Health Action: Special issue on TB (March 2013)

7/29/2019 Health Action: Special issue on TB (March 2013)

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Health Action March 2013 1


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A HAFA NATIONAL MONTHLY FROM

THE HOUSE OF THE CATHOLIC HEALTH

ASSOCIATION OF INDIA (CHAI)

MANAGING EDITORRev. Dr. Tomi Thomas, IMS

EDITOR-IN-CHARGEN Vasudevan Nair

EDITORIAL ASSISTANTTheophine V. John

LAYOUT & PAGE MAKE-UP

M S Nanda KishoreCIRCULATION SUPPORTT K Rajendran

EDITORIAL BOARD

Rev Dr Yvon AmbroiseSr Anne Ponnattil

Dr B Ekbal

Dr Amarender Reddy

Dr M V Ramana Rao

Dr Ravi DSouza

Ravi Duggal

EDITORIAL ADVISORY COMMITTEE

Dr Sunny Chunkapura

Dr S Ram MurthyDr P Sangram

Dr Gopala Krishna

Dr Venugopal Gouri

M C Thomas

Dr P V Sharada

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Thought for the Month

health

action

Health Action March 2013

Vol 26 No.3 MARCH 2013

Contents

Cover: Editorial Team

Picture courtesy:

Cover and Text: Google.com

Everything we hear is an

opinion, not a fact. Everything

we see is a perspective, not the

truth.

Marcus Aurelius

Tuberculosis:what, why and how

Dr Anand Das .................................. 4

Engaging communities in the

fight against TB

Project-Axshya Programme

Management Unit....................... 8

Evolving TB control strategies in .

India

Courtesy: Central TB Division..... 11

Tuberculosis and silicosis at

workplace

Axshya India team of TB Alert...... 14

Experiences of Lepra India in

TB control in Andhra Pradesh

Drs J Subbanna & Aparna S

Srikantam..................................16

TB in childrenDr Shoma A Chatterji................. 18

Social stigma attached to TB

Dr G Srinivas Rao..................... 20

Frequently-asked questions on TB

Source: TBC India ......................21

Knowledge, attitudes andpractices on TB

Courtesy: The Union ................... 22

World TB day: 24 March 2013Vinay Kumar G......................... 24

Project Axshya has helped thestate in reaching the unreached

Interview with Dr S Jayasankar,

State TB Officer, Government ofKerala........................................ 25

Why should BPL TB patients be

included in the food security

bill?.................... ....................26

CHAI-Axshya: the global fund

round 9 TB project

Rev Dr Tomi Thomas, IMS ..........27

District TB officers speak........ 30

TB patients, communities,RHCPand TB forum members

testify................................... 32

Reducing stress in type 2 diabetic

patients through yoga

Shanthi and Karoline Rajkumar...33

Rediscovering the forgotten

millets... for health

Aparna Kuna et al ......................35

Vaccinaion in children

Suchitra B.S............................ 37

Health bits...............................38


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EDITORIAL

Rev Dr Tomi Thomas, IMS

Managing Editor

When India woke up to her sixty-fourth Republic Day the thought that was uppermost in the mind of anaverage Indian might have been about the life-situation in the country which is far from what one wouldwish it were. A Republic of ideas, dreams and imagination has become one of hate and nightmares. Livingcondition is below mediocre. Unemployment is massive. Healthcare is abysmal. Education is in a shambles. Thereis massive corruption. There is misgovernance or lack of governance. Assaults on democratic values from withinand without and violation of womens rights, dignity and lives are rampant. And costly are the grievous failures toaddress the inequalities and the mass and multiple deprivation that plague the lives of millions of people.

Our national aim should be to transform India into a powerful, secular, industrial or economic powerhouse whereeveryone can lead a decent and healthy life. In this task each individual has to chip in with their creativity andinitiatives. In spite of three decades of high economic growth, social progress continues to elude us. For India toreap rich dividends from its democracy, it requires an educated, skilled and healthy workforce to compete in aglobal economy. A manifold increase in funding for education and health coupled with copious reduction in expenditureand waste, subsidies and warfare is the need of the hour.

India recently marked a major milestone: two years without a single case of polio. The success of fighting poliowas the result of a concerted effort that included strong leadership and commitment of the government as well asclose partnership between public and private sectors. The world is in the cusp of eradication. We are not yet there.As regards leprosy it is the same story. It was announced that leprosy had been virtually eradicated. But the curseis very much here. In 2010, out of 2,28,000 cases in the world, India accounted for 1,26,000. We need to step upeffort to achieve zero-prevalence (Times of India, 29 January, 2013).

Indias TB burden is staggering. Every year, 1.8 million people get the disease; and about 800,000 cases areinfectious. Until recently, 370,000 died of it annually. An estimated 100 million workdays are lost to it, with thecountry incurring a huge cost nearly $3 billion. The direct costs are $ 300 million. Since its launch in 1998 throughRevised National Tuberculosis Control Programme, more than 14.2 million patients have been treated and 2.6million lives saved with DOTS.(The Hindu, 21 October, 2012)

Around 99,000 Indians suffering from TB become drug-resistant every year. In India, around 3% of all newcases and 12-17% among treatment cases are MDR. In 2010, 2.3 million cases occurred of which 360,000 peopledied; nearly 1000 deaths per day. (Times of India, 8 August 2012). An easy and effective way to diagnose TBhas remained a challenge. Emergence of drug-resistance has made its management more complex.

MDR TB is caused by bacteria that are resistant to anti-TB drugs (isoniazid and rifampicin). XDR TB iscaused by bacteria that are resistant to isoniazid and rifampicin as well as any fluoroquinolone and second line anti-TB injectable drugs. Sixty-nine countries including India have reported cases of XDR-TB. An estimated 25000cases of XDR TB emerge every year. (Times of India 21, October 2012)

Earlier, the focus was on detection to encourage people to go for a check-up and sputum testing. But withMulti Drug Resistant TB cases proliferating, the focus is more on completion of the first course which is thesimplest way to defeat resistance.

The Project Axshya is a civil society initiative to strengthen TB care and control in India. It is the largestAdvocacy, Communication and Social Mobilization (ACSM) initiative supported by Global Fund Round 9 Grantand is being implemented in 375 districts across 23 states by the UNION and World Vision India ably assisted bya network of civil society organizations. The project takes a holistic approach towards improving tuberculosisquality care and control. In its second phase, by the time the project closes, perceptible difference would havebeen made to the tuberculosis situation in the country. Let us hope our dream of a TB-free India comes true!

The Catholic Health Association of India (CHAI), the biggest sub-recipient of the UNION, as part of its advocacyeffort, took up with the government the idea of providing additional nutritional support to the BPL TB patients byincluding them in the Food Security Bill. This will ensure their completion of treatment.

This issue deals in depth with the care and control of tuberculosis.

Improving access to tuberculosis care and control


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Tuberculosis (TB) is a disease of great antiquity.

Tuberculous lesions had been found in the

vertebrae of Neolithic humans and Egyptian

mummies as early as 3700 BC.Today, tuberculosis has become the most important

communicable disease in the world. In 2011, there were

an estimated 8.7 million new cases of tuberculosis (13%

co-infected with HIV) and 1.4 million people died from

tuberculosis, including almost one million deaths among

HIV-negative individuals and 430 000 among people

who were HIV-positive. TB is one of the top killers of

women, with 300 000 deaths among HIV-negative

women and 200 000 deaths among HIV-positive women

in 2011.

PathogenesisRobert Koch first described the

tubercle bacillus known as

Mycobacterium tuberculosis in

1882. Mycobacteria are known to

comprise a large group of acid-fast,

alcohol-fast aerobic or

microaerophilic, non-spore forming,

non-motile bacilli. Of the many

different mycobacteria, only M

tuberculosis, M bovis and M

africanum are recognized as tubercle bacilli, all being

sub-species of a single species. M tuberculosis is an

obligate parasite that is infectious to humans, other

primates and many other mammals.

TransmissionFor many years, TB was thought to be transmitted

genetically. It is now known that the infection is

transmitted through the airborne route and that the unit

of infection is a small particle called the droplet nuclei.

Successful transmission requires airborne infectious

droplet nuclei to be small enough to reach an alveolus

COVER

STORY Tuberculosis

What, Why and How

Dr Anand Das (MBBS, DTCD, DNB)

in the periphery of the lung. There is a critical diameter

range that maximizes the probability of inhalation and

retention of infectious particles leading to the

establishment of the infection. The diameter lies

somewhere between 1 mm and 5 mm.

