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:  

Global TB Control, WHO Report 2003

Global Tuberculosis Control Report 2003 issued by World Health Organisation on World TB day ranks India as number one in the world by estimated number of tuberculosis cases. TB remains the leading infectious cause of death in India, killing close to 500 000 people each year. India also has about 2 million new cases of TB each year, far more than any other country, and accounts for nearly one-third of the global burden of TB. As DOTS population coverage increased from 30% in 2000 to 45% at the end of 2001, the number of smear positive cases notified under DOTS has nearly doubled. However, the number of smear-positive cases notified nationally (DOTS and non-DOTS together) changed little. This suggests that if India is to reach the target of 70% of cases detected under DOTS, the RNTCP must, in addition to extending geographic coverage, continue to increase the proportion of cases being detected by DOTS programme within designated DOTS districts. The report identifies the following constraints to achieving targets:

• Uncertain funding from 2005 onwards.

• Challenge to maintain quality of TB services with rapid expansion to remaining 450 million population.

• Lack of TB awareness in some parts of the community.

• Decentralization without adequate local management, supervision, and monitoring
  

It also suggests a few remedial actions, which include continued efforts to obtain funding from the GFATM and other sources, increased supervision of implementation areas and strengthening of public-private partnerships to standardize and facilitate the delivery of TB services.

The report expresses concern over the situation after the expiry of the current loan agreement of Government of India with the World Bank at the end of the next fiscal year (2004). A potential funding gap of around US$ 27 million will then need to be filled. Both the political leadership of the country and managers of RNTCP will have to ensure that quality of service delivery is steadily improved along with sustained geographical expansion so that the international donors feel confident while making commitments. The Governments both at Central and State levels have to remain prepared to fill any funding gaps, from their own resources. At no cost can the nation afford to slow down the march of tuberculosis control.

You can read the full report on tuberculosis control in India at:
http://www.who.int/gtb/publications/globrep/pdf/country_profiles/ind.pdf 

TB Report Card is full of Red Grades

An Express News Service story datelined Pune, March 25 says that the TB report card is out and the Indian States of Andhra Pradesh, Assam, Bihar, Haryana, Jharkhand, Karnataka, Madhya Pradesh, Orissa, Punjab and Uttar Pradesh have clearly failed the test. Comprising 56 per cent of the population, these states have made no progress in the past year to extend the Directly Observed Treatment Short Course — DOTS — for curing Tuberculosis. 

Currently, less than three out of 10 people infected with TB are being cured using high quality DOTS treatment services. In 2000, the Government of India had pledged that seven out of 10 infected people would be treated by these services with at least six of them being cured by the year 2005. 

As part of the campaign launched by www.MassiveEffort.org , a ‘‘tuberculosis control report card’’ of the states of India has been prepared.

While Delhi, HP, Manipur and Rajasthan have cured more than 60 per cent cases using DOTS, Arunachal Pradesh, Chandigarh, Chattisgarh and Sikkim have just started providing treatment based on DOTS.

Gujarat, Kerala, Maharashtra, Tamil Nadu and West Bengal have cured between 30 and 60 per cent infectious cases using DOTS. 

People do not have access to DOTS services in Andaman and Nicobar Island, Dadra and Nagar Haveli, Daman and Diu, Goa, Jammu & Kashmir, Lakshwadeep, Meghalaya, Mizoram, Nagaland, Pondicherry, Tripura and Uttaranchal. 

Read the full story at: 
http://www.indianexpress.com/full_story.php?content_id=20859

Also visit DOTS Watch section of our website at: http://www.healthinitiative.org/html/dotswatch/index.htm 

Deadly strain of Tuberculosis stalks Faridabad (Haryana)

A Tribune News Service story datelined Faridabad, March 22 filed by Bijendra Ahlawat says that the health authorities seem to have turned a blind eye to a fatal form of the disease, which claims about 400, 000, lives every year in India. Studies conducted recently at the reputed laboratories in private sector revealed that there had been a high incidence of Multi-Drug Resistance (MDR) of Mycobacterium Tuberculosis in the patients at least in Faridabad and neighboring areas.

