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  Controlling TB - establishing rationality: 
    

The emerging tuberculosis epidemic is a critical challenge to national health services in India. Half a million people lose their lives due to tuberculosis and its complications every year. Each year two million fresh cases of TB are detected and every single minute, one precious life is lost due to tuberculosis in the country.

Significant ground has been covered in the country in the field of tuberculosis control ever since the Revised National Tuberculosis Control Programme (RNTCP) was launched in the country in 1998. Every month 25,000 new patients are being included under the RNTCP and 3500 lives are being rescued from the clutches of Tuberculosis.

The World Health Organisation (WHO) has devised a five-pronged strategy for tuberculosis control. This strategy is being implemented as Directly Observed Treatment Short course (DOTS) chemotherapy. These core principles for Tuberculosis control are:

	Early detection of all suspected cases.
	A speedy and correct diagnosis.
	Effective treatment with quality drugs.
	Elimination of treatment dropouts.
	Constant supervision.

Early detection of a suspected case is key to tuberculosis control. There are five cardinal symptoms, which raise the suspicion that a person might be suffering from tuberculosis: a cough with expectoration of more than fifteen days duration, fever with an evening rise, pain in the chest, blood admixed sputum, loss of appetite and weight. Most people have a false notion that tuberculosis is a disease of the under privileged and elderly. Tuberculosis on the contrary recognizes no socio-economic or age barriers. Persons with diabetes, end stage Kidney disorders, injectable drug users, those who are immunologically challenged (such as HIV positive, those on chemotherapy or malnourished) or under going periods of stress (convalescing after an illness, pregnancy, adolescents) are more likely to fall prey to tuberculosis. In many instances, physicians tend to ignore the symptoms and keep on treating patients for other ailments thus leading to a delay in accurate diagnosis and initiation of treatment.

The patient on his part can help the treating physician by explaining to him the symptoms truthfully and in detail. There are two key tools in the armamentarium of your physician for confirming the diagnosis of tuberculosis, Sputum examination for detecting bacteria (tuberculosis is caused by a bacteria called Mycobacterium tuberculosis) and an X-Ray of the Chest. Sputum examination is a cost effective and reliable test, which guides the physician in choosing the right treatment regimen and monitoring treatment. An undue over reliance by physicians on repeated X-Ray examination adds to the cost of treatment and needs to be used prudently.

It is essential to understand that no single drug can cure tuberculosis and multiple drugs need to be combined. The commonly used anti-tubercular drugs are Rifampicin, Isoniazid, Ethambutol, Pyrazinamide and Thiacetazone. The access of most patients to quality anti-tubercular drugs in India is restricted. A number of ‘combination-packs’ of anti-TB drugs are now available which ensure better compliance. In order to enable anti-TB drugs to be effective, these need to be taken in appropriate doses and regularly. WHO has worked out clear-cut drug intake regimens and these need to be strictly followed. The duration of treatment with these regimens depends upon the severity of illness and previous treatment history and ranges from six to nine months. Neither a physician nor patients should try to invent their own regimens.

Whenever the drugs are taken after a correct diagnosis and in appropriate dosage form the patient experiences a remarkable improvement in symptoms within a month. At this stage a sense of complacency tends to creep in and the patient is tempted to discontinue treatment. This is a crucial juncture, as any disruption of treatment at this stage will not only result in treatment failure but also development of drug resistance. If during the treatment patient develops rashes, jaundice (dark colored urine and yellow coloring of eyes) or any other adverse reaction, the treating physician should be contacted immediately in order to replace or temporarily discontinue the offending drug. This will help in avoiding any interruption of the treatment. The treating physician would also want to get patient’s sputum examined at fixed intervals (depending upon the regimen); which will help in monitoring the progress of cure and addition, withdrawal or dose adjustment of a drug. A patient therefore needs to visit the physician consistently for follow-ups. Sputum examination is also a determinant of the fact that a person has been cured and it is safe to terminate treatment.

Multi drug resistant tuberculosis is a new problem, which has cropped up in our country. This emerges from non-adherence to standardised regimens, inadequate dosage forms, interruption of treatment due to non-availability of drugs or patients stopping or altering treatment on their own. MDR-TB is difficult to treat with the cost of treatment being five times higher. Patients also need to discuss with their physicians the prescribed drug regimen and whether it is one of the approved courses of therapy.

District Tuberculosis Centers (DTC) have been set up in all the districts of country. These centers that, are manned by skilled personnel provide facilities of clinical laboratory, radiography and drug distribution, act as a nodal point for treating patients. Patients need to be encouraged to visit these centers instead seeking treatment from unqualified persons.

We can contribute to tuberculosis control by observing the following:

	If a person in your family, office or community has cough with expectoration and fever for more than fifteen days (or other symptoms as explained above), take him to DTC or a qualified physician.
	Help the physician in reaching a correct diagnosis by giving a truthful and detailed history.
	Ensure that treatment regimen advised by your physician is WHO approved.
	Sourcing dependable brands from a reliable chemist can ensure the quality of anti-tubercular drugs.
	Patients should continue to take treatment without interruption and never stop treatment on their own. In case of any adverse drug reaction the physician should be informed immediately.
	Patients should get their sputum examined at regular intervals, as advised by the physician.
	If you know a person who is receiving anti-TB drugs and cannot afford them, help him in contacting DTC or a NGO. A support group can be formed in your community to help get these drugs.  email : dinesh_kumar@vsnl.com