Tuberculosis (TB) is one of the most ancient diseases of mankind’s history, has co-evolved with humans perhaps for several million years. Tuberculosis, generally called TB, is an infectious bacterial disease caused by Mycobacterium tuberculosis, which most commonly affects the lungs, but can also damage other parts of the body. The first reference to tuberculosis in non-European civilization is found in the Vedas. In most ancient Indian Veda Rigveda, (1500 BC) the disease was pronounced as the Yaksma.  The Atharvaveda called it Balasa. In Atharvaveda the first description of tuberculosis was corresponds to scrofula. The Sushruta Samhita, written around 600 BC, recommended breast milk, various meats, alcohol and rest for the treatment of tuberculosis. The Yajurveda advised patients to move to higher altitudes.

According to the World Health Organisation “India is the highest TB burden country” Tuberculosis is the biggest health issue that lies around the India. Approximately three million people infected from tuberculosis in India. Tuberculosis still remained a major health threat, in India. Total antibiotic resistance of tuberculosis bacteria is another critical and challenging problem with tuberculosis, which make disease more severe and complex.

An overview of TB

19^th Century:  At the beginning of the nineteenth century it was generally thought that there was hardly any TB patient occurs in India. By the middle of the nineteenth century TB was thought to be common in some districts particularly among the English troops, and in some areas it was thought to be common “among natives as well”, such as in the district of Madras. It was also believed that TB in India was of an extremely damaging type.

In 1881 it continued to be believed that TB or “Phthisis” was more prevalent in India among European soldiers and their families, than among the native troops. This led some people to consider whether Europeans suffering from confirmed Phthisis would be better off going to India for a prolonged period. However, when this was considered in greater detail, it was believed that any advantage from the improved climate would be offset by other disadvantages.

The TB problem in India was first officially, recognised through a resolution passed in the All India Sanitary Conference, held at Madras in 1912. The TB picture started becoming clear with the introduction of tuberculin testing. The Bhore committee report issued in 1946 estimated that about 2.5 million patients required treatment in the country with only 6,000 available beds. The first open air institution for isolation and treatment of TB patients was started in 1906 in Tilaunia near Ajmer and Almora in the Himalayas in 1908. National Tuberculosis Control Programme (NTP) was formulated in 1962 which was implemented in phased manner. The deficiency in NTP was identified in 1963 and Revised National TB Control Programme (RNTCP) was developed. There is a commitment for Government of India to expand RNTCP to cover the entire country by 2005.

 

 

RNTCP reported that 12 lakh Indians are annually notified as having newly diagnosed TB. In addition at least 2.7 lakh Indians died every year. TB can affect any age, caste or class but cases are mainly poor people and mostly men. Slum dwellers, tribal populations, prisoners and people already sick with compromised immune systems are over-represented among the cases, compared to their numbers in the population. Children comprise 40% of the population but are currently under-diagnosed in India.

Case notification is estimated to be only 58%. Over one third of cases are not diagnosed, or they are diagnosed but not treated, or they are diagnosed and treated but not notified to the RNTCP. This could be even higher, and the WHO (World Health Organisation) estimated that another 10 lakh Indians with TB are not notified. The economic burden of TB is extremely high. Between 2006 and 2014, TB cost the Indian economy a massive USD 340 billion.

24 March, is announced as world TB Day. It sets targets and outlines action for governments and partners to provide patient-centred care, to eliminate TB. A WHO estimate says there are 37 million TB pateints were saved through effective diagnosis and treatment, during 2000-2013, furthermore 480, 000 people developed multidrug-resistant tuberculosis (MDR-TB) worldwide in the same year.

Based on pathogenesis Tuberculosis infection may be of two types:

Latent: TB germs are dormant (asleep) in the body. This phase can last for a very long time even decades. No sign and symptoms occur and patient generally unable to spread disease. The only manifestation of latent TB encounters in to the tuberculin skin test (TST) or interferon-gamma release assay (IGRA).

Active: In active phase TB germs rapidly reproduce and multiply in the body, causing tissue damage,  cough, phlegm, chest pain, weakness, weight loss, fever, and chills. T B can be spread other parts of body such as gastrointestinal tract, liver, bones and brain, however, lungs T B is more common.  A person with active pulmonary TB disease may spread TB to others by airborne transmission of infectious particles coughed into the air.

