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Tuberculosis in India Multidimensional

Analysis
Tauseef Ahmad
The problem of Tuberculosis and its rampant elusive spread has shackled the world and particularly
India. According to WHO report 2013, out of total number of TB cases 2-2.5 million cases are from
India alone.
So it is very important to cover and analyze all the aspects and issues associated with TB in India and
world.
Let us connect it with our General Studies paper wise.
Paper 1
1. Issues associated with Women and their remedies: This topic is very diverse and I think
mention of TB affecting women at social and economic level with the efforts to lessen them is
worth here.
Here we will look into the affliction of women in TB related issues. There is socio-economic impact of
TB on women.
Social Stigma and Economic constraints: Social stigma is pervasive in Indian society, not only TB but
with many such diseases. When a person is caught with such disease, they are compelled to live in
segregation and societal illiteracy surmounted by negligence creates annihilating atmosphere for
them. This cause irreparable damage to their health care and the negligence of society never allow
them to open up to the fact of being diseased and share their burden. Women are most prone to such
unscientific temper and negligence of society. Indian women, mostly rural populace are more prone
to harsh living and as soon as they are caught, they find innumerable alliances against them.
These alliances are twin in nature. First, the disease itself and secondly the pressure due to gigantic
responsibility under which they live. The parochial and catastrophic temperament of society for
women acts as catalyst under testing circumstances. They find themselves under great stress, mental
and physical. Unlike men and children, women in India are preoccupied by many responsibilities
and the pressure of being diseased is not borne by their poor family set up.
Gender biasness plays havoc here. Women are more delicate to bear such torments (TB) and the
multiple atrocities coupled with social, physical, economical and biological in nature leads to their
segregation and moral downfall.
In many places women are also levied for others disease (Superstition). This is most pervasive in
tribal and village populace. Family responsibility, poor background, illiteracy and grave superstition
have led Indian women to live a life of hell.
The condition aggravates when a women is pregnant. Many a times the threat of physical abuse
coupled with superficial care taking is found.
Note: Add the role of NGO and SHG working for the cause. Do add other points of relevance. The
issue of social stigma is also related to ethical domain. So connect accordingly. (Hint: Human Rights
Issues)
2. Effect of Globalization on Indian society:
One of the negative aspects of globalization is Diseases of Globalization.
Although TB is pervasive in India from ancient time (mentioned in Ayurveda Samhita and Vedas)
but ineffectiveness to deal it in contemporary times has some relation to globalizing trend and
intermixing of people. HIV and Diabetes needs special emphasis here and these two gives a bigger
picture on how globalization of disease has bent the very backbone of citizens health issues.
TB and HIV:
People living with HIV are more likely than others to become sick with TB. Worldwide, TB is one of
the leading causes of death among people living with HIV. The main factor is low immunity among
HIV patients. India has major patients of TB and HIV aggravates the condition.
Among people with latent TB infection, HIV infection is the strongest known risk factor for
progressing to TB disease. A person who has both HIV infection and TB disease has an AIDS-
defining condition.
WHO Report on TB-HIV
At least one-third of people living with HIV worldwide in 2012 are infected
with TB bacteria, although not yet ill with active TB. People living with HIV
and infected with TB are 30 times more likely to develop active TB disease than people without
HIV.
HIV and TB form a lethal combination, each speeding the others progress. Someone who is infected
with HIV and TB is much more likely to become
sick with active TB. In 2012 about 320, 000 people died of HIV-associated
TB. Almost 25% of deaths among people with HIV are due to TB. In 2012 there were an estimated
1.1 million new cases of HIV-positive new TB cases, 75% of whom were living in Africa. As noted
below, WHO recommends a 12-component approach to integrated TB-HIV services, including
actions for prevention and treatment of infection and disease, to reduce deaths.
TB and DIABETES:
According to the government-run Revised National TB Control Program (RNTCP), people with
diabetes have a two-three times higher risk of TB compared to people without diabetes and about
10 per cent of TB cases globally are linked to diabetes. People with diabetes who are diagnosed
with TB, an infectious disease of the lungs, have a higher risk of death during TB treatment
and of TB relapse after treatment is over. Diabetes is complicated by the presence of infectious
diseases like TB.
The reason behind diabetes patients easily contracting TB is the low immunity in them that
results in higher chance of infection. Diabetes can lengthen the time to sputum culture
conversion and theoretically this could lead to the development of drug resistance in TB
patients.
Paper 2
National
1. Government policies and design : National TB Control Program, Revised National TB Control
Program : Issues (Major crux)
First let us understand the basics of TB, issues in TB control mechanism and related terms.
