoms that should never be ignored.

Be cautious against infections

If you work in high risk zones such as hospitals, you should be all the more cautious. Maintain high levels of personal hygiene, avoid close contact with the infected and follow infection control mechanisms to prevent the disease.