The risk between infection and progression to disease

is multifactorial. The risk gets elevated in the first years

following infection and then remains low for a prolonged

period of time. Other risk factors include HIV infection,

lung diseases such as silicosis, carcinoma of the head

and neck, immunosuppressive treatment, smoking,

diabetes and surgeries like gastrectomy and jejenoileal

bypass.

PathologyDeposition of TB bacilli in the lung

alveoli is followed by vasodilatation

and an influx of polymorphonucleo-

cytes (PMNs) and macrophages to

the area. After several weeks, the

PMNs decrease and macrophages

predominate. The macrophages

crowd together as epitheloid cells to

form the tubercle or the unit lesion

of tuberculosis. Some mononuclear

cells fuse to form the multinucleated

or Langhans giant cell.

Lymphocytes surround the outer margin of the tubercleand in the centre of the lesion a zone of caseous necrosis

may appear that may subsequently calcify. Primary,

infection is usually evident as a subpleural tubercle (the

Primary or Ghons focus) in any lung zone and drains

via lymphatics to hilar lymph node to form the primary

complex.

Most primary infection heals although haematogenous

spread probably occurs via the lymphatics in majority

resulting in seeding of the bacilli to other parts of the

lung as well as other organs. The primary lesion


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sometimes progresses and the pathological changes are

similar to those seen in reactivation tuberculosis.

Reactivated pulmonary tuberculosis is most often seen

in the upper lung zones and limited to the posterior

segment of the upper lobe or the apex pf the lower

lobe.

The high ventilation-perfusion ratio with alveolar Po2

elevated relative to other zones, predisposes to

reactivation at these sites. Proliferation of the bacilli in

the caseous centres is followed by softening and

liquefaction of the caseous matter, which may discharge

into the bronchus with resultant cavity formation.

Whereas approximately 104 bacilli per gram are fund

in caseous tissue, upto 109 organisms may be harboured

in a single cavitory lesion. Fibrous tissue around the

lesion, is incapable of limiting the extension of

tuberculosis process. Spread of caseous material mayresult in development of tuberculous pneumonia.

Rupture of caseous pulmonary focus into blood vessel

may result in military tuberculosis (0.5 to 2mm

tuberculous foci) in the lung and other organs.

Encroachment of pulmonary or lymph node caseous

material on the bronchi may lead to tuberculous

bronchitis. Rupture of caseous glands into the trachea

or major bronchus may cause collapse of lung or even

sudden death by suffocation in young children.

ImmunologyThe immune or antimycobacterial response of

previously infected individuals to subsequent

mycobacterial challenge is mediated by a population of

mononuclear phagocytes that ingested and killed TB

bacilli in an increased rate compared with normal

macrophages. Cell-mediated immunity is alone

responsible for this acquired resistance. The immunity

transferred by an initial infection is utilized in the form

of BCG vaccination. BCG confers immunity by

activation of macrophages within the reticuloendothelial

cells of the immunized host with resultant limitation of

mycobacterial growth on subsequent challenge.

The positive tuberculin test is the earliest indicator of

infection with TB. However, a negative tuberculin test

does not exclude tuberculosis. Negative tuberculin tests

may be found in patients with military TB, extensive

disease and elderly.

Patterns of presentation (Timetable)

Most primary TB heals spontaneously without residueon the chest film. In some patients there may be

sequelae to the primary infection. In children, enlarged

hilar lymph node may compress or erode bronchi with

resultant lobar consolidation and collapse called

epituberculosis.

Miliary tuberculosis and tuberculosis meningitis occur

usually within 6 months of primary infection and is

common among children less than 5 years old. Pleural

effusion, due to seeding of the pleura from a lung focus,

occurs within 6 to 12 months and is commoner among

younger adults. Increasing infiltration and cavitation

called progressive primary or post-primary disease

occurs 1 to 2 years after the primary infection. Skeletal

tuberculosis, most commonly of the spine, could occur

1 to 5 years after primary infection. Genitourinary

tuberculosis commonly occurs 5 to 15 years after

primary infection.

EpidemiologyMorbidity

Age: Median age of TB patients has increased

markedly in countries where the risk of infection

declined rapidly and thus the infected populationsegments became increasingly older. In contrast, in

low income countries, Tb notification rate still peaks

in young adults.

Sex: Risk of progression from infection to disease

also differs among males and females and varies

depending on the age. The M:F (male-female) ratio

of 2:1 explains higher prevalence of infection among

males.

Socio-economic Status: There is a strong association

of poverty with the incidence of TB. Low socio-

economic conditions lead to increase in transmission.

Today tuberculosis has become the most

important communicable disease in the

world. In 2011, there were an estimated

8.7 million new cases of tuberculosis (13%

co-infected with HIV) and 1.4 millionpeople died from tuberculosis, including

almost one million deaths among HIV-

negative individuals and 430 000 among

people who were HIV-positive. TB is one

of the top killers of women, with 300 000

deaths among HIV-negative women and

200 000 deaths among HIV-positive

women in 2011.


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Poverty is also associated with

reduced access to health care

services.

Race and Ethnicity: The decline

in incidence in the US has beenthe greatest among the 5 to 14

year-old, greater among females

than males and more pronounced

among the white.

Migration: High incidence among

South-East Asian refugees

appears because of high risk of

tuberculosis infection in their

countries of origin.

Population Density: Age-specific

prevalence is frequently lower in

rural than in urban areas. Marital Status: Highest incidence

found in men who were divorced

and lowest incidence was found in married men.

Single and widowed men had an incidence between

the two extremes.

Substance Abuse: Despite the long-standing notion

between alcohol and other substances and incidence,

the epidemiological evidence of a causal association

is not convincing.

Other Risk Groups: Health care workers are at an

increased risk. Impact of HIV Infection: TB and HIV are two

conditions that are intrinsically linked as the prevention

of TB depends on the integrity of Cell Immune System

and HIV destroys precisely that. HIV may alter the

epidemiology in three ways:

Endogenous reactivation in persons

who become HIV-infected

Progression from infection to disease

in pre-existing HIV-infected individuals

Transmission of TB to general

population from individuals who

developed TB because of HIV

infection

Mortality

Major site of disease: Sputum-positive pulmonary

tuberculosis has a higher fatality rate than sputum

negative.

Delay in diagnosis and treatment: Failure to diagnose

may result in death as well as unrecognized

transmission to family and friends.

Age: Mortality is highest among young adults.

Industrialization: Spanning 300 years, the epidemic is

coming to an end.

Official estimates: 1.5 million deaths/

year (Difficult to verify)

Chemoprophylaxis: Administration of

chemotherapy (use of chemicalagents to treat or control disease) to

prevent the development of

tuberculosis disease

Primary: Given to individuals who

have so far not been infected.

Isoniazid is used based on its value in

experimental animals.

Secondary (or disease): Household

contacts, Positive TB skin test reactors

with abnormal but inactive X Ray,

positive skin test in special clinicalsituations are given 300 mg INH daily

for prevention of development of

disease.

Clinical features

Symptoms Symptom-free, discovered on routine chest

radiography

Persistent cough with or without expectoration

Malaise

Loss of appetite and weight loss

Recurrent colds Low-grade fever, evening rise of temperature

and night sweats

Physical Signs Pallor, hectic flush or cachexia

For many years, TB was thought to be

transmitted genetically. It is now known

that the infection is transmitted through the

airborne route and that the unit of infection

is a small particle called the droplet nuclei.Successful transmission requires airborne

infectious droplet nuclei to be small

enough to reach an alveolus in the

periphery of the lung. There is a critical

diameter range that maximizes the

probability of inhalation and retention of

infectious particles leading to the

establishment of the infection.


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Increased pulse rate and respiratory rate (if febrile)

Clubbing (Rare)

Post-tussive crepitations in upper zones and apices

Advanced or pneumonic disease: signs of

consolidation

Chronic disease: deviation of trachea due to fibrosis

Physical signs of cavity: seldom found even with large

cavities

Localized wheeze: endobronchial tuberculosis

Diagnosis Sputum smear examination: ZN staining

LED FM Microscopy

Culture : Solid and LPA

Xpert MTB/RIF (MTB integrated cartridge-based

automated nucleic acid amplification test (CB-

NAAT) that uses a common platform to diagnose

both TB and Rifampicin resistance), which has a

sensitivity and specificity equivalent to that of solid

culture, while providing the results rapidly within 2

hours.

Bacteriological examination of samples other than

sputum: Gastric aspirate, Laryngeal swabs, Fibreoptic

bronchoscopic specimens (bronchial washings,

brushings or transbronchial biopsies), Transtracheal

aspirates, FNAC etc.

Radiology: Opacities mainly in upper zones, patchy

or nodular opacity, presence of cavity/cavities,

calcification, bilateral opacities in upper zones,opacities that persist even after several weeks.

