Health impact

Tuberculosis is an infectious disease caused by a bacillus -Mycobacterium tuberculosis- that spreads through the air when untreated TB patients cough. Left untreated, a single person with active TB can infect 10 to 15 others each year, creating a self-perpetuating pool of infection.

Someone in the work! is infected with TB every second. Seven to eight million people become sick and two million die from it each year.

Tuberculosis has existed in India since the earliest days.  In 1500 BC, the Rig Veda described the illness as Rajayaksma, king of diseases. Today, India accounts for nearly 30 per cent of all tubercuiosis cases in the world, a figure that is likefy to increase as India's population grows and the HIV epidemic progresses.

Tuberculosis burden and control —10 countries with most cases. 1997

COUNTRY	Population (millions)	Estimated Total TB Cases (thousands, 1997)	Estimated incidence per 100.000 per year	Estimated new infectious cases treated under DOTS. 1997	New infectious cases
India	960,178	1,799	187	805,000	7,708
China	1,243,738	1,402	113	630,000	147,905
Indonesia	204,323	583	285	262,000	19,492
Bangladesh	122,013	300	246	135,000	25.871
Pakistan	143,831	261	181	117,000	-
Nigeria	118,369	253	214	110,000	11,235
Philippines	70,724	222	314	100,000	3,190
South Africa	43,336	170	392	69,000	4,146
Russia	147,708	156	106	70,000	660
Ethiopia	60,148	156	260	66,000	15,753
Sourse: Dye C, Scheele S,Dolin P, Pathania V ,Raviglione MC ,Global burden of tuberculosis.JAMA ;292:677-686

 

 

 

Most adults in India have been infected with the tuberculosis bacteria. In a 1997 review. Prevalence and incidence of Tuberculosis infection and Disease in India, A.K. Chakraborty found that tuberculosis is common over all of India, in both rural and urban areas. About 38 percent of people all  ages are infected with the disease, while infection among males above

40 years of age runs as high as 70 percent.

According to the 1999 World Health Report, the burden of tuberculosis in India is 36 times more than leprosy, 1 3 times more than malaria, 2.5 times more than tropical diseases, and 35% more than HIV AIDS.

More adufts in India die fromTB than from any other infectious disease one every minute and more than 1,000 every day - a grim statistic that has changed littte over the past two decades.

Every year, 2 million people in India develop the disease, half of whom - more than 2,000 patients every day - have infectious and often fatal tuberculosis. Prevalence of the disease is more than twice the incidence, indicating a failure of current treatment programmes and a pooling up of previous cases. Unless promptly and effectively treated, these patients will infect succeeding generations and the cycle of infection, disease, and death from tuberculosis will continue for centuries.

Economic impact

The burden of suffering caused by tuberculosis in India is enormous. TB is one of India's biggest public health problems - a problem that India can ill-afford.

 

Tuberculosis and its spread remind us that we are all connected by the air we breathe.

Although sometimes considered a disease of slums and ghettos, affecting only the socially disadvantaged, tuberculosis can in fact affect anyone - from remote villages to bustling urban centers. Those infected are disproportionately young adults in the most productive years of their lives, often the primary wage earners of their families.

ŇÂ is a disease that impoverishes families and undermines economic development. In 1996, the World Health Organization estimated that India loses about 400 million dollars (Rs. 1 700 crore) in economic output every year from tuberculosis.

In a 1997 study conducted in Tamil Nadu, researchers at the Tuberculosis Research Centre in Chennai found that an average patient suffering from tuberculosis incurs a total loss of Rs 3469 (US$ 99) while shopping for diagnosis and treatment. For a daily wage laborer who might hope to earn the equivalent US$ 200-400 per year, this is a prohibitive sum - equivalent to 3-6 months of wages. This study indicates that tuberculosis may cause 300,000 children to become orphans, and 100,000 Indian women to be rejected by their families each year.

