Despite the emergence of newer killer pathogens like Ebola, M. tuberculosis still remains the top pathogenic killer. In spite of being discovered as early as the 1880s, the pathogen continues to affect millions of people – even more than malaria. Recently, WHO highlighted India’s position as the country with the highest-burden of this preventable and curable disease.
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What causes tuberculosis?
- Tuberculosis is a bacterial disease, which is spread through the airborne route. It spreads from an infected person to others through a sneeze, spit and cough.
- It is commonly caused by Mycobacterium tuberculosis.
- The bacteria is noted for its weak gram-positive nature and less than the average rate of multiplication.
- The pathogen can persist in a dry state for several weeks and can survive mild disinfectants.
- However, these are not the only species to cause tuberculosis and humans aren’t the only ones affected by the disease.
- Other animals including cattle, birds, rodents and reptiles can also be affected by the disease. A noted bacteria, Mycobacterium Bovis is a significant causative of tuberculosis among cattle.
- A genetically related group of Mycobacterium, which is referred to as MTC or Mycobacterium tuberculosis Complex, is the causative pathogens of tuberculosis among animals and humans.
What are the symptoms of tuberculosis?
- Tuberculosis most commonly affects the lungs and the respiratory system.
- Cough with sputum (sometimes with blood), chest pain, night sweats, fever, loss of body weight, weakness, etc. are some of the common symptoms.
- The scarring of the lung tissues, especially in the upper lobes, is one indicator of the disease.
- In its extra-pulmonary versions, the disease may infect other systems like the lymphatic system, central nervous system, skeletal system, joints, etc.
- One-quarter of the patients are asymptomatic (latent tuberculosis).
What are the types of tuberculosis?
- Active tuberculosis: This is the most common type. The risk of spreading the disease to others is high in this type. The pathogen actively multiplies and spreads to different organs of the body from the lungs.
- Latent tuberculosis: This is the asymptomatic version. Unlike active tuberculosis, it is not contagious. The patient does not suffer from any of the symptoms of the disease.
- Military tuberculosis: It is one of the most fatal forms. It affects multiple organs at once by entering into the bloodstream. It is a type of active tuberculosis but rarer.
- Multi-drug resistant tuberculosis (MDR-TB): Tuberculosis infections that are resistant to treatment using the first line anti-Tb drugs are called MDR-TB. Infections resistant to treatment using Rifampin and Isoniazid are termed MDR-TB. A strain called ‘Beijing lineage’ is responsible for most of these cases.
- Extensively drug-resistant tuberculosis (XDR-TB): Tuberculosis infections that are resistant to both first and second-line anti-TB drugs are called XDR-TB. These are MDR-TB infections that are resistant to Fluoroquinolone (a first-line anti-TB drug) and at least one second-line anti-TB drug-like Amikacin, Kanamycin or Capreomycin.
Who are at risk of infection?
- Almost one-quarter of the people in the world are infected by the pathogen. However, not all exhibit active tuberculosis.
- All the age groups are at risk, including children.
- Most of the cases are in developing countries (95%).
- HIV patients are 19 times more likely to be affected by the disease due to a weakened immune system.
- Undernourishment increases the risk of 3 fold.
- Alcoholism increases the risk by over 3 times.
- Tobacco smoking almost doubles the chances of contracting the disease.
How is tuberculosis diagnosed and treated?
- Tuberculosis is preventable and curable.
- The microscopic examination of sputum samples detects half of the cases. Chest X-Ray is a common diagnostic tool.
- Asymptomatic cases are detected using tests like the Tuberculin Skin Test.
- Treatment usually involves a 6 months course of 4 anti-TB drugs.
- MDR-TB treatment is more difficult and it involves the use of the harsher second-line anti-TB drugs like Amikacin and Kanamycin.
- Vaccination using the BCG (Bacillus Calmette Guerin) is an ideal practice. It is the most commonly used vaccine worldwide.
What is the global impact of tuberculosis?
- It is one of the top 10 causes of death (from a single pathogen). It ranks even higher than HIV.
- According to the Global Tuberculosis Report 2019, about 10 million people were affected by the disease. Of this, 1.1 million were children, 3.2 million were women and 5.7 million were men.
- The highest tuberculosis burden is among men who account for about 57% of the cases.
- It caused the death of 1.5 million people in 2018.
- It has become the leading cause of death among AIDS patients (1.2 million people died in 2018).
- It has also become a major cause of death due to anti-microbial resistance.
- The disease’s burden is highest in the South East Asian region (44%), followed by Africa (24%) and the West Pacific region (18%). It is lower in Europe and America (3% each).