Assessment of activityIt is often difficult to decide whether a particular lesion

should be treated or merits further assessment. The

following may give some guidance:

Bacteriologically positive patient indicates activity and

is an absolute indication for treatment

Symptoms such as cough, hemoptysis, tiredness and

weight loss are suggestive that a lesion demonstrated

radiologically is active

Persistent crepitations

Certain radiological appearances: cavity, widespread

soft shadows, shadows that extend on serial chest x

rays

Clinical features in the HIV-positive patientWhen TB occurs late in the course of HIV infection

or in patients with AIDS, the features are more atypical:

lower zone or diffuse consolidation, mediastinal

adenopathy and involvement of extrapulmonary sites

like brain, pericardium, bones and gastro-intestinal tract.

Cavitation of pulmonary lesions and tuberculin positivity

are less common.

Differential diagnosis of pulmonary

tuberculosis Pneumonia: sputum-positive for TB and radiographic

opacities not improving in 2 -3 weeks Carcinoma of the bronchus: Consolidation distal to a

proximal carcinoma particularly may be cavitated and

mimic TB. Sputum examination and CT, FNAC and

transbronchial biopsy may be done.

Lung abcess due to Staphylococcus pyogenes and

Klebsiella: Acute severe illness with marked

leucocytosis and organism readily isolated from blood

or sputum

Pulmonary infarcts: Upper zone infarcts with

cavitations may mimic TB. Routine investigations,

deep vein thrombosis and improving serial x rays helpdifferentiate

Other pulmonary diseases: Atypical mycobacteria is

a frequent source of confusion.

Complications Pleurisy : a classical pleural rub may be heard

Tuberculous empyema: Following artificial

pneumothorax therapy and can present thirty years

after therapy. Could result from the rupture of a

cavity in the pleural space. Chemotherapy, tube

suction and decortication may be needed.

Tuberculous laryngitis: Laryngoscopy and biopsy maybe needed to establish diagnosis.

TB of other organs: Testes in males and urine

examination should be done.

Chronic obstructive airway disease: May result from

a severe fibrotic pulmonary disease.

Corpulmonale: Distortion of pulmonary parenchyma,

emphysema and airways obstruction.

Miliary tuberculosis and tuberculosis

meningitis occur usually within 6 months

of primary infection and is common

among children less than 5 years old.

Pleural effusion, due to seeding of the

pleura from a lung focus, occurs within 6

to 12 months and is commoner among

younger adults.

(*Technical Officer, International Union Against Tuberculosis

and Lung Diseases, The Union South-East Asia Office, C-6,

Qutub Institutional Area, New Delhi 110 016. Email:

[email protected])


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Revised National Tuberculosis Programme(RNTCP) was initiated in 1997 and expanded

at an unprecedented scale to cover the entire

country by March 2006. During this expansion phase(called phase 1) the programme, focused on enhancing

political and administrative commitment, establishing

quality diagnostic and treatment services through publichealth facilities, systematic supervision and monitoring

and accountability towards TB care and control.

In the years to follow (2006-11) the programme

focused on universal access to TB services, in line with

the Millennium Development Goals, with DOTS strategyat its core.This strategy also took cognizance of six key

strategies proposed by the global Stop TB strategy

of WHO (2006-2015) to have World Free of TB.Strengthening involvement of civil society through NGO

and Private Provider schemes, Advocacy,

Communication and Social Mobilization (ACSM) began

to appear on the programme agenda in this phase.Currently, the proposed National Strategic Plan (NSP)

document for Phase III (2012-17), emphasizes earlycase detection and improved diagnosis of all TB patients

with better outreach, increased case finding,

involvement of private providers and community-basedsupervision, monitoring and accountability to TB care

and control.

Early case-detection and ensuring complete treatment

of sputum-positive TB clients has always been a major

public health challenge for TB control programme. The

programme strategies adopted were able to cater toonly those clients who visited public health institutions

or those who were identified by community-basedhealthcare workers. Clients outside the public health

network continued to go undiagnosed and untreated

thereby increasing the TB burden in community. Thus

community engagement strategies were to be developed

to create awareness about TB care and control. In the

process, Project Axshya evolved with objectives to

expand reach, visibility and effectiveness of RNTCPby engaging community-based providers to improve TB

COVER

STORY Engaging communities in

the fight against TBservices, especially for women and children,

marginalized, vulnerable and TB-HIV co-infectedpopulations. The Union, being the oldest organization

working in TB care and control with a mission to bring

innovation, expertise, solutions and support to addresshealth challenges partnered with RNTCP, World Vision

India to implement the largest ACSM project ProjectAxshya. The project supported by Global Fund Round

9 grant, is implemented by the Union in 300 districts

across 21 states of India through a network of partnersfrom nine civil society organizations.

Over a period of two years, the project has been able

to network with over 1200 NGOs and 3000 CBOs who

are involved in the implementation of ACSM activities

at the community level.Activities listed in the table are all interlinked to


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Thematic areas Activities

Community Engagement Community Group Meetings(GaonKalyanSamitis)

Engage/Train Community

Volunteers

Mass Media Campaign

(Bulgam Bhai - campaign)

Mid Media Activities

Axshya Village (TB Free Villages)

Empowering TB-Affected Communities Dissemination of Patient Charter

District TB Forums

Sensitizing people affected by HIV

Engaging Healthcare Providers Engaging Rural Healthcare Providers

Engaging AYUSH Providers

Health Systems Strengthening Sputum collection and

transportation

Human resource development

component

Health infrastructure support

component

Default retrieval

Sensitization of NGOs on RNTCP

scheme

Technical support to CTD, State

TB cell in areas of ACSM

Capacity building of program staff

on MDR TB, OR, Epidemiology and

Health Management

Other Advocacy Efforts Enhancing political and

administrative commitment.

Engaging professional

associations

Supporting national partnership

for TB care and control.

Activities of Project Axshya

engaging communities advocating for TB care and

control (identifying symptomatics, sputum collection andtransportation, referrals, treatment adherence,

completion, default retrieval etc); Informing

communities through communication tools about TB,rights and responsibilities of patients through patient

charter, and service availability at health facilities;

Mobilizing communities to advocate for political and

administrative commitment in ensuring services at health

facilities and also for creating awareness about TB

more specifically to reduce TB stigma. Community

engagement involves people from all sectors of thesociety. In Project Axshya through

GaonKalyan Samitis the focus has been

(a) to involve members of Village

Health Sanitation and Nutrition

Committees (VHSNCs), Self-HelpGroups, Panchayati Raj Institutions,other influential people through

community group meetings. (b) to build

capacity and sensitization of local health

care providers - Rural health care

providers (RHCPs), Ayurveda, Yoga

and Naturopahty, Unani, Sidha andHomeopathy (AYUSH) providers, soft

skill training for health staff and other

private providers in referrals/

management of referrals. (c) to build

capacities of volunteers in hard-to-

reach areas, marginalized and

vulnerable populations (eg. HIVaffected, tribal, naxal affected areas,

slums etc), for identifying

symptomatics, collection of sputum and

transportation to nearest DMCs and

support the system/programme in

tracing lost to follow-up of patients ontreatment.

Gaon Kalyan Samiti

Gaon Kalyan Samiti (GKS) meetingsare organized by volunteers of partner

NGOs at village level and or at wardlevel (in Urban areas). During the

meetings, (a) the members are

sensitized about TB care and control,(b) information is provided about

availability of services eg. Name of the

DMC, TU, etc (c) facilitate volunteersin identifying TB symptomatics in

community (d) inform about patients

rights and responsibilities through Patient Charter (e)

support TB patients in social acceptance eg. Toovercome stigma, (f) support treatment adherence etc.

Nearly 36,000 such meetings have been conducted

across 21 states of India. In addition to GKS, Axshyavillage concept is implemented. This intervention is

aimed at community awareness, engagement and

empowerment on TB care and control.

Communities in India access private health care

providers (~90%) for any type of illness. Privateproviders often are the first-point of contact, and

awareness about TB among them is most important for

Table 1


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TB care and control. Limited knowledge or lack of

knowledge has been found to contribute to poor

adherence to treatment regimen prescribed underRNTCP. As a result of non-adherence to treatment

regimen, the burden of multi-drug resistant form of TB

tends to increase in communities. It was thereforeenvisaged under Project Axshya to engage private

providers most importantly RHCPs (unqualified

providers) in the identification of symptomatics,referrals, treatment (completion) and default retrieval.

Currently, about 17,000 RHCPs have been sensitized

under project and are referring TB symptomatics,engaged in sputum collection and transportation and are

recognized as DOT providers under RNTCP. DCs and

the other project staff have strongly advocated for the

involvement of these unqualified practitioners inreferrals & DOT provision as they are usually the first

point of contact for the community members.

