Tuberculosis In India Health And Social Care Essay

Tuberculosis or TB is a bacterial disease. The most common microorganism that causes TB is mycobacterium tuberculosis. This organism was discovered in 1882.Robert koch was the scientist who made the discovery. This organism has slow growth and a very thick capsule outside that protects it from threats and hence it is one of the most toughest organism causing very tough infections. There are a few other organisms that cause the disease as well. America was considered to be one of the countries that have been safe from the disease up untill 1990 s when the disease was discovered in the congested city areas especially those affected by aids. This has become the new public health challenge for the america . The TB attacks lungs usually and it is the most common of the sites affected by TB. The same organism causes the infection in the lungs but does have the capability to travel to any part of the body by entring into blood. TB spreads from one person to another by the cough or sneezing from a sick person who has the germ in his sputum of the air carries the droplets.our body’s immune system, that has the role of defending our bodies against the infections normally does destry these organisms upon entry into the body.

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Some times our defence system doesn’t kill the organisms but creates a think wall arround the bacteria thus limiting their affect and hence saving the body from active disease although the organism does stay inside the walls capable of creating infection if given chance by the decrease in immunity during diseases like aids. This situation is called latent TB in which the person has the capacity to spread the infection but isnt suffering from the disease itself.

Sometimes, If our immune system does not effectively kill the bacteria’s these organisms create thick walls arround themselves and remain dormant for years and wait till they find decreased immunity in the host and a chance to cause infection, thus attacking the host either inside the lungs or any other area. Many diseases are the cause of increased latent TB such as Aids , diabetes mellitus and at times simple nourashment problems caused by physical and some times mental illness.Most of the times Tb starts in the lungs and person suffers from symptoms of lung disease but it can often involve lymph nodes(small glands that help getting rid of the waste and infections) or some times it can effect bones intestines etc. meningitis(the inflamation of brain and

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its membranes) is one serious disease that can be caused by the same bacteria. Although it is very rare.

Tuberculosis is one of the most ancient disseases .In neolithic times (8000 BC) there Were incidents of the same disease affecting bones and skeleton called Pots disease .The records are also found in Egyptian and pre Columbian new worlds (1000 BC) During times of Hippocrates (400 BC) it was known to be a contagious disease, the disease which can spread from one man to another. They used to call it phthisis(which meant to waste away). There are clear evidences of increase in the number of people suffering from disease during time of population growth in urban areas especially in European countries . Industrial revolution of 1750 has witnessed about 25 % of population eradicated by this disease. In the early 20th century it was the main cause of death in America.

(CDC) The US Centers for Disease Control and Prevention, has been recording detailed epidemiologic information on tuberculosis (TB) since 1953. Due to basic infection controle practices and other factors it was observed that the infection rate (incidence) of TB has droped since the beginning of 20th century A resurgence of tuberculosis was observed from the data collected in 1985. This increase was observed in ethnic minorities and more so in the population suffering from other diseases like Aids. Since than there are increases efforts in TB control activities in America and world wide.

AIDS causes immunity problems and hence it is often related with TB as an opportunistic infection attacking the vulnerable hosts. It is found to be co existing usually with Aids. Globally, coinfection with HIV is highest in South Africa, India, and Nigeria.

Aids affected persons are 20 times more vulnerable to TB as compared to normal person with intact immune systems. Correspondingly, TB is the leading cause of mortality among persons infected with HIV.

Worldwide, TB is most common in Africa, the West Pacific, and Eastern Europe. These areas are full of factors causing and helping TB ,that includes limited financial resources and poor food supplies ,poor sanitation, and living conditions. Aids and multidrug resistant TB are other contributing factors. Despite aggressive measures to cut down the rate of growth of this disease these factors have contributed in continuous rise in the number of cases annually

Epidemiology:

1.In 2007 there were 9.27 million cases of TB globally against the figure of 9.24 in 2006, 8.3 in 2000 and 6.6 million in 1990.Asia was reported to have most of these cases(55%) while Africa was second highest with (31%) of all the cases .Eastern Mediterranean had 6% European region 5% and the American region 3% were the smaller contributants.