In this section we will learn the importance of whole issue involved with TB for which it has been in
news from past few months. The reason of course is not good but pathetic.
In 2012, Indias golden jubilee year of TB control, the World Health Organization (WHO) named
India the worst performer among developing nations, with 17 per cent of the global population
carrying 26 per cent of the global TB burden. In WHOs Report, 2013, India is lamented as worst
performer.
Tuberculosis was very much in news because of:
1. Shortage of drugs,
2. Increasing case of Multi-drug and Extensive drug Resistance leading to failure of Indias
Revised TB control program and questioning the mechanisms involved to check this menace.
3. Total drug resistance (TDR) as a veritable death warrant and inefficiency to tap and notify
this. Even WHO is yet to notify this in spite of its solid recognition in few nations including
India.
4. Popularly used serological tests for diagnosis being declared worse than useless, TST tests,
Gamma ray tests, Blood tests and bottlenecks in them.
5. A government order for mandatory case notification making TB a notifiable disease.
6. Private practitioners are legally authorized to treat TB, but without quality check mechanisms.
7. Volunteers are least expertise and literate to handle the cases legally and ethically.
8. Pediatric TB and issues associated with it.
9. Contact screening
Now let us understand TB
TB:
Tuberculosis is caused by various strains of mycobacterium, usually Mycobacterium tuberculosis. It
usually attacks the lungs but can also affect other parts of the body. It is spread through the air when
people who have active MTB infection cough, sneeze, or spit. In most cases the disease is
asymptomatic, latent infection, and about 10% latent infections eventually progresses to active
disease. If untreated, it kills 50% of its victims. One third of the worlds population is thought to be
infected with M. tuberculosis, and every second a new infection occurs. About 80% of the population
in many Asian and African countries test positive in tuberculin test.
DRUG RESISTANT TB
Until 50 years ago, there were no medicines to cure TB. Now, strains that are resistant to a single
drug have been documented in every country surveyed. Drug-resistant TB is caused by inconsistent
or partial treatment, when patients do not take all their medicines regularly for the required period
because they start to feel better, because doctors and health workers prescribe the wrong treatment
regimens, or because the drug supply is unreliable. A particularly dangerous form of drug-resistant
TB is multidrug-resistant TB (MDR-TB), which is defined as the disease caused by TB bacilli
resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB
are high in some countries, especially the former Soviet Union, and threaten TB control.
MDR-TB
TB that is resistant at least to isoniazid and rifampicin the two most powerful first-line anti-TB drugs
are called the Multidrug-resistant tuberculosis (MDR-TB). It develops because the when the course
of antibiotics is interrupted and the levels of drug in the body are insufficient to kill 100% of bacteria.
This means that even if the patient forgets to take medicine, there are chances of developing MDR-
TB.
MDR-TB is treated with second line of anti-tuberculosis drugs such as a combination of several
medicines called SHREZ (Streptomycin+isonicotinyl
Hydrazine+Rifampicin+Ethambutol+pyraZinamide) +MXF+cycloserine.
XDR-TB
When the rate of multidrug resistance in a particular area becomes very high, the control of
tuberculosis becomes very difficult. This gives rise to a more serious problem of extensively drug-
resistant tuberculosis (XDR-TB). XDR-TB is caused by strains of the disease resistant to both first-
and second-line antibiotics. This confirms the urgent need to strengthen TB control. Thus,
Extensively-drug resistant TB (XDR-TB) is a sub-set of MDR-TB which is further resistant to
at least two more drugs which are second line drugs and is thus virtually incurable.
TDR-TB
Totally drug-resistant tuberculosis (TDR-TB)
It is TB which is believed to be resistant to all the first and second line TB drugs. TDR-TB has
resulted from further mutations within the bacterial genome to confer resistance, beyond those seen
in XDR- and MDR-TB. Development of resistance is associated with poor management of cases.
Drug resistance testing occurs in only 5% of TB cases worldwide. Without testing to determine drug
resistance profiles, MDR- or XDR-TB patients may develop resistance to additional drugs. TDR-TB
is relatively poorly documented, as many countries do not test patient samples against a broad
enough range of drugs to diagnose such a comprehensive array of resistance. The United Nations
Special Program for Research and Training in Tropical Diseases has set up a TDR Tuberculosis
Specimen Bank to archive specimens of TDR-TB.
India started its TB program with National TB Control Project in 1962 and used BCG as its main
intervention. Few years later The Expanded Program on Immunization took over BCG vaccination
(1978).