Empowering TB communitiesEmpowering TB communities through TB forums is

an innovative approach. TB forums aim to serve as a

platform to share the experiences of TB patients.

Formation of this forum is facilitated by the project at

the district level ensuring representation from TB

affected patients (cured/on treatment) and civil societymembers journalist, lawyers, NGO representatives,

Opinion leaders etc. to discuss the overall experience

of TB-patients and suggestions to improve TB care

services. The forum meets regularly with DTOs/other

officials to brief them about the issues and challenges

faced by the patients. Through Project Axshya, TB

patients have also been made aware of their Rights &Responsibilities by means of Patient Charter. This is a

tool that informs TB patients about TB disease per

se, patient entitlements, responsibility of patient towardscommunity and family members.TB patient

representation in TB forums, also discuss about their

rights to get free diagnosis and treatment and other

benefits under the existing social welfare schemes.

Health systems strengtheningThe cycle of community engagement would be

incomplete without Health System support/strengthening. Health System support/strengthening forAxshya comes from partnering with Central TBDivision, Ministry of Health and Family Welfare. TheUnion has extended support to CTD in terms of providingtechnical support in areas of ACSM, PP and Monitoringand Evaluation (M&E).ACSM support is also providedto RNTCP in six states namely Karnataka,Maharashtra, Madhya Pradesh, Uttarakhand, UttarPradesh and Punjab through the 6 Union consultants.At the district level, activities are focused at sputumcollection and transportation in areas of vulnerable/

marginalized/hard-to-reach, poor case detection etc.Secondly to support DTCs in default retrieval throughthe network of volunteers established under projectAxshya. Thirdly, soft-skill training has been provided tohealth staff to impart communication and counsellingskills, improve Inter Personal Communication (IPC)which helps in better patient-provider communicationand building healthy relationships. Fourthly, in manystates, Designated Microscopic Centres (DMCs) havebeen supported through providing quarterly preventivemaintenance of the binocular microscopes therebyensuring quality sputum microscopy and hence, betterdiagnostic care to TB patients. These are some of themajor areas of support provided through ProjectAxshya. The District Tuberculosis Officers (DTOs),State Tuberculosis Officers (STOs) and many healthofficials, are extending support and guidance to project

Axshya at various level of implementation.

Holistic approachProject Axshya envisages a holistic approach towards

TB care and control. It does so by engaging communitiesthrough a strategy of Advocacy, Communication andSocial Mobilization. This model of Community

engagement aims at the impartation of knowledge aboutTuberculosis and services. This thereby generates ademand for services from communities. On the otherhand, it also supports health systems in catering to theservice demand that is thus generated. The Union haspartnered with multiple stakeholders the Governmentof India, politicians, community members, civil societyorganizations and many others, who are willing tocontribute for a cause that is to have a TB - Free

society.

(Project Axshya-Programme Management Unit, The GlobalFund Round 9 TB Project, The Union South-East Asia Office,


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COVER

STORY

The National Strategic Plan for TB Control for

2012-17 developed by the Union Ministry of

Health and Family Welfare has raised the bar

for tackling the fast- growing TB epidemic in the

country. Revised National TB Control Programme hasmade historical achievements in the recent past years

and the programme stands at the point where achieving

the ambitious goal of Universal Access to TB Care is

in sight. The programme has been continuously been

innovative and progressive in addressing issues related

to TB control in the country.

The National Strategic Plan (2012-2017) was

prepared through a consultative process involving a wide

cross-section of stakeholders and experts in the

programme. Innovation and consensus were the

highlights of the process adopted for development ofthe National Strategic Plan.

National Strategic Plan (2012-2017)With progress in achieving objectives in the 11th Five-

Year Plan and defining newer targets of Universal

Access to TB care, newer strategies have beendeveloped as a comprehensive National Strategic Planunder the 12th Five-Year Plan of the Government of

India. The following thrust areas were identified:

Strengthening and improving the quality of basic

Evolving TB Control

Strategies in India(Universal access to early quality diagnosis

and care of tuberculosis)

DOTS services Further strengthening and aligning with health system

under NRHM Deploying improved rapid diagnosis at the field level Expanding efforts to engage all care providers Strengthening urban TB Control Expanding diagnosis and treatment of drug resistant

TB

Improving communication and outreach Promoting research for development and

implementation of improved tools and strategies.

Strategic vision to move towards

universal accessThe vision of the Government of India is for a TB-

free India with reduction of the burden of the disease

until it is no longer a major public health problem. Toachieve this vision, the programme has now adopted

the new objective of Universal access for qualitydiagnosis and treatment for all TB patients in the

community. This entails sustaining the achievementsof the programme to date, and extending the reach andquality of services to all persons diagnosed with TB.

The objectives of the programme proposed in the planare:

To achieve 90% notification rate for all cases To achieve 90% success rate for all new and 85%

for re-treatment cases To significantly improve the successful outcomes of

treatment of Drug Resistant TB Cases To achieve decreased morbidity and mortality of HIV

associated TB To improve outcomes TB care in the private sector

PROPOSED STRATEGIES IN THE

NATIONAL STRATEGIC PLAN 2012-2017:

Case-finding and Diagnostics: Early identification of all infectious TB cases.

Improved integration with the general health system,

The rich technical and managerial

capabilities of the programme with the

support from all stakeholders aiming

towards Universal Access to TB Care

will ensure that the programme is able to

overcome all challenges successfully and

will contribute to developing a healthy and

economically productive population.


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and leverage field staff for home-based case finding.

Improve communication and outreach

Screen clinically and socially vulnerable risk groups

for TB. Develop improved sputum collection and

transportation systems. Deployment of higher-sensitivity diagnostic tests for

TB suspects (and incorporate new tests) and

decentralized DST services Catch patients already diagnosed through notification

from all sources, improved referral for treatment

mechanisms, and deployment of Laboratory &Private Provider notification

Patient-friendly Treatment Services Promptly and appropriately treating TB, increasingly

guided by DST.

Making DOTS more patient-friendly throughincreased communitization of DOT; pilot incentives/

offsets for patient costs to help patients completetreatment and better monitoring through InformationTechnology.

Improving partnerships between public and privatesector Establish Indian Standards for TB Carewhich can be used to engage providers using existingprivate treatment and improve care with some publicsector support and supervision.

Research will guide improvements in regimens and

delivery systems. National Treatment Committee/TWG for regular

review of regimens, all treatment- related technical

guidance

Scale-up of Programmatic Management of DrugResistance -TB Developing network of C&DST Laboratories and

Strengthening of Reference Laboratories Decentralized DST at the district level for early MDR

detection Improved information system for PMDT Humanpower support for additional workload by

aligning with NRHM health blocks and rationalizationof number of patients per STS

Improved drug management of second-line anti-TBdrugs (22% of budget, even at low GOI procurementcost)

Scale -up of Joint TB-HIV Collaborative Activities: Activities will aim at early, rapid TB diagnosis with

high sensitivity tests for HIV-infected TB suspects& ART for all HIV-infected TB patients, with

transport support.

Integration with Health Systems: Integrating the RNTCP with the overall health system

will increase effectiveness and efficiencies of TB

care and control which has been depicted in thepicture.

In rural areas, the RNTCP can focus integrationthrough the National Rural Health Mission.

In urban areas, the RNTCP can integrate throughthe private sector and the evolving National UrbanHealth Mission.

Engagement of Private Sector: Private sector engagement essential for universal

access and early detection RNTCP set norms and conduct surveillance while

maintaining some flexibility Move from sensitization model today to output- based

contracting of services through interface/ aggregators States need to experiment with innovation and scale-

up of those models that are successful

Inclusion of private laboratories and pharmacists todetect patients at earliest points of care

Technical working group (for guidance, policy advice) Technical support unit (for assistance to States for

contracting) Accreditation and innovative financing

Human Resource Development The goal of RNTCPs HRD strategy is to optimally

utilize available health system staff to deliver quality

TB services, and to strengthen the supervisory andmanagerial capacity of programme staffs overseeingthese services.

RNTCP will align more effectively with health systemunder NRHM to leverage field supervisory staff moreeffectively, and increase capacity building of staffs

to equip them to handle multiple tasks of DOTS,MDR-TB, TB/HIV.

Support cells at State and District levels will be

The vision of the Government of India is

for a TB-free India with reduction of the

burden of the disease until it is no longer a

major public health problem. To achievethis vision, the programme has now

adopted the new objective ofUniversal

access for quality diagnosis and treatment

for all TB patients in the community.


