Tuberculosis (TB)

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TOPIC: General Studies 2:

• Government policies and interventions for development in various sectors and issues arising out of their design and implementation
• Issues relating to development and management of Social Sector/Services relating to Health, Education, Human Resources

Tuberculosis (TB) is a disease caused by bacteria called Mycobacterium tuberculosis. The bacteria usually attack the lungs, but they can also damage other parts of the body.

TB spreads through the air when a person with TB of the lungs or throat coughs, sneezes, or talks. If you have been exposed, you should go to your doctor for tests. You are more likely to get TB if you have a weak immune system.

• TB is, by and large, easily diagnosable and curable. It is unacceptable that it nevertheless remains the leading causes of death from any single infectious agent worldwide.
• Each day, thousands of people with TB die, often because of inequitable access to quality diagnosis and treatment.
• In addition, the rapid emergence of drug-resistant forms of TB (DR-TB) in many countries brings a fresh set of needs including new and comprehensive diagnostic tests and second-line TB drugs, and health systems trained anew to manage DR-TB.

Three processes: Infection, Progression, Transmission

• Infection: Infection occurs when TB bacilli are inhaled. Bacilli may stay in the lungs or travel to other organs. Infection is lifelong, with bacilli lying dormant. This phase is “latent TB”, diagnosed by a tuberculin skin test (TST). The “annual rate of TB infection” (ARTI) is about 1%. Cumulatively, 40% to 70% of us are living with latent TB. From this reservoir pool, a few progress to TB disease, one by one, 5-30 years, average 20 years, later.
• Progression: Progression occurs when bacilli become active, multiply and cause pathology; now we have “active TB”.
• Transmission: When active TB affects the lungs, the bacilli find an exit route to the atmosphere, necessary for transmission.

Symptoms of TB in the lungs may include

• A bad cough that lasts 3 weeks or longer
• Weight loss
• Loss of appetite
• Coughing up blood or mucus
• Weakness or fatigue
• Fever
• Night sweats

In India:

• India not only accounts for a fifth of the world’s TB burden, it also has the largest number of people living with multidrug-resistant TB.
• India has fought to retain its status as a maker and distributor of generic medicines, thereby protecting the right to health of people in developing countries.
• Indian patent law contains important provisions that help protect and promote public health goals — for example, by overcoming bids by big pharma to evergreen patents of old drugs, through compulsorily licensing for certain drugs, and by permitting pre- and post-grant opposition to patents to challenge unfair patenting practices by big pharma.

Reasons for the rising crisis

In addition to the failure of political machinery, the other major reasons for this are as follows:

• Adult and child under-nutrition
• Lack of active door-to-door detection
• Shortage of drugs
• Increasing Multi-Drug Resistant TB (MDR-TB) and Extensive Drug Resistant TB (XDR-TB)
• Total Drug Resistant TB acting as an assured death warrant
• Inadequate prescription by doctors and inadequate follow up of proper prescription by patients is aggravating the problem of antibiotic resistance
• Disease becoming expensive and difficult to treat
• Poor quality serological tests for diagnosis; poor quality diagnosis and treatment by medical practitioners
• Delay in implementation of critical programmes under the Revised National TB Control Programme (RNTCP) such as expansion of the GeneXpert pilot programme, scaling up of drug sensitivity testing, and the introduction of a child-friendly paediatric TB drug.

India’s vision: To end TB by 2025, five years ahead of the World’s Target under SDG’s

• India’s estimated annual TB burden is 28 lakhs, 27% of the global total; our population is only 18%. Every day 1,200 Indians die of TB — 10 every three minutes.
• According to Health Ministry data, only 63% of the patients infected with the airborne disease are currently under treatment. Further, 1,47,000 patients are resistant to first- and second-line TB medicines.
• At the current rate of progress, global targets to eliminate TB by 2030 will be missed by a 150 years.

India’s War on TB – The Way Forward

Countering Delay in Diagnosis:

• To block transmission, treatment should begin as soon as a symptom shows up. As cough is a very common symptom of many diseases, doctors don’t think of TB until other treatments fail.
• Partnership with the private sector is essential for early diagnosis of TB.
• Universal primary health care, a basic human right, and a diagnostic algorithm for early diagnosis are essential for TB control.
• To retard progression: Employ the biomedical method is drug treatment of latent TB. Experts recommend an age window of 5-10 years when all children must be screened with TST; those with latent TB must be treated to prevent progression.

