Health and Development Initiative-India, (www.healthinitiative.org), publishes TB News from India' once every two months. The objective of newsletter is to highlight issues related to Tuberculosis and HIV/AIDS control in India and enlist political, public, professional and administrative support for its cause. Health and Development Initiative-India is a not-for-profit organization and the news items have been quoted from various sources for fair use and in public interest. Reproduction of the material published is welcome provided a reference is made to the original source of the news item and TB News from India.

Editorial note:  

Message from Bangkok: Fight AIDS, Fight TB, Fight now

The message from XV International AIDS Conference (IAC) held at Bangkok in July this year is loud and clear, " HIV/AIDS cannot be tackled in isolation from other diseases like tuberculosis (TB). Nelson Mandela, the octogenarian leader from AIDS ravaged South Africa set the ball rolling the moment he arrived at the majestic Impact Convention Centre, venue of XV IAC. He declared, "The world has made of AIDS its top priority. This is a blessing, but TB remains ignored. Today, we are calling on the world to recognise that we cannot fight AIDS unless we do much more to fight TB as well."

TB is the leading killer of people infected with HIV. Up to 50% of people with HIV or AIDS develop TB. Worldwide 14 million people are co-infected with TB and HIV. TB control can contribute to better HIV/AIDS control both by reducing the TB burden in people with HIV and by providing an entry point to HIV prevention and care for people with TB.

The 3 by 5 initiative has set up an ambitious target to get 3 million people in developing and middle-income countries on antiretroviral (ARV) treatment by 2005. However without good TB control many of those alive with HIV today may not live to see the day by the time ARV programmes become available.
 

Deadlier In Combination

Editorial in The Hindu, 4th July 2004

India has far more tuberculosis (TB) cases than any other country, which is bad enough. Nearly two million people in India develop the disease every year and one person dies of it every minute, making tuberculosis the leading killer among infectious diseases in this country. In addition, India is second only to South Africa in the number of people infected with the Human Immunodeficiency Virus( HIV) that causes the Acquired Immune Deficiency Syndrome (AIDS). It is estimated that there are already about four million HIV-infected people in India.

The combination of TB and HIV makes for a lethal mix. Most people who get infected with Mycobacterium tuberculosis (which causes TB) do not develop the disease, as their immune system is able to keep the bacterium in check. But once an HIV infection cripples the immune system, it paves the way for a dormant TB infection to become active. HIV infected people are also less able to withstand new TB infections. While a person with only TB infection has just a 10 per cent lifetime risk of developing active tuberculosis, the risk is six times higher for those infected with both TB and HIV. There is also evidence that tuberculosis accelerates the progression of an HIV infection into full-blown AIDS. Not only is tuberculosis the most common opportunistic infection among HIV positive people in India, but it also substantially increases the chances of death due to HIV.

The advent of HIV has also made diagnosis of tuberculosis more difficult, observes the Government's National AIDS Control Organisation (NACO) in its "Guidelines for Management of TB in HIV Infected." If TB occurs in the early stages of HIV infection when immunity is only partially compromised, it usually manifests as typical tuberculosis that affects the lung. But as the HIV infection advances, patients can develop other lung infections that resemble tuberculosis or forms of tuberculosis that affect other parts of the body (extrapulmonary TB). "The definitive diagnosis of extra-pulmonary TB is often difficult because of the paucity of diagnostic facilities, and at times difficulty in accessing the affected tissue for intervention," say the NACO guidelines.

With over half of India's adult population infected with Mycobacterium tuberculosis, there have been warnings that the spread of HIV could lead to "a potentially explosive increase" in tuberculosis. A study published recently by scientists at the Tuberculosis Research Centre in Chennai suggested that HIV infection is on the rise among TB patients in Tamil Nadu (a south Indian state). Scientists at the All India Institute of Medical Sciences in Delhi have also drawn attention to the increasing prevalence of HIV among TB patients at their hospital.

Meanwhile, health professionals worry that the country's separate TB and HIV control programmes are running in isolation. Only if the two control programmes work together for the early diagnosis and treatment of tuberculosis, and secure the cooperation of private health care providers for these efforts, is there a realistic chance of stemming the pestilence.