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strengthened to increase administrative and

managerial capacity, creating space for localprogramme managers to focus on supervision andquality of services.

Web based application will be developed for creatingdynamic HRD database to assist better planning andfacilitate faster communication.

Advocacy, Communication and SocialMobilization: Generating demand for earlier diagnosis and

treatment Community ownership, participation and involvement

are essential for universal access.

Enhancing the ACSM capacity of service providersto improve the quality of service delivery.

ACSM can reduce stigma which is critical foruniversal access.

Increased coverage can be achieved by focusing onat risk and clinically, socially and occupationally

vulnerable populations.

Monitoring and Evaluation, Surveillance andImpact Assessment: Case-Based Web-Based application will be

developed for real time data entry to enhanceprogramme management and better decision-making.

Relevant, timely and accurate data collection at eachlevel of programme and the healthcare system.

Analysis of these data is critical for ensuring continual

programmatic improvement.

Research to inform TB Control policy and practice: Operational research will be promoted to optimize

TB control Priority research agenda to be developed.

Conduct or commission priority

researchRapidly translate lessons intoinnovative policy and practice

Web-based application for faster

feedback to the Principal Investigatorsand facilitate monitoring of the processof proposal submission and thedecisions of respective committees

Key Interventions: Strengthening and improving the

quality of basic DOTS services Further strengthen and align with

health system under NRHM Deploying improved rapid diagnosis

at the field level

Expanding efforts to engage all careproviders

Strengthening urban TB Control

Expanding diagnosis and treatment of drugresistant TB

Improving communication and outreach

Promoting research for development and

implementation of improved tools and strategies.

What will NSP achieve? Control TB: compared to todays activities, success

will :

Accelerate decline in incidence and prevent 22lakh TB cases

Reduce TB deaths by 75%, and save 17 lakh

lives from TB

Contain MDR TB: avert 1 lakh MDR cases

and reduce incidence by 50%

Return on investment: For each additional $1

1$ buys quicker diagnosis of more TB patients,

more effective treatment

~14$ gained [ongoing analysis being done here]

in future direct economic expenditure on TB

cases prevented and Leadership for India: Sustain Indias global leadership

in TB treatment and control

The rich technical and managerial capabilities of the

programme with the support from all stakeholders aiming

towards Universal Access to TB Care will ensure

that the programme is able to overcome all challenges

successfully and will contribute to developing a healthy

and economically productive population.

(Central TB Division, Ministry of Health and Family Welfare,

Government of India)


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COVER

STORY

I

ndia has the highest TB burden in the world,accounting for one-fifth of all new TB cases andtwo-thirds of the cases in South and South-East Asia.

While India has made great strides in addressing TB,many challenges remain to expanding case-detectionand treatment. Involvement of the private sector incase-detection, TB awareness and prevention, andpromotion of safe and effective TB treatment practicesis vital to the continued success of Indias RevisedNational TB Control Programme (RNTCP). Workplaceinterventions could be one potential private-sector entrypoint for reaching the unreached clients at workplacefor TB diagnosis, treatment and care.

The World Economic Forum reports that managersaround the world are more ill-informed about

tuberculosis (TB) in their workplaces than about HIVand AIDS. 63% of firms in low-income countries expectsome impact from TB in the next five years comparedto 46% of all firms expecting some impact from HIV/AIDS. Prevalence of TB is about 3 times higher amongsmokers.

TB Alert India initiated TB workplace interventionsin ACSM project supported by USAID and World Visionin October 2008. During the project period (Oct 2008 Sept 2010), TB Alert India withits local partner organizationscarried out 68 sensitizationworkshops at workplaces andreached out to more than 3000employees in 5 districts. Theproject facilitated in placing TBworkplace Policy andCommitments from the 25Industries. The workplacesincluded Tobacco companies,Steel factories, Stone crushingunits, Granite companies, Cargocompany/Mosquito coil company-

Tuberculosis and

Silicosis at WorkplaceA Situational Analysis Study in seven districts of Axshya India

Project in Andhra Pradesh

NET Slab Industries,Rice Millers Association.

TB Alert India continued TB workplace interventionsin Axhsya Project from October 2010 with the support

of Global Fund through World Vision in reaching out tomore than 1600 employees in 40 Industries. Secretary,Labour Employment Training and Factories Department(LET&FD) & State TB Officer identified 6 vulnerablesegment industries which are prone to chest diseases.These vulnerable segment industries are Stone Crushers,Cement Companies, Jute Mills, Brick Kilns, Quarriesand Mines. A situational analysis study was taken upby TB Alert India on the suggestion of Secretary, LabourEmployment Training and Factories Department(LET&FD) and State TB Officer. Assessment was

taken up under New Initiatives of TB Alert India underAXSHYA India Project supported by World Vision &Global Fund.

Situational analysis study

TB Workplace Intervention Situational Analysis Studycarried out by TB Alert India in identified 54 industries(Stone Crushing Units(25), Brick Kilns (11), CementMaking Unit(3), Glass Manufacturing Unit (3),Foundries(12)) in 7 districts (Hyderabad, Ranga Reddy,

Medak, Nalagoda, Chittoor,Prakasham, Khammam) ofAndhra Pradesh State. Thestudy was carried out with 528employees and 41 focal persons(Owner/CEO/Director/ Sr.Manager) in the industry.

The objectives of study wereto assess awareness levels ofemployees at workplace ontuberculosis and silicosis; tounderstand attitudes ofemployees at workplacetowards TB and silicosis and to


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assess the interest of stakeholders of workplace inbecoming part of TB and silicosis control.

Major findings of the studyMajority of permanent employees constituted

Cement, Glass Manufacturing Industries and Foundries(90 %( 162), 83%(55), 76%(77)) respectively.Temporary employees were those from brick kilns andstone-crushing units. Employees of stone-crushing unitsand brick kilns are not enrolled with ESI. More numberof employees enrolled under ESI are in Foundries60%(61) followed by Glass Manufacturing 37% (25)& Cement Industries 18%(32). About 37% of therespondents, who are at the risk of getting TB have notheard of TB. However, among the respondents whoare aware of TB, only 32% have listed out correctsymptoms of tuberculosis, further only 10% of the

respondents who have listed correct symptoms of TBknow that DOTS is the treatment for it. Percentage ofrespondents with TB in family stands at 11% amongtotal respondents questioned. However, stigma attachedto TB is less where 60% expressed that they will feelcompassionate to TB patients.

Employees expressing the need to carry out morehealth camps at workplaces stands at 50%. Healthawareness programmes are a necessity which shouldcover TB/Silicosis, other non-communicable diseasesat workplace. As large as 55% of employees acrossthe industries are of the opinion that their industries havea role in the prevention of TB, and silicosis at theirworkplace. Health awareness programmes whichinclude TB, HIV, Malaria and other diseases like BP,sugar, and cancer should be carried out.

Interactions with focal persons atindustries

About 41 focal persons at the industries wereinterviewed by TB Alert India. Out of a total 41respondents, 83% (34) of focal persons feel that thyneed help of NGOs for greater liaison with GovernmentHealth Services for better Workplace and Community

Health Services. Dispensaries at workplace, doctorvisiting the work place on call are the arrangements insome industries to deal with minor alignments. However,as large as 61% of the industries, mostly brick kilns andstone-crushing units dont have any such arrangementat work places. 73% (30) expressed interest in takingup health activities at workplaces with the support ofNGOs.

RecommendationsIn liaison with the Director of Factories, Director of

Medical Insurance and Commissioner of Labour, State

TB Officer, there is a need to talk to managements ofindustries and plan a cascading model of sensitizationprogrammes to employees (From top management toworker level) on TB, HIV, Malaria, Silicosis, andLifestyle Diseases. Sensitizing ESI hospital / dispensary

staff on RNTCP is crucial for enhancing outreachactivities. Establishing/strengthening linkages betweenDistrict Inspector of Factories, District HealthAuthorities, Labour Department and ESI Hospital /Dispensaries is an important aspect to be taken upimmediately. Where large numbers of employees arepresent, there is a need for establishment of Sputum-Collection Centres/DMC/ICTC at workplace.Employee workforce services can be utilized forspreading disease awareness, referral services andfollow-up of patient, advocating with workplace

management for workplace policy on health (TB, HIV,Malaria, Silicosis, Lifestyle diseases) using IBAmaterials.

ConclusionFor better health of employees, interventions need to

be identified to raise awareness about TB, HIV, HIV-TB co-infections, silicosis, non-communicable diseases(lifestyle diseases like Hypertension, Diabetes, Cancer,Heart diseases) on symptoms as well as availability oftreatment facilities.

