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Timeless terror

TB is preventable and curable, yet it kills the largest number of people worldwide. On the occasion of World TB Day on March 24, JANARDHAN ROYE looks at global efforts to fight the resurgence of this disease.

AP

TB causes approximately two million deaths a year, creates and perpetuates a cycle of poverty and despair.

TUBERCLE BACILLI are the deceptively small creatures that destroy far more humans through infection than any other disease. "It's unacceptable that TB continues to kill someone every 15 seconds when we have the ability to discover new tools to stop it," says Dr. Richard Klausner, Executive Director, the Gates Foundation's Global Health program. "Through accelerated research and development, a new vaccine could permanently change the trajectory of the epidemic and save millions of lives every year." The Gates grant will more than double the amount currently being spent annually on TB vaccine research worldwide.

The vaccine will hopefully stop the alarming spread of this highly infectious disease. In addition, a broad coalition known as Stop TB Partnership has been formed to reverse the epidemic. Appeals have been made to the developing and developed world to step up their budgets and programmes to tackle this problem on a war footing.

Emphasising that TB's association with HIV/AIDS represents a major threat to the world, Dr Lee B. Reichman and Janice Hopkins Tanne in their best-selling book, TimeBomb, say "TB and HIV are gasoline and a match."

Vulnerable and poor populations across the globe are especially at risk of contracting the disease, which spreads through the air, attacks the lungs, and kills gradually and painfully.

Some two billion people are thought to presently carry the pathogen, three million people fear imminent death, and nearly 30 million are in the "can be saved" category. The developing world accounts for a majority of these cases, given its poor living conditions, widespread malnutrition, illiteracy and other factors that contribute to infection and re-infection.

TB management has not been easy even in the developed world either. It is suspected that the incidence of tuberculosis is on the rise. Worldwide experiences in the management of TB have shown that there is poor patient compliance with the physician's advice and dosage regimen.

JANARDHAN ROYE

The problem is to reach medical facilities to the large number of affected people.

Often patients abandon therapy when they "feel better" or become asymptomatic. This leads to the development of new strains of drug-resistant TB. This strain is cause for serious concern in the medical world.

The WHO and the International Union Against TB and Lung Disease are addressing this issue of multi-drug resistant TB (MDR-TB) strain on an emergency basis. The MDR strain has closed ranks with another deadly contemporary problem, HIV, to form a lethal combination. Together the old and the new are spreading danger and destruction.

"HIV patients, owing to their immune suppressed status, easily catch TB infections, more likely with strains other than m. tuberculosis," says Dr. Dara S. Amar, Department of Community Health, St John's Medical College in Bangalore. "Some of them can be started on ATT. But, in multi-drug resistant TB, a more intensive therapy may be required."

As per current statistics, "somewhere someone gets infected by TB every second". Dr. B. Mallappa, a former specialist at the Lady Willindon TB Training Center, Bangalore, reels off some disturbing global statistics. "In all, for every 1000 people, around 40 people have TB, in one form or another."

Scientists point out that the microorganism survives in a very hostile immune system that is committed to devouring and destroying it. Typically this air-borne bacterium descends in the lungs.

The immune system cells immediately detect it and a deadly battle is waged on the intruder. In 90 per cent of cases, it is destroyed. But in the 10 per cent with a weakened immune system, the bug escapes into some secret crevice in the body and covers its tracks, leaving behind overlapping or confusing symptoms.

It is "bagged", not destroyed, and may stay that way for years. When least expected, it bursts out of captivity and races, through blood, to other parts of the body.

Secondly, there are age-old sociological barriers to overcome. People are generally not forthcoming when it comes to TB detection programmes. The social stigma is such that often the infected persons and their family hide the problem and do not seek suitable medical help.

"The undetected pool of TB cases is the source of infection," says Dr. Amar. "Even with standard regimens in place, many doctors (and patients) do not follow prescribed courses and treatment. This is the main reason for patients remaining uncured."

While accepting that TB continues to be a public health problem, the Government has pumped in finances for implementing the Revised National Tuberculosis Control Programme (RNTCP) as per WHO recommendations.

Apart from effective control measures, improvement in quality of life and general socio-economic betterment will also help to alleviate the TB problem.

In India due to the huge population, illiteracy, inadequate facilities, difficult to reach terrain and such factors, the task has been complicated by other challenges like ignorance, superstition, quacks and lack of commitment or participation by people affected.

"It is important to clearly communicate to the general public," suggests Dr. Bobby Joseph, Assistant Professor of Community Health in St John's Hospital, "that firstly, all newborns should get the BCG vaccine so that the disease can be prevented in them.

"Next, cases should be detected early by getting the sputum examined when a patient has long-standing cough and fever, loss of appetite and loss of weight. Finally, people must avail of treatment and complete the course, which may last at least six months even if the symptoms are relieved in a few days."

"We cover a very large geographic area with remote and difficult to access village communities. To monitor such a large project, we require continuous training of staff, doctors and lab personnel," say experts. "The situation demands greater commitment by all sectors of society including NGOs."

This thinking is best exemplified in a board at the National Institute of Tuberculosis, Bellary Road, Bangalore: "The problem really is how to reach these large numbers of unfortunate men, women and children spread over 3,000 cities and towns where nearly 3.5 million are patients and 0.7 million spread the disease, and in 600,000 villages where nearly 10.5 million people are patients and 2.3 million spread the disease. These TB patients must be found and treated."

Says World Bank President James D. Wolfensohn, "Given that TB causes approximately two million deaths a year, creates and perpetuate a cycle of poverty and despair, the development rationale for reversing this epidemic could scarcely be more urgent."

TB's dangerous secrets

  • TB is an airborne disease that usually affects the lungs. You get it by breathing.

  • Of the world's six billion people, two billion are infected with latent TB.

  • There are 8.4 million new cases of active, usually infectious TB, every year.

  • TB kills 2 million people every year. Due to complacency and neglect, this preventable problem has become the largest cause of death of any single infectious disease.

  • Each person with TB infects up to 20 others before he or she is treated or dies.

  • TB is the leading infectious disease killer of adults, usually in their most productive years.

  • TB kills more women than any cause related to pregnancy and childbirth.

  • Every TB death is unnecessary. TB is preventable and curable.

  • A long but effective treatment regimen, endorsed by WHO, is used in 128 countries, but only 23 percent of TB patients actually get this treatment.

  • Poor treatment of TB leads to MDR-TB, which if not fatal, requires up to two years of very expensive treatment often with toxic drugs.

  • TB and AIDS are deadly twins. TB promotes progression of AIDS and AIDS promotes progression of TB. TB is the leading cause of death in people with AIDS.

    Extract from TimeBomb, Dr. Lee B. Reichman and Janice Hopkins Tanne, McGraw Hill.

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