This strategy and program didnt work for India and results were disastrous as BCG trials responded
badly and showed no protection against infection by TB bacilli (1979)
It was recognized that TB control project has been out of its reach and needs effective restructuring.
India launched Revised National TB Control Program on the backdrop of WHO recommended DOTS
strategy after piloting tests from 1993 to 1996.
RNTCP is a fully Central Sponsored Scheme and works for free from diagnosis to treatment. It uses
DOTS strategy of WHO and all component of STOP TB strategy of WHO.
It had two phases. First phase was from 1998 to 2005 where focus was on ensuring expansion of
quality DOTS services to the entire country. The second phase (2006-2011) concentrated on
extensive services and set target to detect the rate of new smear positive cases (70%) and maintain a
cure rate of at least 85%.
DOTS: Direct Observatory Treatment Short-course
It is a key component of the WHO campaign to Stop TB strategy. Indias RNTCP is premised upon
DOTS. It involves the volunteers (trained health professionals) based health services to patients,
drugs and services are provided at the doorstep of patients and service provider keeps a track on the
diseased.
Key elements:
1. Sustained political and financial commitment
2. Diagnosis by quality ensured sputum-smear microscopy test
3. Standard short course anti TB treatment given under direct and supportive observation
4. Regular and uninterrupted supply of anti TB drugs.
5. Standardized treatment and reporting
As a part of DOTS strategy health workers counsel and observe their patients swallowing each dose
of powerful combination of medicines and keeping track on their complete drug usage.
In 2012, WHOs Annual Report on TB reported that though DOTS saved lives from TB mortality but
has failed to control TB.
Why this happened?
The Revised National TB Control Program (RNTCP) achieved country-wide coverage in March 2006
and achieved 86 per cent treatment success rate in recent years. More than 15,000 suspects are
examined for the disease every day and about 3,500 patients are started on treatment. And to its
credit, for the very first time in 2007, RNTCP achieved the global target of 70 per cent case detection
(53 cases per 100,000 populations per year).
Despite these impressive achievements, India has the highest TB burden in the world 3.5 million
active TB cases. The number of new active TB cases detected every year is over two million; it was 2.2
million in 2011. And the disease kills two people every three minutes. Incidentally, the incidence and
prevalence figure is not a true indicator of the ground reality reason being the number of patients
treated by the private sector is not known.
But why is India continuing to record the most number of TB patients in the world every year? A
closer inspection reveals that the program is far from perfect and may require a thorough re-
examination of both design and implementation. The massive country-wide drug stock-out crisis
that played out recently is, but, just one of the malaises that the program faces.
Issues in RNTCP
The national TB control program (RNTCP) uses a passive system for diagnosing TB patients. The
design of the system is such that it waits for patients to walk into the centers to get tested. It is well
known that patients walk into these centers quite late in the day. And in the process, they end up
infecting many people. That a single active TB patient who is not on treatment is capable of infecting
10 or more people in a year shows how badly our RNTCP program is in need of a reorientation. It has
to necessarily shift gears and seriously consider changing its strategy from the current passive case-
detection system to an active mode of detecting cases.
For those with extra-pulmonary TB, a sputum test will not help in diagnosis. RNTCP is not interested
in them as they do not spread TB bacilli. So, the project illustrates incomplete health care and
inadequate public health.
Control is a defined term in epidemiology the disease burden should be reduced to a pre-stated
level, within a stipulated period of time, and proven to be due to intervention and because of a
secular trend. As socio-economic status increases, TB should decline even without specific
interventions that is a secular trend. RNTCP has not set control targets in terms of a time frame
and disease burden. It is not measuring a secular trend. Thus, the control in RNTCP is not
epidemiologically sound.
The Centre, in line with WHO recommendations, had sent an advisory few months ago, to
discontinue serological (or blood-based) tests to diagnose TB, as its results arent accurate. But
serological tests continue to be used in labs across the India, for economic reasons, say several
studies done by TB experts. It doesnt have the stigma and low-margins of a sputum-smear
microscopy the basic TB test. And it is as expensive as a liquid culture test.
Private practitioners are legally authorized to treat TB, but without quality check mechanisms. They
often bypass the prescribed treatment protocol, while MDR, XDR and TDR result from non-protocol
drug treatment. They also encourage serological tests which are banned.
In young children, infection can rapidly lead to disease, called childhood TB, which can be serious
and life-threatening. BCG fails to protect against infection by TB bacilli, but protects against
infection progressing to childhood TB. Thus, universal neonatal BCG vaccination saves thousands of
lives and huge costs for diagnosis and treatment. Childhood TB is not infectious so, treating
childhood TB has no role in TB control. So RNTCP is far from recognizing the menace of Pediatric
TB which is a major issue.