As health activities of industries are limited to merehealth camps, the scope of diseases and frequency of

health activities need to be increased. There is a greaterneed to establish linkages between workplaces andGovernment health services. Further efforts need to bemade to rope in industries and volunteers at workplacefor facilitation of disease-specific policies at the industrylevel by establishing linkages with district healthauthorities. There needs to be sustained effort andgreater involvement of industries in carrying out health-related activities at workplaces. There is also a greaterneed for tripartite linkages as well as effort industries, Department of Factories/ Labour and StateDistrict Health Authorities.

Limitations of studyA number of limitations to the methodological approach

were identified which include the following: Available employees in the respective department

were called for the study as per the sample The sample group was restricted to 10% based on

availability of resources and time Capacity of District staff for efficient translation of

questions and interpretation of responses was limitedin some areas.

(Axshya India Team of TB Alert India, Hyderabad)


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LEPRA Society (India), a national NGO, has field

and clinic-based activities for TB control, carried

out in partnership with Revised National TB

Control Programme (RNTCP). In response to revisedNGO schemes, it has further expanded the partnership

to offer laboratory services of MDR TB.

LEPRA Indias foray into Tuberculosis

Control ProgrammeLEPRA Indias participation in tuberculosis control

programme has been justified by a combination of

factors: The expertise that has been built in the field

workers all through the years needed to be channelled.

Also, the reappearance of tuberculosis as an epidemic

and the similarity in diagnosis and need of regular

treatment in both tuberculosis and leprosy warrantedparticipation in tuberculosis control programme. In

addition, field-level education and counselling that

LEPRA India is equipped with could be utilized to create

an impact on allied areas like TB and HIV/AIDS.

LEPRA Indias Participation in TB control

programmes is in five different ways:

Direct participation in TB control

Capacity-building

Advocacy, Communication and Social Mobilization

(ACSM)

Research activities Field / laboratory Publications

COVER

STORY Experiences of LEPRA

India in TB Control inAndhra PradeshDr. J. Subbanna* and Dr. Aparna S Srikantam**

In Andhra Pradesh, there are 12 Designated

Microscopy Centres (DMCs) including one Tuberculosis

Unit (TU) of LEPRA India, which is being implemented

in partnership with RNTCP under signed NGO schemescovering a population of 12.3 lakh population.These

DMCs are situated in Hyderabad, Rangareddy, Adilabad

and Krishna districts. During 2012, the performance of

these centres is as follows:

The annualized total case-detection is 2262 with

ANCDR as 187/lakh of which 1018 were new

sputum-positive-cases and all were initiated on

DOTS. This includes 110 paediatric cases (4.9%),

and 243 TB cases which were found to be HIV +ve

(11%).

The sputum conversion rate was 93% and cure ratewas 88% and defaulter rate 2.9%.

236 children were provided INH prophylaxis

121 new MDR TB diagnosis (for Sikkim) and 3230

MDR TB cases follow-up sputum examinations (for

AP and Sikkim) done at BPHRC

Three-hundred-and-eighty local private health care

providers in the DMCs/TUs were sensitized and

involved in referrals of TB suspects and in provision of

DOTS. Capacity-building activities in TB was provided

to PHC/UHP staff and TB sensitization for involvement

was carried out with local private health care providers

(380), DOTS providers (1170) and target groups like

Private Practitioners (Sensitization) TB Patients (Discussions)TB Forum Members (Discussions)


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self-help groups, youth clubs, AWWs, village volunteers,

tribal leaders, teachers, students, local NGOs/CBOs/

FBOs and VHSC members.

Community awareness programmes consisted of film

shows, group meetings, observation days, folk art /stage

plays by local artists. Supported the DTCS in

implementing tribal action plan and participated in

monthly and quarterly review meetings with the staff

concerned and DTCS. Support was provided to DTCS

in implementing awareness programmes with LEPRA

IEC vans.

LEPRA India is the NGO member in the District TB

Control Society (DTCS) and State TB Control Society

in the implementing states and districts.

LEPRA India-Blue Peter Public Health and

Research Centre (BPHRC) has undergone aformal accreditation process between 2007 and 2009and entered into a memorandum of understanding

(MoU) with the State TB Control Programme of the

Government of Andhra Pradesh.

Microbiology Division of BPHRCwith a provision for

BSL III and accredited to the Central TB Division, GoI,

has been taking part in the MDR case-detection and

monitoring from 2009 onwards.

The laboratory caters to the diagnostic needs of

patients from BPHRC, other LEPRA field projects,

RNTCP-DOTS plus phase-II districts of AP (E.

Godavari, W. Godavari, Guntur & Krishna), Sikkim andAP Chest Hospital (for extra pulmonary TB patients).

The laboratory performs about 2000 cultures each year.

Since 2009, the lab confirmed the MDR status of around

500 out of 1200 clinically suspected patients through

these lab tests. Diagnosis of extra-pulmonary TB is of

special focus covering specimens like fine needle

aspirates, urine, endometrial aspirates and pleural fluids

for diagnosing TB. The laboratory recently was

accredited to perform line probe assay for rapid

detection of MDR TB. Operational research on second

line anti-TB drug resistance and genotyping has been

undertaken in the division in collaboration with and

funding from AP State TB office.

Current research interests of the division include

diagnosis and epidemiological features of drug resistance

in TB (such as geography-related prevalence and

correlation with treatment outcome); diagnosis,

epidemiology and pathogenesis of extra pulmonary TB.(lymph node TB) and molecular epidemiology of TB.

Attempts are being made to identify potential new

diagnostic markers specific to Mycobacterium

tuberculosis.

At present, in BPHRC there are

5 PhD students pursuing work in TB and TB-HIV

6 ongoing research projects in TB and TB-HIV

During the last couple of years, 6 research papers on

TB and TB-HIV from BPHRC were published in

various international journals.

(*Director- LEPRA India BPHRC; ** Group Leader-

Microbiology Division, LEPRA India BPHRC)

Case-StudiesMr. Kamruddin, a 50-year-old male, and resident of Bhavaninagar, was suffering with persistent cough and fever. He

approached a private doctor, who diagnosed it as TB and started Anti-TB Treatment (irregular treatment/doses) for 9

months. Even after 9 months, the symptoms persisted. After that, he went to Osmania General Hospital. In the DMC, they

did sputum examination, and the result was positive (3+). They referred (transferred) him to DMC Bhavaninagar for

Anti TB treatment and he was put on DOTS (Cat II, Relapse as per the transfer letter by the Medical Officer - DMC

Osmania General Hospital). After three months follow-up of sputum test the result was positive and was given prolonging

pouches for one month. Thereafter, the sputum test result was negative. During his phase of treatment, he refused to

continue treatment (defaulted-5/6/2009). In one months time, he became serious and was admitted to AP Chest

Hospital on 8/7/2009. After two months follow-up, sputum test was done. The result was found positive (2+). Later inthe last follow-up, sputum test was found positive (1+). He was suspected of MDR TB and his sputum sample was sent to

AP Chest Hospital for diagnosis. They confirmed it as MDR case and started DOTS PLUS treatment and completed

successfully.

Arshiya, 16 year-old daughter of Mr. Khamruddin, was suffering from stomach pain, cough, fever and she went toOsmania General Hospital. Sputum examination was done and the result was found positive (2+). They referred her to

DMC Bhavaninagar for DOTS, LEPRA registered her and put on Cat I (new case) on 19/10/2009. Sputum examinations

were done in a routine manner and all the results were negative. Completing treatment she was declared as cured. She

came back to the DMC Bhavaninagar with cough, fever and body pains again and her sputum examination result was

positive (2+). She was put on DOTS as Cat II (Relapse). The same day she was suspected for MDR TB and the sputum

sample was sent to AP Chest Hospital for diagnosis of MDR. She was diagnosed as MDR TB at AP Chest Hospital and

put on DOTS Plus treatment and is continuing treatment.

(DJS & DAS)


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Tuberculosis (TB) is one of the most under-

reported and underrated chronic diseases of

children across the world. Although childhood TB

has been receiving attention from global health experts,it still remains a major cause for illness and death of

children. TB is preventable, treatable and curable.

Children generally contract this disease because they

are in proximity to elders who are already affected by

the TB bacterium such as a nanny, mother, the care-

giver or other infected family members.

Children are the prime targets as their immune

systems are not fully developed. Children with TB are

often poor and live in vulnerable communities where

there may be lack of access to health care. According

to the Stop TB Partnership, newborn infants of womenaffected with TB are at increased risk of contracting

TB. Children living with adults suffering from TB can

become ill with the disease even if they are vaccinated

with the BCG vaccine. Tuberculosis among children is

often overlooked due to non-specific symptoms and

difficulties in diagnosis such as obtaining sputum from

young children.