Read the full text of editorial at:
http://www.thehindu.com/2004/04/07/stories/2004040703241000.htm

Kolkata Municipal Corporation plays Catch-22 with TB patients

Ravik Bhattacharya, The Statesman, August 18 2004

Their fate rendered them homeless and for that precise reason, Kolkata Munucipal Corporation (KMC) is depriving them of treatment. Hundreds of TB patients have been denied free medication in KMC-run DOT centres because they do not have a permanent residence.

Rathin Halder (50) stays in a slum by the side of the Circular railway tracks in Baghbazar. A tuberculosis patient, Haldar has been refused treatment in a DOT center because he failed to produce residential proof, needed for registration. And he's just one of the hundreds who have been turned away. There are 95 TB centres run by the KMC across the city. These have been set up to provide TB medicines under the DOT programme.

First the patient is diagnosed at the Mayor's chest clinic. Once the disease is detected, free medicines are given to patients. "I thought the centres were meant for our treatment. When I went there I was first asked for residential proof. I live in a slum and could not produce one, because of which the staff refused to register me. I could not pay for my medicines nor do I have money to buy food. I am growing weak and will not be able to earn any more," said Halder, a rickshaw puller.

Doctors plead helplessness. "We get critical TB patients, but cannot treat them because they lack residential proof. We are bound by the laws and cannot give medicines for free," said a doctor in a Baghbazar centre. "I used to stay near the canal. After being evicted, I built a shanty across Canal East Road. I know I have TB but cannot buy medicines. I went to the DOT centre but was not given medicines because I don't have a permanent residence. Since I also do not have a voter ID card and live in a slum, the councillor did not give me a residential certificate. If I had money to buy a house why should I go looking for free medicines?" Sabitri Ram, a domestic help, wanted to know.

Read the full story at:
http://www.thestatesman.net/page.arcview.php?clid=22&id=79919&usrsess=1

Abandoned girl diagnosed with TB

Tribune News Service, July 13 2004

Eight-year-old Pooja, who was abandoned by her brother, is suffering from tuberculosis (TB). Her condition is stated to be serious. The girl was admitted to General Hospital Chandigarh, yesterday by a social worker, who found her crying at Raghunath temple in Sector 15 on the night of July 11. The malnourished girl had been abandoned by her brother, her only surviving relation after their parents died a few years ago. The doctors attending to the child say that her X-ray results have confirmed that she is suffering from tuberculosis.

Dr Rahul Kakkar, who is handling the child's treatment, says that the child is malnourished and has oedema in her feet. "As of now we cannot say if she will pull through. Though we have started treatment, she will begin to respond to the treatment only after 15 days," he says. Dr Kakkar says that the girl is still in a delirious state and is not responding to anybody.

Meanwhile, attendants of patients in the Emergency Ward at the hospital have taken upon themselves the opportunity of attending on her.

Read the full story at:
http://www.tribuneindia.com/2004/20040714/cth1.htm#9

Drive to treat tribal TB cases

The Statesman, June 21 2004

The North Dinajpur district (in West Bengal) administration today conducted a door-to-door survey in Lichutola and Pirdangi villages under Raignaj police station, to identify the tuberculosis patients who have allegedly been facing neglect for years and to arrange for their proper treatment.

Raiganj SDO Mr KN Dew and BDO Mr.S Dukpa, along with a medical team, visited the villages and asked the people affected by tuberculosis to visit the government hospital. The survey revealed that around 25 people from the tribal communities have been suffering from this disease for years mainly due to lack of proper food. But, neither the district health authorities nor the Harsamaj - an organization set up with an objective to help the tribal communities - have come forward to help them with medical facilities.

Read the full story at:
http://www.thestatesman.net/page.arcview.php?clid=10&id=74637&usrsess=1

Steps To Ensure Medicine Supply To Hospital Treating MDR-TB Patients

The Hindu, 25th June 2004

The health authorities have made arrangements for purchasing increased quantities of second-line tuberculosis drugs at the Government TB hospital in Pulayanarkotta in Kerala State of India, so that more patients suffering from multidrug-resistant TB (MDR TB) in the waiting list can be roped in for immediate treatment.

