By Sandra Albert
In the current scenario of COVID-19 holding sway in the media and the minds of people, it is worthwhile flagging that we continue to have older, more persistent, and pernicious infections amidst us. March 24 was world TB day, so let us take a moment to review this disease and think about why we continue to have such a high case load in Meghalaya.
Tuberculosis (TB) remains the top infectious disease killer worldwide, with 10 million people falling ill with TB and approximately 1.5 million TB-related deaths occurred in 2018 across the world. India is one of the eight countries that accounted for two thirds of the new TB cases in 2018. It is a social indicator as well, the highest burden of disease remains in the impoverished countries. In 2018 India had an estimated 27 lakh new cases of TB and 440,000 deaths.
In Meghalaya of the over thirty-three thousand presumptive cases examined, over 4800 patients were diagnosed and notified to be TB in 2019. Despite TB being a treatable disease approximately 167 patients died due to TB in Meghalaya in 2018; it is an underestimate as it largely represents patients who reported to the public sector hospitals.
TB is caused by bacteria (Mycobacterium tuberculosis) that most often affect the lungs. But the infection can affect any other organ such as intestines, bones and skin.
TB spreads from person to person through the air. When people with TB of the lung cough, sneeze or spit, they disperse the TB germs into the air. Spitting in public spaces is of particular importance to us as chewing kwai and spitting in open spaces is something we see around us as a matter of routine. So hygienic practices being recommended to avoid COVID-19 such as coughing into one’s sleeves, hand washing and avoiding spitting in public spaces are good practices that can help reduce spread of other infections as well.
While any person inhaling TB germs could become infected, most will not fall ill with TB. Rather the state is considered as being ‘latent TB’ which means people have been infected by TB bacteria but are not (yet) ill with the disease and cannot transmit the disease. Those infected have a 5–15% risk (chance) of falling ill with TB during their lifetime. The risk of becoming ill with TB is higher in those who are malnourished, in those who smoke and or have compromised immune systems, such as people living with HIV and diabetes. Some risk factors worth noting and of relevance to our State is poor housing;homes with poor ventilation and overcrowding as all these factors are associated with higher transmission of infection. In our state and region during the colder months people often remain huddled indoors around the hearth with no or little ventilation.
TB can affect any age group, although it mostly affects adults. The BCG vaccination offers partial protection especially to children from serious forms of TB such as infection of membranes of the brain. The symptoms of active TB include fever in the evenings, cough, night sweats and or weight loss. These symptoms can be mild and last for many months. So delays in seeking care can result in transmission of the bacteria to others for a longer period. It is estimated that untreated people with active TB can infect 5–15 people through close contact over the course of a year.
Over the years diagnostic tests for detecting and confirming TB has become better and quicker. For treatment a cocktail of about four drugs has to be taken for 6 months. Unfortunately the long duration of treatment involved tends to make people stop taking medications as soon as they feel better. But to get rid of the infection fully and prevent resistant TB from emerging, a patient needs to adhere to the treatment protocol prescribed. Resistance to first line anti-TB drugs (isoniazid and rifampicin) is referred to as multi-drug resistant (MDR) TB. These drug resistant bacterial strains can emerge when anti-TB medicines are used inappropriately; patients stopping treatment too early, or doctors or other health care providers prescribing drugs inadequately and and if poor quality drugs are used.
MDR-TB is treatable and curable but it requires additional drugs, that need to be used for longer. Most MDR-TB can be managed with 9months to one year treatment but sometimes may require upto two years of treatment. The WHO describes MDR-TB as a public health crisis and a health security threat. India contributes to one of the highest numbers of MDR-TB. Meghalaya too is seeing increasing numbers of MDR-TB. A new and increasing concern is the emergence of extensive drug resistance or XDR-TB.
The government of India through its National TB Control programme, offers free diagnostic tests and treatment for TB to all patients.Additional schemes such as NikshayPoshan Yojana launched in 2018 is available as an incentive for nutritional support of Rs 500 per month given via direct transfer to the account of the beneficiary.
This decade has seen increasing global attention and commitment to addressing TB though the Sustainable Development Goals (SDGs), WHO’s End TB Strategy and others. But our society does not talk enough about TB; prevalent stigma around this disease tend to hide the problem and reveal just a tip of the problem in our region.
TB is a social issue, to address is effectively the wider issues of poverty, inequality and malnutrition that are highly prevalent in our state need to be looked at with greater attention and urgency.
(The author is Director, Indian Institute of Public Health Shillong)