2 .Top five countries in terms of .TB cases in 2007 are India (2.0 million), China (1.3 million), Indonesia (0.53 million), Nigeria (0.46 million) and South Africa (0.46 million). Of the 9.27 million incident cases in 2007, an estimated 1.37 million (14%) were HIV-positive; 79% of these HIV-positive cases were in the African Region and 11% were in the South-East Asia Region.

3.Cases per capita for TB are falling although the total number has increased mostly due to population growth. The decline rate about 1% is quite slow .in Year 2004 there was a spike in number of cases per 100 000 population which shoot upto 142 cases per 100k. While in 2007 the reported cases per 100k were 137.Among 6 of the regions of WHO. incident rate is falling in five regions with exception of European region.

4.There were an estimated 13.7 million prevalent cases of TB in 2007 (206 per 100 000 population), a decrease from 13.9 million cases (210 per 100 000 population) in 2006.

5.In 2007 there were 20 per 100k cases in HIV negative cases an estimated 1.3 million deaths occurred .While incident HIV positive cases numbered to an additional 456 000 deaths; these deaths are classified as HIV deaths in the International Classification of Diseases (ICD-10). The 456 000 deaths from HIV-positive cases of TB incidence make upto 33% of HIV-positive incident cases of TB and 23% of the approximate 2 million HIV deaths in year 2007.

6.Overall mortality and prevalence rates have a global falling trend in all 6 regions of world health organisation. The American region and the region of east Mediterranean are close to their targeted points in stop TB partnership program ,to achieve a 50 % reduction in the prevalence and death rates from TB by year 2015 , If we compare with the base line of 1990. The Western Pacific Region is also moving rapidly to its target of achieving half reduction by 2015, with exceptions of mortality target may be narrowly missed. African and European regions are not going to meet either mortality targets or the targets set for prevalence in these regions .. the huge difference in prevalence rates in year 2007 and the mortality and prevalence targets achieved in theses two regions do warn us towards the bleak probability of achieving the targets in year 2015 .

7. the approximately estimated numbers of HIV positive cases of tuberculosis and deaths in 2007 are almost double to that published by WHO in the past years. This necessarily does not mean, that the number of HIV positive ,TB cases and also the number of TB deaths among HIV positive population has been doubled from 2006 to 2007 .probable cause of that is the new data used that became available from provider initiated testing of HIV in year 2008, in African region , were used to (a) measure the prevalence and mortality in 2007 (b) to revise the previous estimates of mortality and prevalence rates in past years.it was estimated that the number of HIV positive cases (prevalence )and deaths had a peak in 2005 and the number reached to 1.39 million cases approximately 15 % of all incident cases with a death number of 480 thousand .

8 . As expected routine the new estimates made of number of HIV positive cases of TB and the mortality among were largely based on the prevalence of HIV in the normal population which is published by Joint United Nations Programme on HIV/AIDS, or UNAIDS . The latest data available since 2008 ,showed the direct measurement of proportion of TB infected HIV positive cases among the 64 countries (previously it was 15 countries in 2007 ). IT is appreciated from these 64 direct measurements that the prevalence among HIV positive cases of TB is approximately 20 times more likely as compared to normal population , Especially in countries facing generalised HIV epidemic .(previously it was estimated to be six) These 64 direct measurements suggest that HIV-positive people are about 20 times more likely than HIV-negative people to develop TB in countries with a generalized HIV epidemic (compared with a previous estimate of six), and about 26 and 37 times more likely to develop TB in those countries where HIV prevalence is lower (compared with a previous estimate of 30). These higher estimates were used to estimate the number of HIV-positive TB cases in countries for which direct measurements were not available.

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9 . In year 2007 there were an estimated 0.5 million cases of multidrug-resistant TB (MDR-TB) . Among 27 countries (of which 15 are in the European Region) that account for 85% of all such cases. The top five countries in that first to fifth in terms of total numbers of MDR-TB cases are India (131 000), China (112 000), the Russian Federation (43 000), South Africa (16 000) and Bangladesh (15 000). At least one case of TB (XDR-TB). Was reported in 2008, by 55 countries and territories( extensively drug-resistant) .

10 . There are recommendations produced by The WHO Global Task Force on TB Impact Measurement , about how to measure progress in reducing rates of TB incidence, prevalence and mortality (the three major indicators of impact). These include but is not limited to systematic analysis of national and subnational notification data which is combined with modified and improved surveillance systems to measure the incidence, surveys of TB prevalence in 21 global targeted countries between year 2008 and 2015, and strengthening of vital registration systems measure and analyse TB mortality from other causes of death. It is necessary to Implement the recommendations of Task Force to improve measurement of progress in direction of the global targets set for 2015 along with measuring progress in TB control in subsequent years.