Inconsistencies in fund flow and procedural delay had hit the free supply of second-line tuberculosis drugs in the TB hospital. A team of district health administration officials, including the District Medical Officer and the head of the Department of Respiratory Medicine at the Medical College hospital had visited Pulayanarkotta following reports about the non-availability of drugs at the hospital.

Though 40 patients suffering from MDR TB, a highly infective strain of the disease, have been registered as inpatients here, the hospital could supply drugs for only 16 persons, while the rest have been included in the waiting list. About 13 more patients in the waiting list would also receive the drugs for MDR TB by the end of the week, while arrangements were being made for procuring more funds, hospital sources said.

"We have 40 registered MDR TB patients in the hospital and the treatment expense for two years for each patient comes to Rs. 2 lakhs (US $ 4400 approximately). As the drugs are very expensive, we can procure these only through tenders or through the Central Purchase Committee. The treatment has to be consistent and we cannot put anyone on the drug regimen unless we are sure that we can find the funds," a doctor pointed out.

They said that the hospital administration and patient care at Pulayanarkotta had been hampered by a perennial shortage of nursing and other paramedical staff. According to sources, the district health administration has been hard up to find people willing to work here because of the infectious nature of the disease

Read the full story at:
http://www.thehindu.com/2004/06/25/stories/2004062514420300.htm

Government's TB Project Fosters Drug-Resistant Variety

Abantika Ghosh, Times News Network, July 26, 2004

Delhi government's tuberculosis treatment poster project, DOTS is plagued by a high dropout rate. With the result that even by official estimates, about 4,000 new patients of the drug resistant variety of the disease are added every year to the existing pool in Delhi. The total number of new cases of TB annually, is about 31,500. DOTS was started in 1997, interestingly to stem the same problem of multi-drug resistant (MDR) TB.

According to figures available with the Delhi government, till June 2004, 1,77,859 TB patients have been treated under DOTS. Dr R P Vashist, in-charge of the programme, says, "The cure rate is about 83%, in 4.5% of the cases the drug is found to be ineffective. About 9-10% of the patients do not complete the course." Which means the last 15% of the patients annually swell the ranks of MDR TB patients.

Read the full story at:
http://timesofindia.indiatimes.com/articleshow/789987.cms

Indian scientists develop new TB vaccine

Indian scientists have developed a new tuberculosis vaccine and found it to be safe and effective for low immunity cases too in the animal-trial stage. The candidate vaccine, a possible weapon against tuberculosis, which has resurfaced as a killer especially in combination with AIDS, has been developed by the scientists at the Central Drug Research Institute (CDRI), Lucknow. The vaccine is a live form of a different strain of Mycobacterium, the bacteria that cause tuberculosis, a Council of Scientific and Industrial Research report said. The vaccine was found to be effective in protecting against TB infection -- 70 percent of vaccinated mice when infected with tuberculosis survived while unvaccinated mice died within 25 days of infection, the report said. The vaccine was also evaluated in mice that were made to be immuno-compromised as happens in AIDS. Growth of infection was restricted in vaccinated mice, it said.

The report said that BCG is currently the only anti-TB vaccine. Though it has provided protection against TB, the variation in its efficacy warrants development of an improved vaccine.

Read the full story at:
http://www.rediff.com/news/2004/aug/24tb.htm

Indian Corporates Turn HIV Friendly

HIV POLICY: L&T, HSBC and 750 other Mumbai business houses say yes

Prachi Jatania, Indian Express, August 21, 2004

HIV stopped being an alien word in the Mumbai corporate world this week. With about 1,500 corporate houses on its rolls, the Bombay Chamber of Commerce and Industry has prepared a non-discriminatory HIV policy for companies. Half of these corporate houses have already adopted the guidelines. Industrial giants such as the Birla group, the Tatas, Hindustan Lever Ltd and banking groups have shown keen interest. ''It's a wish list, but at least there are guidelines we can adopt to battle ignorance, '' says Malini Thadani, HSBC senior president, corporate affairs. For corporate houses investing in staff welfare, increasing susceptibility of its work force to the deadly virus is reason enough to translate such a policy-on paper into action. The policy aims to protect all employees against discrimination. While companies such as Siemens India, Tata Steel, the Wockhardt group and GlaxoSmithKline have awareness programmes in place, there is no specific non-discriminatory policy for employees alone.