Private Sector: The private sector has a very crucial role to play in checking the rise of TB as it is the first place a patient from an urban area visits. We need to make them a partner in this fight.

• Strict guidelines need to be followed to report cases of TB to government.
• Developing a comprehensive set of national guidelines could strengthen private sector engagement in TB
• Efforts should be made to map and categorise private practitioners based on the nature of their education, experience and services provided.
• Private hospitals need to be penalised for failure to report early TB cases to government. This will enhance the accountability of the private players.
• If cannot provide free treatment, it needs to refer the patient to a government clinic.
• Identification, focusing, messaging and testing (IFMeT): Key to successful private-public partnerships to fight TB

Strengthening research: We urgently require rapid and cost-effective point-of-care devices that can be deployed for TB diagnosis in different settings across the country.

• Additionally, new drug regimens are necessary for responding to the spread of drug-resistant strains as is an effective vaccine for preventing TB in adults. It is a big challenge in current times, which is due to irregular treatment.
• Operational research for optimising service delivery is also critical because it is often the case that diagnostics and drugs do not reach those who need them the most.
• TB with other disease like HIV is difficult to treat and the research needs to be strengthened in this field.
• The India TB Research and Development Corporation launched in 2016 must play a pivotal role in accelerating these efforts.

Technology: Technology has to be introduced and utilized in the most effective manner to ensure early access and monitoring.

Ending social stigma: TB is not a health issue alone. It is a broader societal challenge. Patients often hesitate to seek treatment or deny their condition altogether for fear of losing social standing. The consequence is that TB becomes a death sentence for many even though it is a fully curable illness. Women are disproportionately affected with estimates suggesting that 100,000 Indian women are asked to leave their homes every year after being diagnosed with TB.

• Mass awareness campaigns like ‘TB Harega Desh Jeetega’ can play an important role in breaking social taboos.
• Local communication channels such as community radios and street plays must also be leveraged.
• Children should be engaged through anganwadis and schools for disseminating accurate messages about TB to their families.
• Paediatric TB is often a neglected area. Children come from low socio-economic strata with social stigma and discrimination which needs to be de-stigmatised.

Major initiatives taken by India–

Shift to Daily regime of medication: With DOT Centres, the treatment will be at individual door level leading to no defaulter.

Cash benefit for TB patients & Medical Practitioner:

• About 35 lakh identified Tuberculosis patients across the country will soon get Rs. 500 every month from the Centre as social support. The cash benefit for social support will cover loss of wages, travel and mainly nutrition.
• INR 500/- to the private medical practitioner for notification of the disease

Will this work: Need to incentivise both the patients and the private practitioners as both the sides will ensure that they stand to gain from the treatment, which, in the long term, might lead to behavioural change.

Web-based Application – Nikshay: To enable health functionaries at various levels across the country to monitor TB cases in their areas

• Patients receive daily SMSes to ensure they continue their medication.
• The medicines come with a toll free number that is visible only after the medicine has been taken out of the foil pack; patients are required to give the number a missed call.
• Every missed call is tracked, and when there are too many gaps, the patient is traced, often by treatment supervisors who travel to remote areas on bikes that the programme pays for.

Introduction of Cartridge-Based Nucleic Acid Amplification Test (CBNAAT): It is a revolutionary rapid molecular test which simultaneously detects Mycobacterium tuberculosis and rifampicin drug resistance. This test is fully automated and provides results within two hours. It is a highly sensitive diagnostic tool and can be used in remote and rural areas without sophisticated infrastructure or specialised training.

Note: March 24th is celebrated as World Tuberculosis Day

Connecting the Dots:

1. Tuberculosis can be one of the major hurdles in converting the human capital in India to Demographic Dividend. Highlight the reasons for the rising TB problem and suggest measures to eliminate the problem.
2. TB remains one of the leading causes of death from any single infectious agent worldwide. Comment on the national and global efforts to eliminate the disease by 2035.