Historically, though, there has been less investment in TB medicines, because majorities of the
affected were poor, and therefore, there was little market incentive for the industry to invest in this
area.
Note: Kindly address the missed issues of relevance!
DOTS Plus Strategy: For addressing issue of MDR-TB ( Add your points )
2. Role of NGO and SHG
Vasavya Mahila Mandali (VMM), a city-based NGO, has brought into play the Snakes and Ladders
board game to educate TB and HIV-afflicted unlettered patients in the community on the series of
Dos and Donts.
The board used by the NGO reads ART & TB DOTS (Direct Observation Therapy Short Course)
Medicines Good Practices.
Such initiatives and many more for awareness and proper implementation of government policies,
we need a huge back up from our civil society and voluntary organizations.
The role of NGOs and SHG is very important in effective policy implementations of government
plans and policies. We already learnt that how lack of awareness and proper care taking is done.
NGO and SHG may be capitalized by government to provide health care system with volunteers to
work for government plans at ground level.
Note: Add the case studies by specific NGOs and SHGs whereby volunteers work for government
plans under PPP and contractual basis.
3.Vulnerable sections: Children- Pediatric TB
According to WHO, the risk of developing the disease is much greater in infants and those below
five years who have been infected than those above the age of five. In infected children below five
years, if the disease does develop, it usually does so within two years of infection. But in the case of
infants, the disease can set in within a matter of 6-8 weeks of infection.
How far we are from even contemplating a radical change in our case-detection approach can be
assessed by looking at how the WHO-recommended, RNTCP-approved contact screening of children
below five years in households where an adult has been recently diagnosed with active pulmonary TB
(sputum smear positive) is carried out. Children below five years from such households are most
vulnerable to getting infected and probably developing active TB.
As a preamble, one has to only examine the differences between the WHO guidelines and the RNTCP
guidelines to understand the extent of disconnect. While the WHO recommends contact screening in
children below five years, RNTCP has it as below six years. This is the major issue of concern =D
Screening children would help in diagnosing those who have already developed the disease (active
TB) as well as those who have been infected but yet to develop the disease.
While treatment for those who have developed the disease would be through the routine multi-drug
regimen. Children who have been infected but have not yet developed the disease are ideal
candidates for a preventive therapy.
Contact screening of young children combined with chemoprophylaxis (preventive drug therapy)
would go a long way in breaking the TB transmission cycle and reducing the case load by preventing
the number of people who would become TB patients.
Contact screening does not require many additional resources and can be implemented through the
existing system if compliance is ensured through adequate monitoring and supervision.
Indian Scenario:
As per 2008 survey, Only 14 per cent of children aged 6-14 years were screened for TB and only 19
per cent (16 of 84 children) of children below six years were initiated on preventive therapy. There
was no difference between urban and rural areas in terms of preventive therapy initiation. It has not
been prioritized by RNTCP. No reporting of this activity is required.
Health care workers (HCW) in rural areas were themselves less aware of contact screening and
preventive therapy in young children. Awareness level among HCWs that immediate family members
are more susceptible to infection was significantly lower in rural areas. Only one-third of parents in
rural areas were aware of contact screening and the need for preventive therapy in children below
five years.
The DOTS -TB treatment card of the adult (index patient) has no provision for documenting the
details of contact screening, preventive therapy, follow-up and treatment completion.
As a follow up, some improvements like all the health workers, medical officers to DOTS workers
were provided basic training on all aspects of contact screening and preventive therapy. And a
separate preventive therapy register and card were also introduced in line with the WHO
recommendations. After this, 2013 study in same area reveals that the results were quite dramatic.
The health workers were able to identify 82 per cent of child contacts. Sixty-one per cent (53 children
below six years) were screened for TB disease and put on preventive treatment. Of the 53 children,
74 per cent (39 children) completed the treatment. This is a huge improvement compared to just 19
per cent children who were even initiated on treatment in 2008.
Issues in diagnosing TB in Children
Its a fact that diagnosing TB in children less than five years is a challenging task. As WHOs
Roadmap for childhood Tuberculosis, has pointed out, there are no effective diagnostic tests.
Unexplained loss of more than five per cent of the highest weight recorded in the past three months,
or fever and/or cough for more than two weeks make TB more likely, especially when the child has
been in contact with an infectious pulmonary TB patient in the same household. Yet, diagnosis
cannot be made on the basis of clinical symptoms alone.
Young children will not be able to produce sputum. This is largely because their cough reflex is not
fully developed; they tend to swallow the sputum. Sputum is the most basic and important sample
for diagnosing pulmonary TB disease.