Symptoms of TB disease may include: More often cough which persist more than two weeks may be a primary sign of lungs TB. Other common symptoms include are:

• Weight loss
• No appetite
• Weakness or fatigue
• Chills
• Fever
• Sweating at night
• Chest pain, or painful breathing or coughing

Prevention:  A healthy and vaccinated (Bacille Calmette-Guerin) individual has less chance to get infected, compare to the unhealthy (underweight, weak immune system, poor diet etc.) ones, and immune compromise (HIV or other immune deficiency related diseases) individuals. Personal hygiene such as using the mouth and nose mask and using the hanky during coughing and sneezing may reduce the chance of TB infection. A healthy life style also plays significance role to keep the TB at bay. However BCG (only available vaccine against TB in India) doesn’t provides a remarkable immunity against TB.

Diagnosis:  Skin test (Mantoux or tuberculin test), Sputum test (microscopical examination), Chest X-rays and serological test (detection of antibodies against pathogen) are commonly practiced in India.

Treatment and Management:

Infected patients required antibiotics for at least six to nine months. The exact drugs and length of treatment depends on patient age, overall health, possible drug resistance, the form of TB (latent or active) and the infection’s location in the body.

In the case of latent tuberculosis, patient may need to take just one type of TB drug.  Active tuberculosis, particularly if it’s a drug-resistant strain, will require several drugs at once. The most common medications used to treat tuberculosis include: Isoniazid, Rifampin (Rifadin, Rimactane), Ethambutol (Myambutol), Pyrazinamide.

While a drug-resistant TB, a combination of antibiotics called fluoroquinolones and injectable medications generally used for 20 to 30 months. Some types of TB are developing resistance to these medications as well.  In such case disease gets more complicated. Improper and irregular treatment caused Drug resistant TB.

TB treatment & care in India is provided by the government’s Revised National TB Control Programme (RNTCP) as well as through private sector health providers. In 2013 the number of suspected TB cases examined under the RNTCP increased to 651 per 100,000 populations. A total of 928,190 smear positive TB patients were diagnosed. There is more about the testing & diagnosis of TB in India. There is also more about the treatment that is provided for TB in India.

In 2014 India achieved complete geographical coverage for diagnostic and treatment services for multi-drug resistant TB. In 2013, 248,000 cases of TB were tested for drug resistance and 35,400 were found to have either MDR or rifampicin resistant TB. However, only 20,700 received treatment. Yet these cases, about a third of the estimated number, cost over 40% of the annual RNTCP budge

Almost two thirds of TB patients registered by the RNTCP received HIV screening in 2013, and 44,000 (5%) were found to be infected. More than 80% of these received anti-retroviral treatment (ART) and 95% received co-trimoxazole preventative treatment (CPT).

RNTCP Phase II (2007-2011)

Before 2010 all patients receiving treatment through the government’s RNTCP program, were placed in one of three categories, Cat I, Cat II, or Cat III. This was according to whether they had received treatment before, whether they were seriously ill and whether they were sputum positive. However all categories received different combinations of up to four of the main first line anti TB drugs (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol).

Streptomycin was added for those who had received TB treatment before and who had relapsed. Of course the addition of Streptomycin to an existing failing combination contravened one of the fundamental aspects of TB chemotherapy, which is that one single new drug shouldn’t be added to a failing regime. The fact that this was done meant that effectively no treatment was provided for those with drug resistant TB.

The provision of treatment for patients with drug resistant TB

In 2010, with the launch of the DOTS-Plus Guidelines (in future known as the Programmatic Management of Drug Resistant TB) TB treatment for drug resistant TB started to be provided. Treatment categories I & II became the treatment regimes for new and previously treated patients respectively. Category III was phased out, and two new categories were introduced. These were Category IV for patients requiring treatment for MDR TB, and category V for patients requiring treatment for XDR TB.          

National Strategic Plan (NSP) 2012 -2017

For the five years National Strategic Plan for 2012–2017, the vision of the government was for a TB free India. The aim was to achieve the following targets by the end of 2015.

