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Expert Speak

Tuberculosis: Prevalence and Prevention

Is TB the disease of poverty? Are the upper classes exempt from it?

TB is, by and large a disease of poverty. It is a droplet infection. Like the common cold, it spreads through the air. When people who are with TB in their lungs cough, sneeze, talk or spit, they propel TB germs, known as bacilli, into the air. A person needs only to inhale a small number of these to be infected. The spread is more rapid when there is overcrowding and the number of TB patients are high in that particular area. Naturally in chawls, slums and other areas where people are not very healthy and the environments are not clean, spread of infection is high.

But the upper classes are not exempt from it. As I said, as it is a droplet infection. Anyone can be near a TB patient, without even realizing it and can inhale the germs

Is there a pattern to the spread of TB?

Each person with active TB disease will infect on an average between 10 and 15 people every year!

But people infected with TB bacilli will not necessarily become sick with the disease. The immune system fights it and it can lie dormant for years. But the threat remains. And they are susceptible to the disease. WHO says that someone in the world is newly infected with TB bacilli every second. 5-10% of people who are infected with TB bacilli (but who are not infected with HIV) become sick or infectious at some time during their life. TB is never really healed, only sealed.

The National Tuberculosis Programme was begun in 1962 and created an infrastructure for TB control throughout the country. Drugs are often given free. TB is curable. However, TB is a major killer in India. Why?

I think all of us are responsible for this.

At the physicians level: A doctor sees nearly two hundred patients in the Out Patient clinics of government hospitals in towns and cities. He or she is not able brief the patient on protocol. The doctor may not be able to spend enough time with the patient to outline the regimen and the significance of taking the course completely. The doctor may not emphasise the possibility of side effects of the drugs prescribed. There may just not be enough time. Not all hospitals/health centres are equipped with social workers or counselors.

At the patient level: Most often patients are from poorer classes. They are not aware of the importance of completing the course. After a month or so, they might stop as the symptoms subside. They may be day laborers and may find it difficult to miss work and report at the hospital for the next dosage of medication. (Though many of these problems are overcome by the DOTS programme, these have not been solved completely.)

At the community level: The stigma, though not as prevalent as before, still persists. Awareness about spread, prevention and care can be increased.

The Directly Observed Treatment, Short Course (DOTS) programme is said to have been tested and developed in India. Has this been effective?

Undoubtedly, DOTS has been effective. Not only has it improved diagnostic procedures but other areas as well. Medication is given in the presence of the healthcare worker thrice a week. Even if the patient does not turn up, the healthcare worker seeks him out at home and gives him his medication. We also have the medical record of the patient. The DOTS programme in India is said to be the “fastest expanding programme, and the largest in the world in terms of patients initiated on treatment, placing more than 100,000 patients on treatment every month.”

Of course there are some areas where there are some problems: as in the case of medication for a diabetic.

But overall TB has been more under control after DOTS

Why is Multi Drug Resistant TB still prevalent?

MDR-TB is a specific form of drug-resistant TB due to a bacillus resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs.

In India MDR TB is present but need not be.

Multi Drug Resistance, develops most often because treatment regimens have not been adhered to correctly. Essentially, anti biotics have not been used properly. This can be due to factors I discussed at the physician, patient and caregiver level.

In the second round of illness, the patient may have to take the suggested streptomycin injection. These are expensive and toxic. So the patient may not come in for treatment. Or he may have to travel some way and wait at clinics, causing a loss of livelihood.

So if we are able to get the patient to stick to his medication regiment the first time, we can bring the chances of MDR TB down drastically. Compliance, compliance, compliance is the way to go to reduce MDR TB.

There are cases of Primary MDR TB, where improper use of medication is not the cause. But in 95% of the cases MDR TB is preventable.

There is an accusation that even though patients reach the PHC or a treating centre, there is a delay in their receiving treatment…

In most PHCs diagnosis is through sputum smears. If there are two samples positive for a person, he is sent for an xray. For one thing, sputum smears may be negative and still the person may be infected. For another, how many PHCs have an xray facility? If the person does not have pulmonary TB, unless he tells the doctor some significant symptom, there is no way of knowing.

TB is said to be the most common and most problematic of the opportunistic infections in people with HIV. How are you dealing with this?

TB accelerates HIV than HIV accelerates TB. Our hospital has become more focused on HIV. We do not neglect any symptom among HIV patients: be it cough, a rise in temperature or presence of nodes. A complete set of diagnostic test are performed: sputum tests, x rays, ultrasound when there is a slight suspicion. And then they are put on suitable treatment.

HIV patients have a difficult time, but there is a visible change within the community also. The stigma is a little less now.

WHO estimates a crisis in the support system: there will not be enough healthcare workers to cope with the problem. Is that so?

The problem could be one of sheer numbers. More patients, not enough healthcare workers. Often these workers are burdened with anything from attending to deliveries to doing administrative work.

It is also important that a healthcare worker should be more technically versatile. He or she should be capable of not just giving out medicines or counseling patients but also doing sputum smears…

What has been the latest in research on TB: both in terms of diagnosis and medication?

There have been some advancements in the area of diagnosis: the DNA probe and PCR polymerization have been useful.

Apparently a leading pharma company is testing a drug that is more powerful than rifampicin and has less side effects. We will have to wait for this.

Dr. N. Ravichandran

Dr N Ravichandran, completed his MBBS at Madras Medical College in 1989 and went on to do Diploma in Dermatology and then a Diploma in Child Health. He later did his MD in General Medicine. He has been with Government Hospital of Thoracic Medicine, Tambaram, Chennai a premier government Institution dedicated to the care of TB and of late HIV patients.
Dr Ravichandran areas of special interest is HIV And Antiretroviral Therapy

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