TB death rate has fallen from 35% 1990.

Of the 22 TB high burden countries, 13 countries are on track to meet the 2015 Millennium Development Goal target (halt and reverse the incidence of TB by 2015

Estimated TB incidence, prevalence , 2008

Prevalence in india

Widely different results have been observed by Annual Risk of TB Infection (ARTI) studies undertaken in certain countries . During 2000-2003 four zones in india were selected to study and they showed ARTI rates ranging from 1.0 % in the southern zone to 1.9% in the northern zones . ARTI surveys are being repeated in these zones to verify the results but the results are not yet available. A study in west Sumatra Indonesia In Indonesia in 2206 , revealed an incidence rate of 1.3 % While a limited ARTI survey done in 2008 in DPR Korea indicates that the incidence rates for Korea estimated by WHO may need to be revised upwards and might be double the number suggested initially . Nepal was also involved in an ARTI survey for three ecological zones and in Kathmandu valley from 2006-2007, revealed a ratio of 0.86%, substantially lower compared to previous rate of 2.1%.Bhutan and Sri Lanka in 2009.are expected to undergo similar surveys .

TB disease incidence, prevalence and mortality

Where these surveys do indeed contribute to more accurate estimates of the burden of disease on different countries, still uncertainties exist regarding the current estimates for TB disease incidence rates , prevalence and mortality rates among individual countries of the Region. The routine notification data use for as a measure of disease incidence ,is certainly the right way to the future. However we do require to strengthen all aspects of TB surveillance system, focusing primarily on quality of data entry, detail compilation and timely reporting, and giving attention to precise accurate analysis and interpretation of the data.WHO Regional Office for South-East Asia (SEARO)has decided to organize a series of trainings focusing the areas like managing information for action (MIFA) in four of selected Member countries during 2007-2008. Meanwhile ,there is definitely a need to continue and support well-designed population-based surveys through out the Region, particularly in the higher TB burden countries, till such time that the routine case notifications might begin and be used to correctly reflect actual TB prevalence trends.

4: TB in India

TB is one of the most ancient and most important diseases. The Vedas and Ayurvedic Samhitas have clear mentions of the disease. The exact identification of the first reported case In India might not be possible yet we can find out the details of the first open air sanatorium for treatment and isolation of TB patients which was founded in 1906 in Tiluania, near Ajmer,and that followed by one in Almora two years later. The first non-missionary sanatorium was built near Shimla in year 1909 . Upon the earlier work done by Dr Louis Hart from 1908, the United Mission Tuberculosis Sanatorium (UMTS) which was built in 1912 in Madanapalle, south India. Dr Frimodt Moller who was the first Medical Superintendent did play a significant role in India’s fight against TB . He did training of TB workers, and started the TB surveys (1939)along with introduction of BCG vaccination (1948).In 1917 the first TB dispensary was opened in Bombay which was the first real achievement against the fight with this disease. Later on madras also started a TB dispensary . Soon anti-TB societies were formed in Lucknow and Ajmer.

It was advised by dr langkaster that government should take active role in fighting this emerging and high incidence disease in india. India became a member of the International Union Against Tuberculosis (IUAT) in 1929 largly due to his suggestions. In year 1937, Her Excellency Lady Linlithgow had issued a public appeal for anti-TB funds collection on behalf of the government. Nearly a crore (10 million )of rupees was collected; from the original collection 5% of the money was kept by the center and the balance was distributed to the provinces and states. TBI (Tb association of india was formed with this retained fund along with With the help King George V Thanksgiving (Anti-TB) Fund, in February 1939. The provinces and states who received money also started their TB independent associations. The BTA Bengal TB Association, however, was functioning from 1929 and it hadits maintained dispensaries in Calcutta and Howrah. Its activitis benefited greatly this funding. In 1946 only 6000 beds were available for the treatment of TB patients. According to the estimates given by The Bhore Committee there were about two and a half million patients who need treatment and annual deaths are about half a million . India was a huge country , which included Pakistan and Bangladesh in those days, the efforts of NGOs that were not centrally monitored or funded were not adequate. There was no option but The government to intervene. However, diagnosis was a serious unresolved issue, while treatment, remained inadequate. It was by 1925,when chest radiology started detecting a deep-seated area of TB affected consolidation and thoracic surgeons started to demand X-rays. By 1945, the functions of the apparatus were enhanced and new technological advances helped the medical professionals to take help of and embody the MMR version.

