An Investigation into Tuberculosis Control in India Disa Linden-Perlis, Karin Wickman, Saya Kato & Ebony Blanch
Mycobacterium tuberculosis
Taken from Max Planck Institute for Infection Biology /Volker Brinkmann: http://www.mpg.de/496841/cooperation-new-tb-vaccine-2004
90% of cases result in latent infection Remaining 10% of cases will result in active TB Reactivation occurs in 10% of individuals with latent TB
Active Pulmonary TB chronic cough with blood-containing sputum, fever night sweats weight loss Asymptomatic TB No symptoms
~1.2 million newly diagnosed year ~270, 000 reported to die yearly Actual numbers much higher 40% of entire Indian population infected
Diagnostic tests - Simple skin test - Blood test - Imaging - Sputum test
Treatment Antibiotic combination (Isoniazid, Rifampicin, Pyrazinamide, Ethambutol) 6 months Successful in ~90% of cases Important to finish the course Emergence of antibiotic resistance Surgical removal
Vaccine - Bacille Calmette-Guérin (BCG) vaccine - Only vaccine available - Limited efficacy - New vaccine needed
Controlling TB in India India was one of the first countries outside Europe to introduce mass BCG immunization in 1948 In 1962 the Indian Government launched the National TB Control Program ( NTCP) with BCG vaccination as the main intervention. Free TB treatment was included in the communities with help from public-private partnership (PPP).. Research in 1979 found the vaccine was not efficient in controlling TB in India.
Introducing the DOTS Program in India In 1993 the WHO presented the Directly Observed Treatment Short-course program. According to WHO the most cost effective program to control and cure TB on a national and global scale. The DOTS program was implemented in India as a Revised National TB Control Program (RNTCP) When DOTS program was introduced the PPP got less attention from the government
The Five Pillars of the DOTS Program 1. Commitment by the government to continued funding for TB control programs, TB monitoring and training for health care workers. 2. Effective diagnostic methods and case detection 3. A continuing supply of of high-quality anti-tb drugs. 4. Direct observation for the patients to follow their treatment and a standardized treatment regimen for All TB patients up to six to nine months. 5. Establishment of an accurate reporting and recording systems of all registered cases and the treatment results.
External Fundings to the Program The RNTCP in India are dependent on external funding from bilateral and multilateral agencies and international organisations. The Global Fund to Fight HIV/ Aids, Tuberculosis and Malaria (GFATM) is currently contributing with the biggest economic resources and support to the program. Many Non Governmental Organisations (NGO:s ) are also working with DOTS programs in India.
Managing and controlling HIV and TB in India A minimum of 6 months of treatment with 4 drugs (including Rifampin). Patients with HIV are recommended highly active antiretroviral therapy (HAART). Patients with HAART treatment 80% less likely to develop TB. Immune Reconstitution Inflammatory syndrome, IRIS can occur and can Paradoxically worsening infections, especially TB. Isoniazid Preventive Therapy (IPZ) effective for people with HIV. Surveillance and screening for TB in HIV- patients.
Antibiotic Resistant Tuberculosis
Things that can be done to prevent the development of Antibiotic Resistant TB 1. Adequate and efficient administration of medication and regular supplies of drugs. 2. Include health workers in the treatment and control of TB. 3. Encouraging Patients adherence to the treatment and to keep the prescribed medication regimen. 4. Education and improving literacy rates and socioeconomic status in patients. 5. Improve diagnostic methods and quality control measures. 6. Development of a new vaccine.
Challenges for Controlling TB in India Major challenges to control TB in India -poor primary health-care infrastructure in rural areas of many states -unregulated private health care leading to widespread irrational use of first-line and second-line anti-tb drugs -spreading HIV infection -poverty -lack of political will -above all, corrupt administration
Education is important -people are still under the impression that TB is a disease of poor people, mostly of those living in slums. -The rich and affluent persons need to know that their cooks/servants/drivers can be asymptomatic carriers of this deadly disease, right in their mansions, and hence they can potentially get infected with TB even without stepping into these slums.
Education is important Antibiotic resistance- HBM: there is a big problem with non-compliance because people believe they get better so they stop taking the treatment and this leads to Ab resistance.
