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Tuberculosis: the devil still lurks

- With World TB Day on Sunday, a medical practitioner highlights measures to tackle the disease

The other day, flipping through the pages of an Assamese literary magazine, I came across a translated story of renowned Hindi writer Munshi Premchand. It was about the agony of a father whose beloved son falls victim to tuberculosis, which was incurable till the forties of the last century.

Tuberculosis is no longer incurable but the curse still prevails. Though the causative organism was identified by Robert Koch on March 24, 1882 (to commemorate the occasion, World Tuberculosis Day is celebrated on that day), tuberculosis is still a global challenge to the medical fraternity as well as to mankind. Based on the public reports it is estimated that 50 million deaths will occur between 1998 to 2020 because of tuberculosis infection.

The World Health Organisation estimates the burden of tuberculosis to be 8.7 million new cases in 2011. Of 8.7 million, 0.5 million cases are estimated to be children and 2.9 million women. Nearly 1.4 million deaths are attributable to tuberculosis, of which 0.99 million deaths are among HIV negative people and 0.43 million among people with AIDS.

India ranks 17th among the 22 high burden countries with an estimated incidence of 2.3 million cases in 2010. Tuberculosis has a huge impact on socio-economic burden, as it affects people in their most productive years of life. It kills 2.8 lakh people every year in India.

Disease control

Chemotherapy for tuberculosis became available only in the middle of the 20th century. The government of India in 1956 has established the Tuberculosis Chemotherapy Centre, later known as Tuberculosis Research Centre (TRC) in Chennai, under the auspices of the Indian Council of Medical Research (ICMR).

It demonstrated that the much-practised sanatorium treatment such as bed rest, extra diet and good accommodation were remarkably unimportant provided adequate chemotherapy was prescribed and taken. Further, that it was appropriate to treat patients in their own homes. These findings revolutionised tuberculosis treatment. The National Institute of Tuberculosis, set up in 1959, was the first attempt by the Centre to start a programme dedicated to management of tuberculosis. In 1962, the National Tuberculosis Control Programme (NTCP) was initiated, under which district tuberculosis centres and clinics were established. In 1992, the government reviewed the NTCP and concluded that it suffered from managerial weakness, low rates of treatment completion, inadequate funding, over-reliance on X-ray and lack of systemic information on treatment outcomes. Therefore, keeping these points in mind, the Revised National Tuberculosis Control Programme (RNTCP) was designed.

RNTCP began as a pilot programme in 1993. It was eventually launched as a national programme in 1997 with the aim of 70 per cent case detection rate and 85 per cent treatment success rate of new cases. The entire country was covered under the RNTCP programme in 2006. Since its inception, the programme has initiated more than 15 million tuberculosis patients on treatment, achieving global targets, saving 2.5 million additional lives and has become the largest tuberculosis control programme of the world. Till date, more than 2,300 NGOs, around 15,000 private practitioners, 291 medical colleges and over 150 corporate sector health facilities are involved in the programme.

Professional bodies like IMA, IAP and other central government departments/PSUs like CGHS, Railways, ESI Mining and Shipping were also involved.

The vision of the government 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 achieve this vision, the programme has now adopted the new objective of universal access for quality diagnosis and treatment for all tuberculosis patients in the community.

Future plans

This entails sustaining the achievements of the programme to date and extending the reach and quality of services to all persons diagnosed with it. In particular, by end-2015, the programme aims to achieve 90 per cent notification rates for all cases, 90 per cent success rate for new cases and 85 per cent success rate for re-treatment cases. It also aims to significantly improve the successful outcomes of treatment of drug resistant cases, to decrease morbidity and mortality of AIDS associated tuberculosis and to improve outcomes of tuberculosis care in private sector.

Recognising the opportunity to accelerate tuberculosis control further, RNTCP has developed the national strategic plan 2012-2017 under the Twelfth Plan. It seeks to focus on strengthening and improving the quality of basic DOTS services, to further strengthen and align with the health system under NRHM to deploy improved rapid diagnosis at field level and to expand efforts to engage all care providers.

It also aims to strengthen urban tuberculosis control, expand diagnosis and treatment of drug resistant tuberculosis, to improve communication and outreach and to promote research. No doubt the RNTCP has played a great role in the control of the disease and this programme has become a showpiece for the Union ministry of health and family welfare.

Resurgence

It can be assumed that tuberculosis is “resurging”. This may be held true of industrialised countries also. In countries like India, tuberculosis never seems to have “disappeared” to “resurge” later. Tuberculosis has always been with us, only revealing itself every now and then and making us wiser.