Physicians and private practitioners in the field do admit that lack of awareness especially among the patients and their relatives and improper implementation of programmes to check the disease had been mainly responsible for the ‘MDR-TB’.

According to Dr Raman Kakkar, a well-known TB specialist based in Sector-16 here, if a patient discontinues the treatment, TB turns into a dangerous form of disease called ‘MDR-TB’, which means that the drugs stop working on the patient.

He said that such an incidence had assumed serious proportions. Dr Vinod Kaul of the microbiology lab and research centre (VSML) supports this view. He told the ‘NCR Tribune’ that the number of cases of test reports of MDR-TB referred to his lab had been high. The VSML is a microbiology reference laboratory having its branches in Faridabad and Delhi.

He said of the total 810 patients with suspected TB referred to the centre, more than 265 had been confirmed for TB infection by culture test, which revealed the presence of ‘Mycobacterium Tuberculosis’.

He said the sensitivity test was performed which found higher resistance to Rifampicin and Ethionainide in about 64 per cent patients of ‘MDR-Mycobacterium TB’.

He added that 18 per cent patients had developed resistance to three drugs: Isoniazid, Rifampicin and Streptomycin. According to Dr Kaul, the high incidence of MDR-TB bacteria isolated from the region had been mainly due to the intake of inappropriate combination of anti-tubercular drugs, inadequate dosage of the drugs and their intake for insufficient duration.

Dr Kaul said it appeared that the region was heading for TB epidemic unless the government agencies or NGOs come forward and implement the ‘DOTS’ (directly observed treatment short course) programme more rigidly.

According to Dr Raman Kakar, the majority of persons affected with TB were poor people who had no idea about the fallout of the discontinuation of drugs midway. 

Read the full story at: 
http://www.tribuneindia.com/2003/20030323/ncr1.htm

Slum dwellers of UT defaulting on DOTS

A Times News Network story datelined Mohali (Chandigarh), Sunday, April 27, 2003 filed by Sandeep Joshi cautions that Chandigarh's slum population has become a problem for the Directly Observed Treatment Short (DOTS) Course programme for the eradication of tuberculosis being run by the Mohali Civil Hospital under the Revised National Tuberculosis Control Programme (RNTCP).

Doctors engaged in RNTCP at Mohali which is one of the microscopic centres for detection and treatment under DOTS, say that the migrant patients who come from the slum colonies of Palsora and Maloya in the UT, often leave without completing the course thus jeopardizing the whole effort.

"Although the number of patients who give up the treatment is not large, but the risk an infected person, who has tested positive for tuberculosis, poses to that person he comes in touch with is large. The main problem with the defaulters is that they either return to their villages or move to another site where labour is in demand," said Dr Balwinder Singh, Medical Officer TB control, Ropar who oversees the implementation of DOTS in six microscopic centres in the district.

The Mohali Hospital, which also gets a large number of such cases from the neighboring colonies in Chandigarh, has now decided that the persons testing positive, who are migrants from Chandigarh, will not be put on DOTS and would be given a non-DOTS treatment which is of longer duration than DOTS.

According to medical estimates, there are 12 to 15 persons infected with TB per 100,000 population. Presently there are 150 persons undergoing treatment at various TB units in the Ropar district. 

Doctors said that if a person gives up the treatment in between there are chances he might develop multi-drug resistant TB. In other words, he is not only endangering his life, but also that of other's.
Read the full story at: http://timesofindia.indiatimes.com/cms.dll/html/uncomp/articleshow?msid=44694539 

A fighting chance against TB 

An editorial in Hindustan Times dated April 17, 2003 notes that at a time when SARS is so much in the news, it is salutary to remember that TB, too, is a dangerous infectious disease, killing more young people and adults than any other in the world, besides being the biggest killer of women.