Even when a sputum sample does become available, it may contain only a few TB bacteria. So it is
hard to see a few bacteria under microscopy. So, pediatric TB is called Pauci-Bacillary disease
(fewer bacilli). The sensitivity of diagnosis by smear microscopy and culture depends on the amount
of bacteria present in the sample.
But even in the absence of sputum sample for micro-bacterial confirmation, much information can
be gained from tuberculin skin test (TST) and X-ray results. Though infected, TST can be negative in
infants because their immune system is not mature. This is where chest X-rays come in handy.
Positive chest X-rays (e.g. enlarged lymph nodes inside the chest) are also indicative of TB. But X-
rays can be abnormal due to many diseases (e.g. bacterial or viral pneumonia, asthma).If X-rays are
abnormal, that pushes the diagnosis towards active TB, not latent TB. But X-ray results need to be
used along with other tests. A positive TST and suggestive X-ray, plus history of close contact with a
TB case in the house, and symptoms (e.g. not gaining weight, fever) are most likely to point to TB
diagnosis.
The recently updated national guidelines on pediatric tuberculosis lay great emphasis on
bacteriological confirmation using sputum samples even when chest X-ray is suggestive and TST is
positive, and the child has received a complete course of antibiotic treatment.
In cases where sputum is not available for examination or sputum microscopy fails to demonstrate,
alternative specimens (gastric lavage, induced sputum, broncho-alveolar lavage) should be collected,
depending upon the feasibility, under the supervision of a pediatrician.
Facilities to collect sputum using the two different lavage methods from those under five years are
available only in the tertiary centers in the urban areas. So what percentage of children from the
rural areas would end up getting correctly diagnosed and treated, is a question to be addressed?
Incidentally, RNTCP aims to achieve universal access to quality assured TB diagnosis and
treatment during 2012-2017. But near future and present status abhor all these claims.
Thats a very tall order considering the fact that even tuberculin is often not available in peripheral
health facilities.
Treatment and Diagnosis: Issues
1. Tuberculin Skin Test (TST)
Also known as the purified protein derivative (PPD) test,
Used to detect TB infection but will not tell whether a person has active TB or not
Performed by injecting a small amount of tuberculin into the skin of the arm and the reaction formed
on the arm determines the result of the test.
Useful in diagnosis of infection in children where others methods generally fail.
Problems:
Non-availability of diagnostic tools like tuberculin.
Though infected, TST can be negative in infants because their immune system is not mature.
2. Smear Microscopy
First diagnostic tool used to microbiologically confirm TB infection/disease.
A very thin layer of the sample (sputum) is placed on a glass slide, and this is called a smear. A series
of special stains are then applied to the sample, and the stained slide is examined under a
microscope for signs of the TB bacteria. Inexpensive and simple
Problems:
Performs poorly in children, especially in those under five years.
Sensitivity is only about 50-60%
3. Culture
Culturing is a method of studying bacteria by growing them on media containing nutrients.
Culturing and identification of M. tuberculosis provides a definitive diagnosis of TB and can
significantly increase the number of cases found.
It can also provide drug susceptibility testing, i.e. if a person has MDR or XDR.
Problems
It has sensitivity limitations and takes several weeks to yield a clinically useful result.
more complex and expensive
4. X-rays
Acute pulmonary TB can be easily seen on an X-ray.
The picture it presents is not specific and a normal chest X-ray cannot exclude extra pulmonary TB.
Problems
In countries where resources are more limited, there is often a lack of X-ray facilities.
5. Interferon gamma release assays (IGRAs)
A new type of most accurate TB test through which results can be available within 24 hours and these
assays work by detecting a cytokine called the interferon gamma cytokine. They are performed in
practice by taking a blood sample and mixing it with special substances to identify if the cytokine is
present.
Used to detect TB infection/Latent TB but will not tell whether a person has active TB or not.
6. Xpert molecular test (Xpert MTB/RIF
An alternative test that is more sensitive than Smear Microscopy and takes less time than Culture.
WHO endorsed Xpert for rapid diagnosis of drug-sensitive and multi-drug resistant TB
Xpert can be used as the initial diagnostic test in all children presumed to have TB. There is limited
number of Xpert diagnostic machines in India and is used for testing drug-resistant TB.
Introduction of newer diagnostic tests such as Xpert MTB/RIF which can detect MDR-TB from the
sample as well as resistance to rifampicin, a surrogate marker for MDR-TB, in less than two hours
has become important to rapidly diagnose MDR-TB.
