The TB terror

Two per cent of the Indian population is infected with tuberculosis, making it about 20 million patients. There are two deaths occurring every three minutes from TB in the country

Tuberculosis, commonly called TB, is an illness that usually affects the respiratory system. However, it can infect any part of the body. It spreads by close contact through coughing and sneezing thereby adopting the airborne route to get the primary infection. The ongoing AIDS pandemic has worsened the scenario, as immunosuppressed HIV-infected persons are highly susceptible to this bacterium.

The co-morbidity of both these diseases is so alarming that invariably it leads to fatal consequences. This is the most common opportunistic infection among people living with HIV. In 2007, WHO recommended that countries with high co-infection rate should develop TB-HIV collaborative activities through Integrated Counselling and Testing Centers (ICTC).

Even today, 129 years after its discovery, tuberculosis remains one of leading causes of death of several million people, mostly in third world poverty-stricken developing countries. The gross estimation of WHO is that two billion persons, one-third of world's population, are infected by this bacterium. The number of cases had become so enormous that in the year 1993, WHO had to declare a state of Global Emergency on this disease.

Our country is no exception to this epidemiological data; where 2 per cent population is infected, amounting to about 20 million people. It is one of the leading causes of mortality in India — 330,000 deaths each year — nearly 1,000 every day, which amounts to 2 persons dying every 3 minutes. These deaths can be prevented with proper diagnosis and treatment. Patients can be cured and the battle against this scourge can be certainly won.

This is one of the curable diseases if detected timely and managed properly. The standard recommended length of drug therapy is six months, which may be extended in some of the unusual cases. However, if there is delay in establishing diagnosis, irreparable damage takes place. Hence it may not be curable at an advanced stage.

Sometimes, even if diagnosis is timely made, the patient may not take the full course of treatment with prescribed doses. It turns into multidrug-resistant tuberculosis (MDR-TB), where first-line drugs (isoniazid and rifampicin) become ineffective. The situation is already so grim and above all there is now an emerging threat of extensively drug-resistant tuberculosis (XDR-TB) since 2006, where patients do not respond to the first line as well as the second line of anti-tuberculous drugs (fluoroquinolones and at least 1 of 3 injectables — capreomycin, kanamycin and amikacin). Such cases are now being reported from India also. The XDR-TB has really posed a big challenge before the medical fraternity and the ailing community.

In our country, the National TB Programme (NTP) was started in the year 1962 and the Revised National Tuberculosis Control Programme (RNTCP) in 1997, after pilot testing from 1993-1996. It included Directly Observed Treatment Short course (DOTS), which is being implemented to tackle this menace. The WHO-recommended DOTS strategy was launched formally through the RNTCP. Since then DOTS has been widely advocated and successfully applied. The RNTCP has covered the entire population of the country by March 2006. This programme has achieved the global target of 70 per cent case detection for the first time while maintaining the treatment success rate of more than 85 per cent in our country.

The Ministry of Health and Family Welfare, Government of India, has now come up with the DOTS-Plus programme, which refers to DOTS that add five essential components for MDR-TB diagnosis as well as treatment. These are:

* Sustained government commitment;

* Accurate timely diagnosis through quality assured culture and drug susceptibility testing;

* Appropriate treatment utilising second-line drugs under strict supervision;

* Uninterrupted supply of quality assured anti-tuberculous drugs; and

* Standardized recording and reporting system.

There is full integration of DOTS and DOTS-Plus activities under the RNTCP so that patients with MDR-TB are both correctly identified and properly managed under the prescribed recommendations. In the RNTCP DOTS-Plus vision by 2012, it is aimed to extend these services to all smear positive retreatment cases and new cases who have failed an initial first-line drug treatment and by 2015, these services will be made available to all smear-positive pulmonary tuberculosis cases registered under the programme.

The writer is Professor and Head, Department of Microbiology, Govt. Medical College Hospital, Sector 32, Chandigarh



Key facts

* TB is one of the leading causes of mortality in India— killing 2 persons every three minute, nearly 1,000 every day

* The strategy of Directly Observed Treatment, Short-course (DOTS) is based largely on research done in India in the field of TB over the past 35 years.

* Since 1997, after successful piloting DOTS has been implemented in India as the Revised National Tuberculosis Control Programme (RNTCP). In the RNTCP, the proportion of TB cases which are confirmed in the laboratory and the cure rate are both more than double that of the previous programme,

* The operational feasibility of DOTS in the Indian context has been demonstrated, with 8 out of 10 patients treated in the programme being cured, as compared with approximately 3 out of 10 in the previous programme.

* Multidrug -resistant tuberculosis (MDRTB) is a result and symptom of poor management of TB patients.DOTS has been shown to prevent the emergence of MDRTB and to reverse the trend of MDRTB in communities in which it has emerged.

* TB is the most common opportunistic infection among people living with HIV.

* Revised National Tuberculosis Control Programme (RNTCP) has covered the entire population of the country by March 2006.

* Every patient who is cured stops spreading TB, and every life saved is a child, mother, or father who will go on to live a longer, TB-free life.



Together we can eliminate it

The 24th of March every year is observed as World Tuberculosis Day all over the globe. This occasion provides an opportunity to the governmental as well as non-governmental organisations to create public awareness programmes highlighting the magnitude of the problems and devising solutions related to the ongoing pandemic of tuberculosis entailing the strengthening of the control measures.

World TB Day commemorates the historical date in the year 1882 when Robert Koch announced the discovery of Mycobacterium tuberculosis, the causative bacterium of tuberculosis, in one of the meetings of doctors in Berlin (Germany). This used to be was considered a dreaded disease at that time. It used to kill millions of people, as the case fatality was 1 out of every 7 persons, not only in Europe but other continents as well because neither its cause nor any specific treatment was known. This breakthrough discovery on this day paved the way for diagnosing and later on curing this 'incurable disease' of that era.

For the next hundred years, this day was not remembered in any capacity. However, in 1982, while commemorating the 100th year of Koch's discovery, the first World TB Day was observed by the International Union Against Tuberculosis and Lung Disease (IUATLD), which was subsequently joined by the World Health Organisation (WHO). The basic idea of the international event was to educate the public at large about the devastating medical and economic consequences of tuberculosis, its effect on the developing countries and its overall continued tragic impact on global health.

Every year a theme is decided for this day focussing on to how to get rid of this disease and throughout that year a concerted worldwide campaign is initiated to achieve the set goal. The theme of this year is 'TB Elimination : Together We Can' which is more than a slogan and its campaign will be sustained focussing on to people everywhere who are doing their part 'on the move against tuberculosis : transforming the fight towards elimination'.

It is a reminder of the collaborative efforts on eliminating tuberculosis by educating health care workers and volunteers who play a crucial role in identifying symptoms of this disease. It is about highlighting lives and stories of people affected by tuberculosis: women, men and children who have taken tuberculosis treatment; nurses; doctors; researchers; community workers — anyone who has contributed towards the global fight against this dreadful disease.

Every patient who is cured stops spreading tuberculosis and every life saved is a child, mother or father who will go on to live a longer, disease-free life. WHO is working to cut tuberculosis prevalence rates and thereby deaths by half by the year 2015. Eventually by 2050, the global incidence of this disease is expected to be less than or equal to 1 case per million population per year. The day is not far when we will be able to celebrate this occasion, as the disease will ultimately be eliminated from the face of the globe. Our vision is a world free of tuberculosis.