The World TB Day is observed every year on March 24, to commemorate the date in 1882 when Dr. Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacillus that causes tuberculosis (TB).
The burden of tuberculosis
The global burden of TB remains huge and we are faced with many challenges.
• In 2012, there were an estimated 8.6 million new cases of TB and 1.3 million people died from TB.
• Over 95% of TB deaths occur in low- and middle-income countries. Poor communities and vulnerable groups are most affected, but this airborne disease is a risk to all.
• TB is among the top 3 causes of death for women aged 15 to 44.
• There were an estimated 500 000 cases and 74 000 deaths among children in 2012.
• India is the highest TB burden country having 2.2 million cases out of the global incidence
The estimated TB prevalence figure is given as 3.1 million. It is estimated that about 40% of the Indian population is infected with TB bacteria, the vast majority of whom have latent rather than active TB.
• Of the 9 million people a year who get sick with TB, a third of them are "missed" by health systems. It is estimated that India is home to 1 million of these “missed” cases.
• There is slow progress in tackling multi-drug resistant TB (MDR-TB): 3 out of 4 MDR-TB cases still remain without a diagnosis, and around 16 000 MDR-TB cases reported to WHO in 2012 were not put on treatment.
• Provision of antiretroviral therapy (ART) for TB patients known to be living with HIV needs to increase to meet WHO’s recommendation that all TB patients living with HIV promptly receive ART.
It is with this realisation that the slogan for this year’s World Tuberculosis Day is "Reach the 3 million". It is important for all of us to understand the above so that we can combine our energies to combat this disease that despite being curable is galloping away towards disaster.
TB is a treatable and curable disease. Active, drug-sensitive TB disease is treated with a standard six-month course of four antimicrobial drugs that are provided with information; supervision and support to the patient by a health worker or trained volunteer (DOTS). The vast majority of TB cases can be cured when medicines are provided and taken properly.
Some of the TB patients can develop what is called the Multi Drug Resistant form of TB (MDR TB). It is found amongst 2-3% of newly detected cases of TB, however, in those cases who have been on treatment earlier and have stopped it before completing the course (Cat II) the incidence can rise to 15-20%, if such patients are not treated.
Multidrug-resistant tuberculosis (MDR-TB) is TB that does not respond to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. This form of TB can then be transmitted, especially in crowded settings such as prisons and hospitals. One patient can infect up to 15 new patients.
The detection cost, treatment and human cost of MDR-TB is very high. Treatment options are limited and expensive, recommended medicines are not always available, and patients experience many toxic and painful adverse effects from the drugs. The cost of curing MDR-TB can be staggering (INR 200,000 as against INR 600), literally thousands of times as expensive as that of curing drug susceptible TB. This poses a significant challenge to governments, health systems and other organizations working to turn the tide against TB. Only 50% of cases receiving treatment get cured.
In some cases even more severe drug-resistant tuberculosis may develop. Extensively drug-resistant TB, XDR-TB, is a form of TB caused by bacteria that are resistant to isoniazid and rifampicin (i.e. MDR-TB) as well as any fluoroquinolone and any of the second-line anti-TB injectable drugs (amikacin, kanamycin or capreomycin).
As per WHO, MDR-TB is a major concern as we would be hard-pressed to design new drugs if the millions around the world were inflicted with drug-resistant TB.
It is also crucial to note the financial dimension of the global TB problem. The funding gap for TB care and control is substantial. Challenges such as MDR-TB must receive increased funding so as to initiate and sustain focused interventions.
While we look towards the challenges, it is also important to know that there are tests (MTB/RIF assay etc.) that can detect Mycobacterium tuberculosis complex (MTBC) and resistance to rifampin (RIF) rapidly. In comparison, standard cultures, that are Gold standards, can take 2 to 6 weeks for MTBC to grow and conventional drug resistance tests can add 3 more weeks. The information provided by these tests may aid in selecting treatment regimens and reaching infection control decisions quickly.
However, the most important means to cure TB and prevent MDR-TB is adherence to the complete course of DOTS treatment.
The Indian Red Cross intervention
The Indian Red Cross Society is playing an increasingly important role in reducing the burden of MDR-TB by ensuring that patients, who have not completed TB treatment (Cat II), are put back on treatment till they are completely cured. These patients have therefore, lessened chances of developing the dreaded MDR TB.
Indian Red Cross Society launched TB Project, India in 2009 in three states which has now been extended to seven states in 2014. This Project was launched in coordination with the Ministry of Health and Family Welfare, Govt. of India; State health departments and the TB Association of India, with the aim to increase community awareness on. TB, MDR-TB, XDR-TB and TB/HIV through project advocacy, social mobilization and dissemination of IEC materials. The extended aim was also to advocate against stigmatization and discrimination of TB patients, to educate about cough etiquette and to provide care & support and DOTS treatment for cat II patients till they are cured.
The salient points of the TB project are:
RCS volunteers provide personalized support to the TB patients, meticulously helping them out with their problems in adhering to the treatment and making sure that the patient takes the full course of DOTS.
IRCS also provides dietary protein supplements to the patients who are often from the impoverished sections of the society or suffering from alcoholism, drug abuse or HIV/AIDS.
IRCS volunteers reach family member, contacts and peers of the TB patient and encourage them for TB testing and also advise them about prevention of transmission of TB. This approach significantly contributes in increased social mobilization which further contributes in increasing visits of community members to DOTS centers.
In addition to the follow-up exercises that the IRCS volunteers undertake in the communities, they are also running awareness and promotion campaigns using magic shows, posters, leaflets and billboards to take the message where it is needed the most.
The TB patients who get cured are further motivated by IRCS staff to become IRCS volunteers for social mobilization on TB prevention. This helps to sustain the program, getting recognition to the community members as Red Cross volunteers and moreover reduce the stigma and discrimination associated with TB.
IRCS volunteers are trained by trainers of the IRCS and the DTOs and are provide the list of Cat II cases to trace and bring them back ensuring complete adherence. IRCS team works in close cooperation & under the guidance of STO, DTO.
Breaking the chain of transmission is one of the contributions by IRCS volunteers through interpersonal communication which is very important in TB like diseases which are transmitted by droplet infections. The Indian Red Cross has been able to reach more than 2000 Cat II patients. It is important to note that the IRCS TB project achieved 95-100 percent patient adherence to treatment in all the programme districts. The volunteers have also spread advocacy amongst the community members and families of these TB patients.
With its unique network of thousands of volunteers throughout the country, the Indian Red Cross has the perfect platform to reach more communities in India.
The emergence of MDR-TB, at dramatic levels in some settings, is a signal that care and control measures need to be taken at a war footing. There is an urgent and impending need to combat this threat and funds have to be generated to support such programmes. Also, there need to increased involvement of organizations like IRCS to increase the effectiveness and reach of TB prevention initiatives. If the world response to MDR-TB is not scaled up urgently, whatever has been gained through world collaborative efforts will be easily lost.
Dr S P Agarwal
Indian Red Cross Society