Earlier Solid culture method result can be obtained only after 4 months, Liquid Culture method
result in two months, Line Probe Assay test single MDR sample result obtained in two days, Now
Gene Xpert result can be obtained within two hours.
Problems with Xpert MTB
Need for a constant supply of electricity, the high cost of the instrument and cartridges. Waste
management of cartridges and its utility in extra-pulmonary and smear negative samples has been
questionably low.
3. Issues related to social sectors : Health
Here we shall connect the bottlenecks in Indias health care policies and services. Mention and
advocacy of PPP to lessen the burden on government is one way to address the issue in contemporary
times. Lack of resources and proper channelization of resources are also important reasons.
Note: Add specific points as per your convenience.
4. Issues related to Poverty and Hunger (Malnutrition): One of the reasons for ineffectiveness of
TB control in India and world.
Note: I discussed it under economic impact but do make your points and connect
International
1. World Health Organization : On TB, Reports on India
Many of the things have been addressed already.
WHO response
WHOs pursues six core functions in addressing TB.
1. Provide global leadership on matters critical to TB.
2. Develop evidence-based policies, strategies and standards for TB prevention, care and control,
and monitor their implementation.
3. Provide technical support to Member States, catalyze change, and build sustainable capacity.
4. Monitor the global TB situation, and measures to progress in TB care,
Control and financing.
5. Shape the TB research agenda and stimulate the product ion, translation and dissemination
of valuable knowledge.
6. Facilitate and engage in partnerships for TB action.
The WHOs Stop TB Strategy, which is recommended for implementation
by all countries and partners, aims to dramatically reduce TB by public and private actions at
national and local levels such as:
1. Pursue high-quality DOT S expansion and enhancement. DOTS are a five-point package to:
a. Secure political commitment, with adequate and sustained financing
b. Ensure early case detection, and diagnosis through quality assured bacteriology.
c. Provide standardized treatment with supervision and patient support.
d. Ensure effective drug supply and management and
e. Monitor and evaluate performance and impact;
2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations; Most important
3. Contribute to health system strengthening based on primary healthcare;
4. Engage all healthcare providers;
5. Empower people with TB, and communities through partnership;
6. Enable and promote research.
2. Programs and Policies of other International bodies for TB control: Already covered
3. Lessons for India from other nations: Do some case studies of African nations where the fight for
TB with effective policy has been substantial. What India can learn from them?
Paper 3
1. Issues related to Planning and mobilization of resources for TB: 5YP and Economic
implications of TB
Economic Impacts of TB
The development of new and improved TB treatments that reduce the global TB burden could help
increase the productivity of entire regions and promotes sustainable and self-determined economies,
opening up new engines of innovation, trade, and industry. The concept of health being a necessary
precursor to wealth is as true for the world as a whole as it is for the individual.
TB Impacts: The World
TB will rob the worlds poorest countries of an estimated $1 to $3 trillion over the next 10 years .
This will disproportionately impact developing countries , where 94 percent of TB cases and 98
percent of TB deaths occur.
Particularly troubling for the prospects of global prosperity , 75 percent of TB cases arise during
peoples most productive years , between the ages of 15 and 54.
Poor, crowded living conditions increase the risk of contagious infection. TB and poverty create a
vicious cycle, whereby the disease exacerbates poverty, which in turn increases the likelihood of
contracting TB. This is extremely distressing news for the 2.7 billion around the world who live on
$2 per day or less.
TB Impacts: Countries
The World Bank estimates that loss of productivity attributable to TB is 4 to 7 percent of some
countries GDP. Entire economies are affected by the worlds TB epidemic, stifling human
development on a large scale. Concomitantly , the burgeoning cos t of TB medical care is a
constant drain on those health systems whose infrastructures are least able to carry the load.
Many TB-endemic nations cant afford to treat their own patients, leaving donor countries to
procure TB drugs for the developing world. Treatment for drug-resistant TB is financially out of
reach for most who suffer from the disease.
Many national healthcare systems are overburdened by the TB epidemic and the infrastructure
necessary for TB treatment represents the bulk of their costs i.e about $4 billion annually. A shorter
regimen that eliminates many of the doctor visits could drastically cut those expenses. Funding could
then be redirected to basic healthcare and increased resources for TB control. Whole economies
would benefit, especially in nations that bear the brunt of the TB pandemic.
TB Impacts: Families
TB commonly destroys families where it is prevalent, with women bearing the brunt of the stigma of
the di s ease. In TB-endemic regions, the burden of TB is greatest for women in their child-bearing
year. Over the next five years, without effective interventions, up to four million women will die from
TB and 50 million children will be orphaned. Further, hundreds of thousands of children will die
from TB over the same period. It is estimated that 250,000 children suffer from TB each year and
100,000 die. However, TB is notoriously difficult to diagnose in children and therefore many
experts believe the pediatric burden of TB is even higher.