In their study, Mapping of TB Treatment Providers at Selected Sites in Andra Pradesh State, India, Ramana et al found that on average, rural tuberculosis patients spent Rs 1000 ($30) per month on TB diagnosis and treatment while urban patients spent Rs 500 ($15) per month (See figure). This almost invariably resulted in indebtedness and mortgage of valuables.

The World Health Organization estimates that TB patients in India together spent more than Rs. 645 crore ($180 million) on private ŇÂ care in 1997.

 

Indian workers with tuberculosis lost an average of 83 workdays because of the disease, 48 of which were lost while shopping for diagnosis. Considering that two million new cases are reported annually in India, the national loss per year works out to 166 million lost workdays, at a cost of about $200 million (Rs. 694 crore). In addition, the debts incurred by patients because of tuberculosis amounted to $120 million (Rs. 416 crore).

 ŇÂ kills more women of reproductive age than all causes of maternal mortality combined, and it may create more orphans than any other infectious disease. Nearly one third of female infertility in India is caused by tuberculosis.

 Indian women who suffer from ŇÂ face special constraints. They tend to neglect their illness due to household. Responsibilities until they become too sick to attend to their normal duties. They are often dependent on others to get necessary medical attention.

There is also still a social stigma attached to TB. Sixty-nine percent of rural females interviewed by TRC researchers were reluctant to discuss their illness with neighbors.

The indirect impact of TB on children is considerable. Two thirds of the women interviewed in the Tamil Nadu study said that they were unable to look after the needs of their children because of TB. Nearly one-fifth of the school-age children of TB patients either left school or took up employment to help support their families.

A successful DOTS programme could have substantial economic benefits for India, in his 1996 study, The Potential Economic Benefits of the DOTS Strategy Against TB in India, R.H. Dholakia of the Indian Institute of Management, Ahmedabad, divided these benefits into two broad categories.

Direct, tangible economic benefits of DOTS would include:

 

     ●   Reduction in the incidence and prevalence of TB, which improves the efficiency and productivity 

           Of workers by reducing their forced absenteeism on account of ill health;

     ●   TB deaths averted, which adds to the productive capacity of the economy; and

     ●   Release of the hospital beds currently occupied by the TB patients.

In addition, DOTS would enhance India's social welfare through:

     ●   Reduced suffering of TB patients,

     ●   Quicker and surer cure from the disease,

     ●   Lives saved and disability reduced for dependents and non-workers suffering from TB,

     ●   Poverty alleviation, and

     ●   The benefits of living in a more healthy society.

HIV and TB

The Human Immunodeficiency Virus (HIV) has spread across India since the first cases of HIV infection were diagnosed in Bombay and Madras in 1986. WHO estimates that, by 1999, at least 3 million, and possible as many as 5 million people in India are infected with HIV, the virus that causes AIDS. That makes India the home of more HIV-positive individuals than any other country in the world.

Because the Human immunodeficiency Virus breaks down the immune system and makes patients highly susceptible to TB, HIV will have 3 major impacts on the TB epidemic in India. In some countries in Africa, the HIV epidemic has more than doubled or tripled TB cases.

Infection with HIV is the most potent known risk factor for progression to active tuberculosis among adults. Conversely, tuberculosis hastens the development of AIDS in HIV-infected persons. Individuals who are not HIV-infected and who become infected with Mycobacterium tuberculosis have approximately a 10 percent lifetime risk of developing active tuberculosis, compared with a risk of 60 percent or more in persons infected with both HIV and Mycobactenum tubercutosis. The risk of tuberculosis infection progressing to active tuberculosis is estimated to be 8 percent per year in an HIV-positive person, as opposed to a Lifetime risk of 1O percent in an immunocompetent person. This is particularly important in India where it is estimated that more than half of the adult population harbors Mycobactenum tuberculosis infection.

 

In a developing country like India, the potential extra burden of new tuberculosis cases attributable to HIV is staggering and could overwhelm already stretched tuberculosis budgets and support services.

