Published On : Tue, Mar 24th, 2015

Tuberculosis (Tb) Control in India- A Long Way to Go

urlRecently physician friend of mine lost his wife due to sudden and massive haemoptysis (coughing out of blood) that left her choked to death in no time. This talented middle aged lady had undergone full course of treatment for pulmonary tuberculosis almost 15 years ago under proper supervision and was leading a normal life with no forewarning of an impending doom when this catastrophe struck her like a bolt from the blue. This is not an isolated incident since TB is the captain among men of death and a great masquerader that can sting lethally even after remaining quiescent for several years. In India TB kills more adults than any other infectious disease with 300,000 deaths per year and one death occurring almost once in 1.5minutes.

A disease known since antiquity, tuberculosis known as consumption has affected many civilizations and remained a leading cause of morbidity and mortality. For centuries this disease was steeped with ignorance as to its aetio-pathogenesis and posed immense challenge to medical fraternity in tackling this dreaded condition that consumed millions of life including famous artists, thinkers and philosophers. TB once considered being due to King’s curse and wrath from the heaven is an infectious disease transmitted by droplet infection, thanks to discovery of tubercle bacilli and disease transmission to human beings by famous German microbiologist Robert Koch through postulates that goes by his name.

As we commemorate  this epoch making discovery  as World Tuberculosis Day on 24 March each year there is something to celebrate about and a great deal to ponder about. The infection theory propagated by  Robert Koch laid the  scientific foundation for developing precise diagnostic methods and  discovering potent chemotherapeutic agents that form the mainstay of TB treatment namely short course chemotherapy wherein combination of anti TB drugs are given regularly for a period of 6 months. Various studies have shown that disease can be treated with excellent outcome by administrating short course chemotherapy under direct supervision (DOTS) that formed the basis for the national programme for eliminating the disease from the community. It also became clear that by effective implementation of standard guidelines on diagnosis and therapy of tuberculosis, there was substantial decrease in the incidence and the prevalence of this disease in the community.  Thus these path breaking discoveries and their effective translation in to real terms produced tangible results changing the lives of millions who were confined to solitude of sanatorium facing imminent death to that of hope and good health.

Yet despite major advancements in the management of tuberculosis since Robert Koch’s famous discovery, there is a long way to go before the disease can be eliminated from our midst, WHO’s End TB Strategy. Recent epidemiological statistics about the disease not only cast serious  doubts about our ability to tackle it but also remind us in no uncertain terms that a disease that has survived thousands of years is emerging stronger each day, thus posing a serious challenge to human intelligence. The disease caused by a tiny bacillus namely mycobacterium tuberculosis can remain dormant in the body for decades with no overt features of its presence only to manifest in a devastating way when the body immunity goes down. Tuberculosis can affect all strata’s of society and people of all nationalities although is quite prevalent in poor countries and affecting more often younger age groups. The disease though commonly affects lungs can affect any organ of the body manifesting in varied ways from that of gradual attrition to disseminated acute illness often leading to death if not treated in time. Sometimes even after proper  anti TB chemotherapy  foot prints left by the disease can take away the precious life as it happened to my physician friend’s wife. What is a matter of grave concern is that 95% of world tuberculosis problem are confined to 22 countries mostly in Asia and Africa with India having the dubious distinction of being the world capital of tuberculosis with the highest global disease burden. India accounts for an estimated 2 million incident cases out of approximately 9 million cases globally. India with a population of over 1.2 billion has 40% of her total population exceeding 1.2 billion already infected with TB bacillus with an imminent threat of developing the disease when the body conditions are favourable for the dormant infection to flare up.

There are several conditions including infection by human immunodeficiency virus (HIV) and diabetes that are prevalent in substantial numbers in several parts of the world including India that can fuel the occurrence of tuberculosis and send alarm signals of an impending epidemic. In fact several communities’ especially young ones in their formative years have been wiped out in some African countries due to deadly duo of HIV and tuberculosis infection. In recent years adding fuel to the burning problem of high disease burden, has been occurrence of man-made disaster namely drug resistant tuberculosis following inadequate and inappropriate anti TB chemotherapy. Out of estimated 450,000 multi drug resistant (MDR) tuberculosis, China and India account for nearly 50%of global burden.

Management of drug resistant tuberculosis is complex requiring access to quality laboratory for carrying out tuberculosis culture and drug susceptibility testing, steady availability of quality anti TB drugs and specialised TB treatment centres. In contrast to conventional short course chemotherapy, in drug resistant cases the treatment is prolonged requiring the use of several anti TB drugs than the conventional ones that are found to be toxic and less effective leading to a poor treatment outcome. Moreover a poorly treated as well as untreated drug resistant case will infect as many as 10 to 12 people per year in the community with looming threat of an epidemic as it has happened in some African countries. This has resulted in a situation that getting tuberculosis today can be a death sentence since available anti TB drugs become totally ineffective in a scenario of total drug resistance which fortunately is rare. In a HIV setting, the use of highly active antiretroviral therapy (HAART) in combination with standard anti TB drugs therapy is beset with problems of adverse drug interactions leading to poor patient compliance and treatment outcome. Thus the management of drug resistance tuberculosis with or without HIV co-infection is really challenging as it requires implementation of robust diagnostic and therapeutic measures including preventive, there by adding to the burden of already overburdened health care systems in developing and poor countries having resource crunch and high prevalence of the disease.

Considering the enormity of the problem, WHO declared tuberculosis and HIV as a deadly duo and a global emergency in 1993 and directed nations to take urgent measures to put into place effective strategies of quality diagnosis and therapy. In India, the Indian Governments Revised National TB Control programme (RNTCP) was started in 1996 and has expanded over the years to cover the entire country to achieve and maintain a detection of at least 70 % of estimated sputum positive cases and TB treatment success rate of at least 85% respectively. In 2010 RNTCP targets were revised to cover 90% of estimated TB cases including HIV and drug resistant cases. To achieve these targets by the year 2015, RNTCP took measures to improve existing diagnostic and therapeutic measures and strengthen public private mix initiatives.

Despite all these measures the outcome has been far from satisfactory with substantial population having no access to quality TB diagnosis and treatment due to inadequate management and faulty implementation of programme. It is time to make wakeup call for making honest efforts to put in to practice existing guidelines on the management of tuberculosis before it becomes too late. To deal with the TB threat we need to reach those people who have no access to TB care. One cannot be complacent on dreaded disease like tuberculosis that can wipe out the entire population and all efforts should be made through coordinated efforts of both by government and private agencies to ensure that there is universal access to quality diagnosis and TB treatment. The failure is not due to science but in the art of its application.