The economic toll on families is also very difficult. TB treatment is often free, at least for drug-
sensitive tuberculosis , but patients incur other costs , like transportation and hospital costs , at
the same time they have likely reduced their working hours or stopped working completely . The
WHO calculates that the average TB patient loses three to four months of work-time and up to
30 percent of yearly household earnings .
A shorter drug regimen would reduce lost work-time and lessen the economic impact of TB on
individuals lives , and in turn help stabilize families , save and enrich the lives of millions of
children, and enable a healthier, more productive labor force in many TB-endemic countries.
2. Inclusive growth : Bottlenecks in Health sector : Done above
3. Science and Technology: Development and applications of technology in the field of TB
Mention of Treatment, Tests and technology as TST, XPERT Gene and
IGRA etc.
NIKSHAY: Nikshay, jointly set up by Central TB division and National
Informatics Centre (NIC) in May, 2012, is an online record system
Monitor TB patients (Add some your points)
4. Achievements of Indians and Institutes working for TB control and indigenization of
technology related to it.
Note: Do it yourself please:
SENTINEL PROJECT:
The Sentinel Project on Pediatric Drug-Resistant Tuberculosis is a collective power of a global
partnership by experts and others who share the same vision of ensuring that no child dies of
drug-resistant TB that is curable.
One of the most important contributions of the Sentinel Projects field guide is its algorithm for
managing a child who is in contact with an infectious adult with MDR-TB disease. Though WHO has
not come out with guidelines on chemoprophylaxis for children, especially those younger than five
years, who are close contacts of MDR-TB patients, several other agencies have come out with theirs.
The question about chemoprophylaxis is not addressed in the same way among several global
guidelines, Prof. Becerra noted. But the aim of the Sentinel Project has been to provide guidance
on this and other challenges based on the collective expert opinion and observations of colleagues
across the globe.
There are two instances when children aged younger than five years who are asymptomatic, growing
well and have no clinical signs of TB but have been in contact with an adult (index case) would be
eligible for preventive therapy.
The first is when the index case is resistant to rifampicin drug alone. In such a case, the child
needs to be treated with 15-20 mg/kg of isoniazid drug for six months. The second instance is
when the index case has confirmed MDR-TB but is susceptible to Ofloxacin. In such cases, the child
may be treated as per the National TB Program, or by one of the five regimens listed in the Sentinel
Project.
Another important goal of the Sentinel Project is to come as close as possible in knowing the
true burden of TB disease in children. Since bacteriological confirmation is difficult in children
younger than five years, there is a need to have more data on the number of children suffering
from drug-sensitive TB and drug-resistant TB. (The Hindu)
5. Biotechnology and its role in TB :diagnosis and treatment
Done already
6. Food security related:
One of the major causes of TB is the use of tobacco. Due to its pervasiveness there is ineffectiveness
in curtailing TB rise. If somehow there is serious control in sale and production of tobacco then it
would advertently affect the food security as well as TB. How?
When tobaccos production would be curtailed then there will be more land for crop production
which means more land to poor farmers and government to work in crop intensive agriculture and in
turn more food secure our nation will be.
So with one sword, two strikes.
Paper 4
Ethical incapacity among doctors, family and society to treat the diseased under human dignitaries
and the international scenario to fight with this menace is endowed with several other challenges to
be addressed.
The consequences of TB have been, and continue to be, enormous. The fact that TB primarily affects
the poor raises issues of social justice. The fact that drug resistance which exacerbates the TB
threat worldwide is largely a product of the way that drugs are distributed likewise raises issues of
justice . Public health TB control measures such as isolation and quarantine, finally, raise
questions about how the goal to protect public health should be balanced against the goal to
protect individual human rights and liberties.
Very recently it has been compounded that deaths due to TB and AIDS has enhanced drastically. It
has also been recognized that TB treatment is much more cost effective than AIDS. Even then the
ineffectiveness in dealing with TB issue raises several ethical questions.
Mostly TB cases are found in third world nations and developing nations and in-spite of several
technological competence of developed world, the moral obligation to help other nations is still
perfunctory.
A final reason for thinking that TB may be ethically more important than AIDS is that the
former, being airborne, is both contractible via casual contact and much more contagious. While
behavior modification (with respect to drug use and sexual practice) can essentially eliminate the
risk of infection with AIDS, TB can be passed from one individual to another via coughing,
sneezing and even talking. In many ways the threat to innocent individuals and public health in
general is greater in the case of TB and needs to be addressed.