COVER

STORY TB In Children

An Avoidable Problem

Dr Shoma A Chatterji

TB preys on vulnerable childrenThe World Health Organization (WHO)s Global

Tuberculosis Control Report, 2012, estimates that

490,000 children fall sick with TB every year and nearly70,000 of them die. Experts, however, maintain that

these are gross underestimates. TB preys on the most

vulnerable children the poor, the malnourished and

those living with HIV. This leads to an unimaginable

burden on children and their families.

In a Papua New Guinea village, a two-year old orphan

who was infected and whose mother died of the disease,

was taken up for adoption by a school teacher. But all

stories do not end happily. Another adult patient, who

later died of multidrug-resistant TB (MDR-TB), had

told me that he was tormented by guilt because thereare no resources to help them care for their children

while they are being treated at a hospital or at home. In

another case, a stock-out of anti-TB medication in

Southern Romania prevented one 14-year-old boy from

leaving the Bucharest hospital to take his high school

exams, says a Ph.D. student of Medical Anthropology

of the City University of New York.

The only TB vaccine that exists, namely the BCG

(Bacillus Calmette-Guerin), was invented in 1921. In

most countries across the world, BCG is mandatorily

It goes without saying that the more cost-

effective way is to prevent the disease than

to cure it. The most effective way to

prevent childhood TB is to stop it fromspreading. This can be done through what

is known as the three Is (i) Intensified

Case-Finding, (ii) Isonaizid Preventive

Therapy or IPT and (iii) Infection Control.


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given at (or soon after) birth to infants to protect them

from the most severe forms of TB including TB

meningitis. But few are aware that (a) BCG does not

protect children from the most common form of TB

TB of the lungs and (b) the effect of the vaccine wears

off as children grow in age. Besides, children with

HIV cannot receive BCG because it can make them

sick.

Scientists are working on developing new vaccines

that address these drawbacks. A dozen new vaccine

candidates are currently undergoing clinical studies.

Results of a study of a preventable TB vaccine, that

enrolled nearly 3000 infants in South Africa, were

published very recently in 2013, and were disappointing

because the vaccine did not significantly protect children

against TB. Collaboration between the public and privatesectors is urgently called for to ensure adequate

investment to develop and deliver a new safe and

effective TB vaccine soon.

Investing in safe and effective vaccinesEvaline Kibuchi, from the Kenya National Aids NGOs

Consortium (an ACTION partner) says, The Ministryof Health needs to increase contact tracing for adultswith TB. It is the best way to find children who havebeen exposed and it is not happening enough.

It goes without saying that the more cost-effective

way is to prevent the disease than to cure it. The mosteffective way to prevent childhood TB is to stop it fromspreading. This can be done through what is known asthe three Is (i) Intensified Case-Finding, (ii) IsonaizidPreventive Therapy or IPT and (iii) Infection Control.

Intensified Case Findingimplies that when an adultmember in the family is diagnosed with TB, all closecontacts and family members, including children mustbe screened for TB. If symptomatic, they should beprovided appropriate diagnosis and treatment. IPTprevents children from developing the active disease

which is also important in the case of children livingwith HIV. Children with HIV are 20 times more likely

to develop TB than children with healthy immunesystems.

Infection Control covers high burden areas wherechildren are more likely to be exposed to the TB bacteria

such as health care facilities, crches, homes, schools

and other community settings that need to be made

TB-safe. This includes separation of patients who

are coughing from those who are not; providing them

with masks; opening windows and doors to establish

natural ventilation all of which can prevent the

spread of the disease. These methods, endorsed by

the WHO, can prove to be very effective in reducingchildhood TB.

It is also necessary to train health workers to

address childhood TB and TB services which need

to be incorporated into the Integrated Management

of Childhood Illnesses (IMCI) a broad-based

childhood health strategy.

It is also important to link TB services with maternal

health care to prevent mother-to-child transmission

of HIV and TB. All children living with HIV must be

screened for TB regularly,, and vice versa during

visits to the medical centre.

Addressing povertyIn order to end childhood TB, we must address

poverty. Child health is directly linked to povertya

major risk factor for TB which in turn, is a big driver

of poverty. This functions like a vicious circle leading

back to where it began. Children living in poverty

are more likely to be undernourished, lack access to

medical care and live in crowded homes with little

ventilation and poor hygiene. Their parents are also

likely to be ignorant about medical treatment,

importance of hygiene and preventive and curativehealth strategies in daily life, which in turn makes

such children more vulnerable to TB than others.

Then again, people living in impoverished conditions

often cook indoors which creates an environment of

thick smoke for the child that weakens their lungs. A

study in Bangladesh found that children who

completed primary school were less likely to

develop TB.

(The author is a freelance journalist, film scholar and writer

based in Kolkata, India, and has authored 17 books)

The World Health Organization (WHO)s

Global Tuberculosis Control Report,

2012, estimates that 490,000 children fall

sick with TB every year and nearly 70,000

of them die. Experts, however, maintain

that these are gross underestimates. TB

preys on the most vulnerable children

the poor, the malnourished and those

living with HIV. This leads to an

unimaginable burden on children and their

families.


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Although TB is a completely curable disease, there

is still considerable social stigma attached to the

disease. Some of the basis of this stigma is

related to the perception that tuberculosis is a disease

that is related to being unclean, poverty or evenhereditary. There is also a misperception of risk of

transmission to their contacts at home or work even

though the patients are on regular treatment.

Social impact of TB stigmaThe social stigma related to TB leads to a situation

wherein patients refuse to seek treatment till at an

advance stage, and discontinue treatment, stop going

for work and get ostracized by the family and

community. Women are prevented from getting married

or are divorced by husbands.

Overcoming stigmaThe main strategy to overcome the stigma is to give

education that is tailored to the community and the

patients/ family in particular. At the community level ,

constant emphasis that TB is another airborne disease

that is not related to a persons hygiene or economic

status is an important step to address the communitys

anxiety. Apart from this, the emphasis that TB can be

completely cured if detected early and treated effectively

is a major positive point that should be highlighted

constantly. Public testimonies by community leaders /

COVER

STORY

Social Stigma Attached to TB

Dr G Srinivas Rao, MD

celebrities affected by TB and individuals who have

successfully completed their treatment constitute

another useful strategy that can be used to destigmatize

the disease.

Familys supportAt the personal level, joint counselling of the individual

and the family members will go a long way to dispel

misperceptions that sleeping together, sharing cutlery

and socializing spread the disease. It should be clearly

stated that the risk of TB transmission is minimal after

being diagnosed and started on treatment. It is to be

emphasized that the greatest transmission risk is

BEFORE the patient is diagnosed and hence the need

for contact examination.

Employers supportIf deemed necessary, the employers should also be

counselled in a similar way so as to reassure them that

the patient is no longer a health risk to his co-workers

and to ensure that his employment status is not affected

by being treated for TB. Laws are available to prevent

workers from being unfairly dismissed for being treated

for curable diseases such as TB.

Communitys supportRecognizing the great impact social stigma can have

on the effectiveness of the National TB Control

Programme, AXSHYA has taken several communityinitiatives such as disseminating correct technical

information on TB, printing educational pamphlets and

organizing community shows, exhibitions and talks to

reduce the stigma of being diagnosed with TB. Medical

staff treating TB patients are also sensitized to be aware

of the possible social stigma attached to being diagnosed

with TB and actively enquire about the issues and

manage them effectively, if recognized.

(National Manager, CHAI Axshya Project,

The Catholic Health Association of India, Secunderabad))


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What is tuberculosis?

Tuberculosis (TB) is an infectious disease caused by

a bacterium, Mycobacterium tuberculosis.

How is tuberculosis caused?

TB is spread through the air by a person sufferingfrom TB. A single patient can infect 10 or morepeople in a year.

What are the symptoms of tuberculosis?

Common symptoms of tuberculosis include: Cough for three weeks or more, sometimes

with blood-streaked sputum Fever, especially at night Weight loss

Loss of appetite

Benefits of DOTS/ Why DOTS? More than doubles the accuracy of TB

diagnosis. Its success rate is up to 95%. It prevents the spread oftuberculosis by

prioritizing sputum-positive patients for

diagnosis and treatment, thus reducing theincidence and prevalence of TB.

It helps in alleviating poverty by saving lives,reducing the duration of illness and preventingnew infectious cases.

It improves quality of care and removes stigma. It prevents treatment failure and the emergence

of MDR-TB by ensuring patient adherence totreatment and uninterrupted supply of anti -TBdrugs.

It lends credence to TB control efforts and thehealth care system.

What is DOTS that is being implemented?