- 2/3rd of the cases are in just 8 countries: India, China, Philippines, Indonesia, South Africa, Nigeria, Pakistan and Bangladesh.
- Nearly half a million new cases of drug-resistant TB were reported in 2018. Most of these cases were of the MDR-TB type.
What is the impact of tuberculosis in India?
- The Global Tuberculosis Report 2019, published by WHO, noted that India has the highest burden of tuberculosis in the world. 27% of the cases were reported from India. China, another populous country, accounts for 14% of the cases.
- 9 lakh cases of tuberculosis were reported from India in 2018. This is a decrease in the incidence rate of about 50,000 patients since the previous year.
- There has been an increase in the number of drug-resistant tuberculosis cases (especially against Rifampicin) from the previous 32% to 46% in 2018.
- The disease notification trend in India has influenced the global trend greatly. In 2013, 1.2 million cases were notified while in 2018, 2 million cases were notified.
- The domestic funding for tackling the disease has increased 4 fold between 2016 and 2019 in India.
- The success rate in treatment has also increased to 81%.
What are the steps taken by the government to address the problem?
- Tackling tuberculosis is featured in the Sustainable Development Goal 3 under the move towards providing Universal Health Coverage.
- 90-90-90 target by 2035: Indian government has set a goal to achieve a 90% reduction in mortality, incidence and high health expenditure due to tuberculosis by 2035.
- National Strategic Plan for TB Elimination for achieving ‘zero TB deaths’ by 2025.
- By 2020, the government has planned to achieve 100% detection of all TB cases.
- Bharat Kshay Niyantran Pratishthan or India TB Control Foundation for improving detection especially in the slums, rural area, tribal settlements, prisons, etc. It also seeks to address nutritional support for tuberculosis patients.
- Nikshay app: Introduced under the Revised National Tuberculosis Program and developed by the National Informatics centre to track tuberculosis patients. It enables the healthcare workers to track the treatment of the patients even at the level of Tuberculosis Units.
- Swasth e-Gurukul: e-learning platform launched by WHO in India to increase awareness about the disease.
- TB Culture and Drug Susceptibility Testing facilities being set up and strengthened in partnership with private players. By the end of 2020, at least 7 such facilities are expected to be completed.
- India has about 74 laboratories that can conduct drug susceptibility tests on samples. These are approved by the Revised National TB Control Program.
- In 2018, the Drug Controller General of India approved the use of ‘Delamanid‘ drug for the treatment of MDR-TB.
- In 2016, the Ministry of Health and Family Welfare introduced a drug for treating XDR-TB: ‘Bedaquiline’.
What are the challenges?
- Increase in cases of antibiotic resistance among the pathogens.
- Notification: the doctors and health workers are to notify new cases of TB. Though India has improved on the notification front, there is a wide gap between the estimates of the incidence and the actual notified cases. India accounts for 25% of the gap.
- Anti-TB drug misuse: The rise in the number of drug-resistant tuberculosis cases is mainly due to misuse of the first and second-line anti-TB drugs.
- Infrastructure: The need for treatment facilities and trained personnel for quick identification and treatment. The need for diagnostic and research infrastructure is also a challenge. Eg: WHO recommends 1 C&DST lab for every 10 million people. This means India needs nearly 130 such labs in the least.
- Inadequate TB surveillance system.
- Malnutrition and undernourishment.
- Sanitation in India is also contributing to the current trend.
- The stigma surrounding the persons affected by it.
- Alcoholism and smoking issues.
What is the way forward?
- Notification of new cases must be enforced, especially in the private healthcare sector. Such unrecorded cases are a major impediment to controlling the disease’s spread.
- Need to improve healthcare access for the socially marginalised and economically lower sections of the society. This is vital because they are more vulnerable to the disease.
- Increasing preventive treatment against tuberculosis among risk groups like AIDS patients and people with diseases that impairs immunity.
- Improving vaccine coverage. Preventing the disease saves a lot of healthcare costs and human capital.
- Addressing nutritional deficiencies – especially among the vulnerable population.
- Setting up certified diagnostic infrastructure and trained personnel to man them.
- Promotion of research and development for more efficient drugs especially for the MDR-TB and XDR-TB, the cases of which are on the rise in India. These need to be made more affordable too.
- Regulation of drug prescription and creation of awareness about the importance of sticking to anti-biotic courses.
The incidence of a preventable disease like TB is an important indicator of a country’s healthcare infrastructure. There is a need to address the issue of high TB burden if the country is to make full potential of its demographic dividend.
Examine the steps taken by the government and the challenges associated with TB eradication in India? (250 words)