The incidence of HIV seropositivity among patients admitted to the tuberculosis wards of a large public hospital in Bombay increased from 2% in 1988 to 16% in 1998. Among Indian patients who are HIV positive, tuberculosis is by far the most common opportunistic infection. A 1994 study showed that 61 percent of all HIV-positive patients in India had tuberculosis at some point in the course of their HIV disease.

One of the most worrisome aspects of the interaction between HIV and TB is that strains of multidrug-resistant tuberculosis (MDRTB) can spread very rapidly among HIV-infected persons. In both developed and developing countries, outbreaks of MDRTB have spread rapidly on hospital wards for HIV-infected persons.

Fortunately, DOTS is as effective among HIV-infected TB patients as among those who are HIV negative. Even among HIV-infected TB patients, DOTS cures patients and results in longer, healthier lives.

Tanzania, Malawi, and Botswana have had programmes of directly observed treatment for more than 10 years. Despite high rates of HIV infection, which is present in one third of tuberculosis patients or more, rates of relapse drug resistance remain low.

 

 Multidrug-Resistant Tuberculosis (MDRTB)

Multidrug-resistant tuberculosis refers to strains of tuberculosis bacteria that have developed resistance to the two most effective anti-tuberculosis drugs available -isoniazid and rifampicin. MDRTB is an eemerging and ominous problem worldwide. Patients who do not have MDRTB can

Easily be cured with 6-9 months of treatment. In contrast, treatment of MDRTB requires at least 18-24 months of arduous treatment with expensive, often toxic, medications.

 

In the United States, treatment of a single case of MDRTB can cost more than US$250,000. And, the treatment often fails. In a country like India MDRTB is almost the equivalent of a death sentence, as very few patients have the financial capacity or the stamina to complete the Song treatment regimen required.

Effective TB treatment programmes can prevent drug resistance. If patients are prescribed appropriate treatment and complete that treatment, development of drug resistance is extremely rare.  In contrast, when prescribing practices or case holding — or both — are inadequate, drug resistance can emerge. Ensuring the cure of new smear-positive patients is the best way to prevent the development of drug resistant tuberculosis and should be the highest public health priority. A low cure rate among new smear positive cases will create drug resistant cases faster than these cases can be cured, even if unlimited resources are available.

Many of the factors contributing to the development of drug resistance - poor patient compliance, ineffective drug regimens, inadequate follow-up, and poor patient monitoring - flourish in a developing country.  DOTS has been proven to prevent the emergence of MDRTB, and also to reverse it where it has emerged. The only way to confront the challenge of MDRTB is to improve the treatment programme and implement DOTS as rapidly as possible.

Key Findings and implications for Action

Tuberculosis is the leading single infectious cause of death in India. In addition to the negative health impact of tuberculosis, it is a substantial economic burden for families and communities. The problems of HIV and multidrug-resistance will make the tuberculosis epidemic much worse unless urgent action is taken. But there is hope - tuberculosis can be cured and the battle against the disease can be won.

•  Policy-makers, programme managers, and doctors in public and private sector should spread the message that TB can be cured and the epidemic controlled. For too long, tuberculosis has been seen as a natural calamity about which nothing can be done.

•  Researchers and programme managers should promote much more widespread awareness of the massive health, economic, and social costs of tuberculosis - costs which could be greatly reduced by an effective programme.

•   Policy-makers should take into account the negative impact of TB on the economy of individual families and of the country. Tuberculosis does not merely reflect socio-economic status - tuberculosis perpetuates and exacerbates poverty adequate funding for tuberculosis control is required at all levels.

•   Policy-makers and programme managers should recognize the serious risk that HIV infection and multidrug-resistant tuberculosis can convert an already-serious situation into a massive and potentially uncontrollable epidemic. It is essential that DOTS is rapidly and effectively implemented before multidrug-resistant tuberculosis and HIV become more widespread. However, implementation must be phased in order to ensure good quality.