Though bioethics discussion often focuses on health workers obligations and patient relationships,
and issues of social/institutional policy gives emphasis on ethical obligations of individuals that is to
avoid infecting others and treat patients with complete humane behavior.
It would be unreasonable, for example, to expect that potentially infected persons should take all
possible measures to avoid infecting others because potentially infected persons includes all of
us who have been in contact with someone who just might have been contagious without our
knowing it.
In addition to further analyzing, these issues, ethicists should be raising public awareness about the
moral imperative of infection prevention.
Coercive Social Distancing
It is common, at least in developed countries such as the US, to confine TB patients who refuse to
take their medicines. To what extent is coercive restriction of movement ethically justified in the
name of TB prevention? And who, exactly, should be confined? It is one thing to confine infectious
(i.e. contagious) patients who refuse to take their medication. It is quite another thing to confine
noninfectious patients.
Third Party Notification
One of the ethical issues debated in the context of HIV was the question of whether or not an HIV
infected patients right to confidentiality should, if necessary, be breached to notify a third
party at risk of becoming infected by him. Similar questions arise in the context of TB, and they are
especially pressing in the context of XDR-TB. The ethical question for the physician or other health
worker is whether or not to warn close contacts of a patient diagnosed with XDR-TB or a patient
suspected to have active illness, while diagnostic confirmation is awaited, especially if there is
reason to believe the patient has not warned close contacts of the danger of contagion and/or is
failing to take sufficient precautionary measures. On the one hand, disclosure would apparently
violate the patients right to confidentiality. When a patient presents to health care workers, the
implicit or explicit promise is that information regarding his health will be held in confidence. In the
above scenario, then, informing the third party would involve breaking such a promise.
The third party in this scenario, on the other hand, has rights too. Her/his right to life is seriously
threatened if the patient has infectious XDR-TB. While health workers have duties to their patients,
they also have duties to save lives of others when they are in a position to do so. The patients right to
confidentiality in this scenario conflicts with his/her contacts and right to life.
The third partys right to protection is more important than the incautious patients right to
protection. While it is common to conclude that a health worker is ethically permitted to breach
confidence in a case like this, many hold the stronger position that the health worker is not only
ethically permitted but also ethically required to breach confidence in order to protect the third
party.
Duty to Treat
It is commonly believed that health workers have a duty to care for patients even when this poses
dangers to health workers themselves. Facing dangers associated with caring for infectious patients
is arguably part of a health workers jobjust as it is a fire-fighters job to face risks. Facing
such risks, one might argue, is one of the things that a health worker commits to when she
takes on this kind of employment. Some argue that the duty to care is based on a social contract.
Society provides privileges by way of exclusive training to health workersbut it then expects health
workers to provide health care in return.
In addition to duties to immediate patients, health care workers have duties to others. They have
duties to other/future patients that they would not be able to treat if they die as a result of
treating this patient. And they similarly have duties to family members that they could not fulfil
in the event of death. Though such duties may conflict with the duty to treat ( this immediate
patient) , health workers also have duties to their co-workers that support their duty to treat (
this immediate patient) . Co-workers are part of a team and each expects the others to do their part.
If I refuse to treat this patient, then someone else (who might have a family and would have future
patients) will be called in to do my job.
If too many refuse, then the health care system no longer functions. Solidarity is, therefore, needed.
If the risks are exceptionally high in the context of XDR-TB, then the safety of working conditions
must be improved. If it is reasonable for society to expect health workers to treat patients, then
it is also reasonable that health workers expect society ( or the health care system)to provide
safe working conditions insofar as this is possible. This is a matter for reciprocity. Compensation
to health worker should be given with due appropriation.
International Justice
As a disease of poverty, TB raises issues of international distributive justice. Though sufficient
resources for health improvement are lacking in poor countries, there are numerous powerful
moral ( egalitarian, utilitarian and libertarian) and self-interested reasons for wealthy nations to
do more to help improve health care in poor countries. These issues are complex and intertwined
with the above questions regarding liberty-violating public health measures. If health care provision
and thus global health were better to begin with, for example, then the occasions upon which liberty
infringing public health measures are called for would arise less often.
Because infectious diseases including drug resistant infectious diseases such as XDR-TB, do not
recognize international boundaries, bad health in poor countries threatens global public health in
general. The strength of associated self-interested reasons for wealthy nations to help reduce TB
in poor countries ( through targeted or untargeted funding) should therefore, finally, be a major
focus of analysis.