Untill middle of the 20th century there were no really effective drugs or the combinations of any drugs that could controle the disease .Good food, open air and dry climate remained the main stay of medical treatment and the physician was handicapped in having any real intervention for the disease. Understandably treatment used to be the second priority where diagnosis was the main interest for the physicians at that time . In 1939, the TAI recommended the Organized Home Treatment Scheme as the best compromise under the prevailing circumstances.

Second world war started in that time and logically Fighting diseases was accepted as back seat passenger. However, a new TB Division situated in the Directorate General of Health Services (DGHS), was established in New Delhi in 1946,while an advisor was selected As TB head in it. TB started receiving a a prominent place in the planning. Since the government was not only concerned with TB but with other significant diseases and improving health infrastructure, there was constituted a committee under the chairmanship of Sir Joseph Bhore. Its secretary was Rao Bahadur KCKE Raja, who as the Director General of Health Services (DGHS)had done a lot of efforts against the TB disease during his tenure . The Bhore Committee, had published the report in 1946, and they placed organized domiciliary service on the forefront ofant TB programme. setting up of a seperate clinic for each district along with the use of mobile clinics for rural areas were the main suggestions of the committee.

BCG vaccine, was named after the two scientists who worked on mycobacteria and developed the vaccine , stands for Bacillus Calmette Guerín. BCG work was initiated in India as a pilot project and was supposed to be the two centers in 1948. In 1949, the project was extended to schools in almost every state of India. Under the supervision of the International Tuberculosis Campaign, which had collected a significant amount of experience working on BCG in many countries, Madanapalle was selected for the pilot project and it was a small project with Dr Frimodt Moller in the lead. India started working on a mass BCG preparation Campaign in 1951. A large BCG Vaccine Production Center in the city of Guindy, Madras had been set up in 1948. WHO and UNICEF supported the two projects with man power and funding.

The researcher were intrigued by the whole new idea about the possibility of finding an effective new drug against the tuberculosis created a revolution in the field and a new wave of experimental work was initiated with researchers trying a range of experiments and combinations of drugs their dosages against the TB. Affordability was an issue that needed to be studied and tackled in this war against TB .At annual TB workers conference held in 1949 ,number of research papers were presented suggesting the effects of PAS and SM on the tuberculosis disease and distribution of SM in indian cities .1952 Drs Robitzek and Selikoff revealed that INH is a miracle drug against TB and it continues as such till date.

The management of this disease in India and globally will be revolutionized in time ,owing to these studies .The scientists soon learned that the bacillus itself was a tough one and even the most effective drugs and their combinations were failing to eradicate the presence of bacteria completely .This bacillus was expert in fighting the drugs by creating resistance to drugs over and above its innate survival abilities. The short lived effect of these treatments soon helped the workers to realize that in order to fight this infection single drugs are not sufficient and that extensive long treatment might be the required solution ranging upto 9-12 months and at times 18 months .this opened the doors to new problems among which patients compliance was the top one .There were a few patients who could afford and had the temperament to continue the treatment for this long period.. further research and studies were needed to look into these issues of the ways to keep track ,and compliance .there was a need to do further research in this field.

TRC was the tuberculosis research Centre situated in madras chenai . which was established by the government in 1956 and it was related to the chemotherapy in tuberculosis initially .it was supported by government of madras WHO and ICMR along with British medical research council BMRC . The Centre was created to focus on the provision of information at mass level to the public affected by the tuberculosis . It focused pulmonary tuberculosis and found out the traditional sanatorium treatment recommended for the treatment of the disease ,bed rest ,well balanced diet and good accommodation were all relatively less important factors ,provided the adequate medical treatment was initiated and maintained .it was also suggested that the family members of the TB patients do not necessarily have higher risk of getting infected and that the treatment could be conducted in their own homes instead of sanatoriums r. These findings revolutionized the global treatment centers .