• Early detection and treatment of at least 90% of estimated TB cases in the community, including HIV associated TB.
• Initial screening of all previously treated (retreatment) smear-positive TB patients for drug resistant TB and the provision of treatment services for multi drug resistant TB.
• The offer of HIV counselling and testing for all TB patients, and linking HIV infected TB patients to HIV care and support
• Successful treatment of at least 90% of all new TB patients, and at least 85% of all previously treated TB patients.
• The extension of RNTCP services to patients diagnosed and treated in the private sector.

Development of the Standards for TB Care in India (STCI)

The Standards for TB Care in India has been produced in order that there should be a widely accepted standard for the provision of TB treatment and care in India. Based on other international guidelines and standards, it was developed by a large number of organisations and individuals, both within and outside of the Government of India (GOI). It was first published by the World Health Organisation in 2014. The Standards describe what should be done, and the TB treatment and care that should be provided throughout India. This is in contrast to the national guidelines from the Central TB Division of the GOI which describe how actions are to be accomplished.

There is more about the treatment that is provided for TB in India including the treatment for drug resistant TB in India and also more about the testing & diagnosis of TB in India, as set out in the Standards for TB care in India.

Private sector health care

The private sector in India, unfortunately, has been a source of mismanagement of TB and hence of drug resistance. This includes the use of incorrect diagnostics (e.g. blood tests), incorrect regimes and a lack of supervision to ensure all TB patients complete their TB treatment. So every effort is being made to engage the private sector in India and improve the quality of care provided by private practioners.

There is also a lack of regulation for over the counter drugs for TB and this contributes to the problems of drug resistant TB. There have been calls for the Indian government to do more to educate patients about the appropriate tests and the right treatment for TB.

The RNTCP has tried to involve non public health providers in promoting TB care, but it is believed that many patients continue to seek treatment elsewhere and currently go unreported. A number of studies and surveys of TB prevalence including self reporting of TB prevalence, have suggested that up to 46% of patients may not be currently reported.

There are various reasons why people in India seek care from the private sector. These include:

• Poor knowledge about TB
• Poor knowledge about services available through the national programme
• The convenience of services a desire for confidentiality
• A desire for personalized care.

Free TB treatment for patients in private sector:

In 2014 the Ministry of Health and Family Welfare started a pilot project in Mumbai to provide patients in the private sector with free treatment. Since the scheme started in August 2014 some 10,675 new patients have registered under the scheme of which 656 are patients with multi drug resistant TB.

Important facts about TB:

• Tuberculosis is not a family disease. It comes from a germ. TB patients throw this germ in the air while coughing, sneezing or pitting. Any normal person can inhale these germs and then develop disease.
• TB is curable. However the patient has to take regular and full course of treatment, as advised by the doctor.
• We should not discriminate with TB patients. Rather patient should be advised to take certain precaution to avoid spread of disease; he should cover his mouth and nose while coughing or sneezing, proper sputum disposable and take regular treatment.
• Patient should take normal balanced diet.  He should take seasonal vegetables and pulses etc. Special diet is not necessary.
• Smoking can aggravate his symptoms. Therefore, a patient should not smoke.
• Alcohol can increase the chances of side effects of drugs.  Some TB drugs cause nausea, vomiting or jaundice in some cases.
• TB drugs generally safe for pregnancy.
• Following groups with respiratory symptoms are at an increased risk of tuberculosis, persons who have been in close contact with a TB patient, patients suffering from malnutrition, silicosis, diabetes, alcoholics and drug addicts.
• With modern available drugs, germs in sputum die in 2 to 4 weeks and then patient is not able to spread disease.
• TB treatment generally safe. Sometimes one suffers from nausea, vomiting etc. which can be easily tackled by treating doctor.
• Generally treatment required for 6 to 8 months.
• If a person is having cough more than three weeks, he may be suffering from TB. By doing examination of sputum the doctor can diagnose TB.
• TB patients can attend school, office and public places, with proper treatment.

Famous men and women over ages suffered from this disease. Notable among these were poets John Keats and Percy Bysshe Shelley, the authors Robert Louis Stevenson, Emily Bronte, and Edgar Allen Poe, the musicians Nicolo Paganini and Frederic Chopin to name a few. TB spares no one.  Rich and poor, all get tuberculosis. Recently Bollywood actor Amitabh Bachchan, recovered from spinal tuberculosis.