Read the full story at:
http://www.indianexpress.com/full_story.php?content_id=53521

Audit Report Criticises India's Slow Progress On AIDS

An Indian government audit has said that the National AIDS Control Programme has achieved only limited success because of slow implementation, unachieved targets, and ineffective public education. In a report presented to the Indian parliament last week, India's comptroller and auditor general said that various activities under the programme could not be conducted efficiently for lack of infrastructure, drugs, equipment, and human resources. The report, which examined the programme's activities between 1999 and 2003, has listed among the deficiencies misconceptions about HIV transmission, a shortfall in the training of doctors, nurses, and technicians, and the failure of marketing of condoms. It said targeted intervention, viewed as the most effective strategy to stop the spread of HIV in high-risk populations, "had not been conducted effectively."

The latest sentinel survey indicates that India now has 5.1 million people infected with HIV. Earlier this month the National AIDS Control Organisation, which manages the programme, had said there was a "visible decline" in the number of new HIV infections in India: 520,000 in 2003, compared with 610 000 in 2002. "The prevention efforts have definitely made an impact," said Meenakshi Datta Ghosh, director of the organisation. However, the audit report has said that poor awareness of methods to prevent HIV infection is alarming, particularly among commercial sex workers and their clients. Citing an independent survey, it said that just half of the general population and two thirds of female sex workers were aware of how to prevent HIV infection and only a fifth of the general population knew that HIV could not be transmitted through mosquito bites and shared meals.

Although the programme aimed at achieving condom use by at least 90% of commercial sex workers, the report points out that condom use in this group is 57%. Health ministry officials concede that aggressive promotion of condoms is needed. A high-ranking official said that a directive from the previous government to ban condom promotion through television "might have sent the wrong message." But with the change in government earlier this year-and a new health minister in place condoms will be back on television, the official said.

Read the full story at:
http://bmj.bmjjournals.com/cgi/content/full/329/7460/252-b

News from India's neighbours

Tuberculosis: 'DOTS' Strategy Saves Half A Million Infections In China

Cases of tuberculosis have fallen by a third in areas of China where doctors have implemented the DOTS strategy to combat this disease, according to a study published on Saturday. The study, which appeared in British medical weekly The Lancet, assessed the performance of a DOTS programme backed by the World Bank that was launched in 1991 in 13 out of the 31 Chinese provinces, accounting for 560 million people. In 2000, prevalence of TB in these 13 provinces was 32 percent lower than in 15 other provinces, which did not follow the DOTS strategy. Around 660,000 cases of TB were prevented in 2000 thanks to the programme, the study estimated.

China has 1.4 million new cases of TB every year, "more than any country except India," the authors, a group of epidemiologists called the China Tuberculosis Control Collaboration, say. The country is particularly vulnerable to the spread of TB because of its huge population of migrant workers, who often live and work in poor, crowded conditions.

On July 23, China's state media announced the country would dramatically increase funding for the fight against TB, and the DOTS programme would be the chief beneficiary. "Hundreds of millions of Yuan" (tens of millions of dollars) will be spent, compared with just 40 million Yuan (4.8 million dollars) annually as at present, according to the English-language China Daily. The annual death toll from TB in China ranges from 130,000, as reported in the China Daily, to 150,000, as estimated by the World Bank. - AFP

Read the full story at:
http://www.channelnewsasia.com/stories/afp_world/view/98335/1/.html

TBNI Editorial Team

Dr. Dinesh Kumar,
dinesh_kumar@vsnl.com 

Dr. Jatinder Singh,
jatindersingh@vsnl.com