Recommendations: Short-Term Solutions Additional educational awareness in both primary/secondary schools Immediately addressing individuals subject to worst phase of tuberculosis - reduction Individual responses: - Cover one s mouth and nose when sneezing and coughing - Dispose of tissues etc. correctly
Recommendations: Long-Term Solutions National Strategic Plan: Revised National Tuberculosis Control Programme (RNTCP) Financial support from government - link to political stability Regular visitation check-ups for all patients in heavily-affected areas: - Hospitals - Door-to-door doctor visits Aid from other countries and organisations, in terms of medication and
Recommendations Linked to Health Belief Model
Limitations to a Literature Review Certain literature cannot be accessed - databases ask for students to sign up, or pay a certain amount to access the paper Can be time-consuming when collecting and analysing data/information Published information may be biased A lot of unnecessary information involved - makes it hard to really focus on something specific
References Benbaba, S., Isaakidis, P., Das, M.,Jadhav,.S., Reid, P. Furin, J., (2015), Direct Observation (DO) for Drug-Resistant Tuberculosis: Do We Really DO? PLoS One http://dx.doi.org.ezproxy.its.uu.se/10.1371%2fjournal.pone.0144936 Burke, E., 2013. The Health Belief Model. 1st ed. [EBOOK - ONLINE]. ICCWA. Available at: http://www.iccwa.org.au/useruploads/files/soyf/2013_resources_videos/the_health_belief_model.pdf. [Accessed 05 Apr. 2016]. Courtwright, A. & Turner, A N., 2010. Tuberculosis and Stigmatization: Pathways and Interventions. Public Health Reports, 125.4:34. [Accessed 05 Apr. 2016]. Golechha, M., 2015. Can India be Tuberculosis-Free by 2050?. Lancet, 385:9965, pp. 328-329. [Accessed 04 Apr. 2016]. Gopichandran, V., Roy, P., Sitaram, A. & KR, J., 2010. Impact of a Simple Educational Intervention on the Knowledge and Awareness of Tuberculosis among High School Children in Vellore, India. Indian J Community Med, 35.1:174, pp. 174-175. [Accessed 04 Apr. 2016]. Hwang, T. & Keshavjee, S., 2014. Global Financing and Long-Term Technical Assistance for Multidrug-Resistant Tuberculosis: Scaling Up Access to Treatment. PLoS Med, 11.9:1001738. [Accessed 05 Apr. 2016]. Lonnroth, K., Castro, K., Chakaya, J., Chauhan, L., Glaziou, P., Raviglione, M. & Floyd, K., 2010. Tuberculosis Control and Elimination 2010-50: Cure, Care and Social Development. Lancet, 375:9728, pp. 1814-1829. [Accessed 04 Apr. 2016].
NHS Choices., 2016. Tuberculosis (TB) Treatment. NHS.uk. Available at: http://www.nhs.uk/conditions/tuberculosis/pages/treatment.aspx. [Accessed 05 Apr. 2016]. Sandhu, G., 2011. Tuberculosis: Current Situation, Challenges and Overview of Its Control Programs in India. Journal of Global Infectious Disease, 3.2:143. [Accessed 04 Apr. 2016]. Tefera F., Dejene,T., Tewelde T., 2016. Treatment Outcomes of Tuberculosis Patients at Debre Berhan Hospital, Amhara Region, Northern Ethiopia. Ethiopian Journal of Health Science, 1:65-72. [Accessed 07 Apr. 2016]. Todar s Textbook of Bacteriology., 2012. Mycobacterium tuberculosis and Tuberculosis. Keneth Todar. Available at:http://textbookofbacteriology.net/tuberculosis.html. [Accessed 03 Apr. 2016]. Suhail, A., 2010. Pathogenesis, Immunology, and Diagnosis of Latent Mycobacterium tuberculosis Infection. Clinical and Developmental Immunology, 10.1155:20 [Accessed 03 Apr. 2016]. Beresford, B., Sadoff, C, J., 2010. Update on Research and Development Pipeline: Tuberculosis Vaccines. Oxford journals, 10.1086:651489 [Accessed 03 Apr. 2016]. World Health Organisation., 2015. Tuberculosis Vaccine Development. WHO.int. Available at: http://www.who.int/immunization/research/development/tuberculosis/en/. [Accessed 09 Apr. 2016].
Medknow Publication McArthur, E., Bali,B., Khan, A. (2016) Socio-cultural and Knowledge-Based Barriers to Tuberculosis Diagnosis for Women in Bhopal, India Indian Journal of Community Medicine: Official Publication of Indian Association of Preventive and Social Medicine (1): 62-64 http://dx.doi.org.ezproxy.its.uu.se/10.4103/0970-0218.170990 Gursimrat K Sandhu, (2011) Tuberculosis: Current Situation, Challenges and Overview of its Control Programs in India.J Glob Infect Dis. 2011 Apr-Jun; 3(2): 143 150. http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3125027/