The DOTS strategy is in practicein more than 180 countries. ByMarch 2006, India had extendedDOTS to the entire country.

What is RNTCP?Revised National TuberculosisControl Programme (RNTCP)applies the principles of DOTSto the Indian context.

How many people die from

TB in India every year?

Frequently-Asked Questions

on TuberculosisTuberculosis is one of the leading causes of mortalityin india. It kills more than 300,000 people in Indiaevery year.

Which is the strongest risk factor for tuberculosis

among adults and how does it affect the spread

of TB?

The Human Immunodeficiency Virus (HIV, the virus

that causes AIDS) is the strongest risk factor for

tuberculosis among adults. Tuberculosis is one of theearliest opportunistic diseases to develop amongst

persons infected with HIV. HIV debilitates the

immune system increasing the vulnerability to TB and

increasing the risk of progression from TB infection

to TB disease. An HIV positive person is six times

(50-60% life time risk) more likely to developing

tuberculosis once infected with TB bacilli, as

compared to an HIV negative person, who has a

10% life-time risk.

Can tuberculosis be cured in HIV co-infection?

Tuberculosis can be cured, even among HIV-infectedpersons. TB treatment with DOTS reduces the

morbidity and mortality among people living with HIV.

For how long must tuberculosis treatment be

taken?

Tuberculosis requires at least 6 months of treatment.

What is multi-drug-resistant tuberculosis?

Multi-drug-resistant tuberculosis (MDR TB) is

caused by strains of the tuberculosis bacteria resistant

to the two most effective anti-tuberculosis drugs

available-isoniazid and rifampicin. MDR TB can only

be diagnosed in a specialized laboratory. What is the duration

of treatment for multi-drug-

resistant tuberculosis?

M u l t i - d r u g - r e s i s t a n t

tuberculosis requires at least 18-

24 months of treatment with

medicines which are 100 times

more expensive and often highly

toxic.

(Source: TBC India)

COVER

STORY


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The core objective of the Baseline Survey wastogather baseline information on TB-relatedKnowledge, Attitudes and Practices (KAP) among thefive respondent groups and gain a better understandingof how target groups viewed stigma discrimination andgender.

Methodology: The survey was implemented by TheUnion, South-East Asia Regional office in 30 of the 374Global Fund project districts. The districts were selected

by a stratified cluster sampling technique from the statesof the four zones (north, south, east and west) of thecountry. Nearly 75,000 households were visited covering

a population of 374,000 people.

Axshya is a Global Fund supported TB projectlaunched in 2010 that is reaching out to 374 districtsacross 23 states in the country to expand the reach and

visibility of the RNTCP through increased civil societyengagement at the community and the individual levelswith a special focus on marginalized and vulnerable

populations.

Key findingsEach respondent group was interviewed through a

semi- structured questionnaire.

General populationAs many as 4562 persons (2320 males and 2242

females) with an average age of 34-36years were interviewed. Therespondents included labourers,housewives, skilled workers and peopleengaged in agriculture. Students, petty

traders and those in government andprivate service were also interviewed.30% of the respondents were illiterate

and 60% stayed in semi pucca orkachha (temporary) houses.

Findings Almost 15% of the respondents had

absolutely not heard of TB at all

COVER

STORY Knowledge, Attitudes and

Practices on TB

Of those who had heard of TB, 69% recognizedcough for two or more weeks as a major symptomwhile 11 % did not know any symptoms of TB

50% knew TB was transmitted through air when

an infected person coughed/ sneezed 55% felt sputum examination could help diagnose

TB while 60% considered chest X -Ray to be moreaccurate.

Though 80% felt that TB was curable, only 37%knew that TB treatment has to be taken for 6-8months duration

Only 23% had heard of the term DOTS, and less

than a fifth (19%) knew that free treatment fortuberculosis is available under DOTS

10% of the respondents had cough of 2 weeks or

more in the last 2 months and of them only about

30% had visited any health care provider seekingcare

TB diseased personsAs many as 752 TB diseased persons were identified

and 609 were interviewed. Among the respondents,around 77% were married, 43% were illiterate and 33%

worked as daily wage labourers. Importantly 89% usedsolid fuel for cooking and 75% were from householdswith less than Rs 4,000 monthly income.

Findings 66% patients had cough as a

presenting symptom, 47% had feverand 33% chest pain 74% patients were diagnosed withTB within one month of the onset ofsymptoms 60% were diagnosed in agovernment hospital 54% were receiving free treatmentunder DOTS and 46% were takingtreatment from non-Government health

facilities by paying for their medicines

From a Baseline Survey conducted as part of Project Axshya


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While 80% were aware that treatment has to be

taken regularly, only 55% knew that the duration ofTB treatment is for 6-8 months

Health Service Providers (HSP)

About 614 Health Service Providers were interviewedout of which nearly 2/3rds were private practitionersand 1/3rd were doctors in government service. More

than half of them (55%) were qualified practitioners ofallopathic medicine, 26% were qualified practitionersof Ayurveda medicine, 12% were qualified practitioners

of homeopathic medicine and 5% were practitioners ofUnani system of medicine and the remaining were notqualified in any of the systems of medicine mentionedabove.

Findings 94% HSPs identified cough of two weeks, 64%

coughing of blood and 52% pain in the chest as major

symptoms of TB 1/5th of the HSPs did not know that patients can be

sent to government health facilities for sputum

examination Nearly 96% had diagnosed a case of TB of the lungs

in the past and 36% mentioned that they haddiagnosed TB of other organs as well

88% believed that allopathic medicines were the bestform of medicines for the treatment of TB, 10%

informed that homeopathic medicines are good for

TB treatment, and 2% felt that other forms ofmedicines work for TB.

80% were aware that the treatment for TB is for 6-8 months

Nearly 1/3rd of HSPs did not advise TB patients togo to government health facilities for availing freetreatment

64% were not sure what was multidrug resistant TB

(MDR- TB) and how it is diagnosed.

Opinion LeadersAs many as 511 leaders were interviewed. Opinion

leaders influencers in the community, holding sway overpeople propagating messages and instilling behaviorsthrough discourses, interactions and exchanges. Therespondents manly consisted of members of local selfgovernment-Panchayati Raj Institutions (village pradhan,ward member), religious leaders and teachers.

Findings All of the respondents had heard of TB and 92%

knew it, fully curable 91 % knew a person with TB must be referred to

government health centre 67% had faith in allopathic medicine while 34%

advocated for DOTS. However, 7% also felt herbalremedies could cure TB, 6.5% viewed Ayurveda asa good option and 4.3% said that they also believe

that homeopathy works. Only 1/5th of them had undertaken any activities

related to TB control in their community.Non-Governmental Organisations/Community-Based Organisations

As many as 51 NGOs/CBOs were identified in the300 primary sampling units of the 30 districts. They were

selected on the basis of information given by opinionleaders and community members about their presencein their locality. These NGOs/CBOs were working in

the area of education (55 sanitation (43%), ruraldevelopment (33%), domestic violence gender (35%),employment (14%) and environment (4%).

FindingsAbout 50% were engaged in programmes on TB

prevention and control.

Of those who were engaged in TB Control, 88%created awareness on TB, 23% reduced stigma anddiscrimination and provided training on TB health care

Nearly, 84% were willing to collaborate with RNTCPwhereas only 41 % were involved in any of theschemes

12 % helped in the resettlement of TB patients andonly worked as DOTS providers.

ConclusionThis community based survey provides valuable

information on the current levels of knowledge, attitudesand practices of the various stakeholders of the

population with respect to TB. This report provides datathat shows major gaps and opportunities for enhancingthe reach, visibility and access to Government of

Indias Revised National TB Control Programme withinthe framework of the ACSM component of Global FundRound 9 India TB project.

(For the full text of the report, visit: http://www.axshya-

theunion.org/Documents/KAP.pdf.)

Axshyais a Global Fund supported TB

project launched in 2010 that is reaching out

to 374 districts across 23 states in the

country to expand the reach and visibility of

the RNTCP through increased civil societyengagement at the community and the

individual levels with a special focus on

marginalized and vulnerable populations.


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World TB Day is an opportunity to raise

awareness about the burden of tuberculosis

(TB) worldwide and the status of TB

prevention and control efforts. It is also an opportunity

to mobilize political and social commitment for further

progress.

Key facts about TB Tuberculosis (TB) is second only to HIV/AIDS as

the greatest killer worldwide due to a single infectious

agent.

In 2011, 8.7 million people fell ill with TB and 1.4

million died from TB.

Over 95% of

Health Action: Special issue on TB (March 2013)

Documents

Transcript of Health Action: Special issue on TB (March 2013)