But it’s also been said that most people are not too worried when diagnosed with the disease — a sad reflection of the ignorance with which it is often regarded. For unlike other infectious diseases, TB can be cured: it only has to be detected in time. Tuberculosis germs spread through the air, much like the common cold virus, when infected people cough or sneeze and the bacteria attack the body, usually the lungs.

With increasing HIV infection weakening the immune system and the development of drug-resistant TB strains, it’s not surprising that the disease has been on the rise of late in both developing and developed countries. TB has a chilling way of lying dormant, waiting for the right opportunity to strike so that many people play host to the bacteria, and are unaware of it because — thanks to the body’s defenses — they don’t actually develop the disease. 

For happily, the war against TB may be won sooner than many would have thought if the efforts of an India-born British doctor, Ajit Lalwani, and his team bear fruit. They have reportedly developed an effective test that can spot cells in the blood produced by the immune system, unlike the old tuberculin skin test that depended on identifying antibodies in the blood (which made diagnosis a matter of chance). Using the new Elispot test, doctors can now identify people with early dormant TB before they can infect others. Suddenly, eradicating this dreaded disease doesn’t seem so impossible after all.

You can read the full editorial at: 
http://www.hindustantimes.com/onlineCDA/PFVersion.jsp?article=http://10.81.141.122/2003/Apr/17/
181_235387,0012.htm 

Indian Cricket players now ready to take on TB 

A story by K. Kanan in The Hindu dated March 12,2003 says that Union Ministry of Health and Family welfare will be launching a major communication effort on World TB day this year- to combat the dreadful affliction which kills more than 1,000 people a day.

As a part of this drive, a television commercial featuring the cricketers’ endorsement of TB control messages, are scheduled to go on the air in all the leading television channels. Two prominent members of India’s World Cup Cricket team—Rahul Dravid and Zaheer Khan have taken time off for promotion of public service communication involving TB, a preview of which was held in Delhi in March.

Apart from the TV commercial involving cricketers, mass media communication in terms of information and education programmes in television and also press advertisement have been developed. The States are also evolving their own local communication approaches and consultations are on to synergies the various communication efforts over the next eighteen months.

A report on initial mycobacterium drug resistance in HIV-TB dual infection in Mumbai

A preliminary report on initial mycobacterial drug resistance in HIV - TB dual infection in Mumbai, highlights the occurrence of primary multi-drug resistance in dually infected patients. The Foundation for Medical Research, Mumbai, undertook a study to determine the patterns of initial drug resistance in HIV positive TB suspects. Sputum and/ or blood samples from HIV positive freshly diagnosed TB persons were collected for smear examination, culture and drug susceptibility. Resistance to 4 or 5 first line drugs and 4 or 5 second line drugs was seen in 72% and 60% of patients respectively. 

High levels of primary drug resistance would affect the TB control programme in terms of case categorization, management, cure rates as well as resources for therapy says Dr. Yatin Dholakia, who along with Dr. Tannaz J. Birdi, Ms. Desiree T. B. D'souza, Mrs. Bhakti B. Oza, Dr. Subhash Hira and Dr. Noshir H. Antia conducted the study.

Two new books on TB control in India

TB Control in India: Ramakrishna Mission’s contribution

Compiled and Edited by: Swami Deshikatmananda
Published by: Ramakrishna Mission, R.K. Ashram Marg, New Delhi
Pages: 253

Swami Vivekananda started Ramakrishna Mission in 1987. The mission first started outpatient clinic to treat tuberculosis patients when anti-TB drugs were not available. Since then, the Mission has continued to fight against tuberculosis for the last several decades through a network of hospitals and dispensaries located in various parts of the country.

This book enlightens the readers about immense experience gained by Mission through its grass root level work in tuberculosis control. 

The book is divided into five sections:

Section one contains transcripts of speeches on topics such as India’s contribution to TB control, Glimpses and analysis of tuberculosis control in India, TB associated with HIV/AIDS and Glimpses of tuberculosis programme and research in India-yesterday, today and tomorrow. Section two has papers presented by eminent scholars in the seminar organized by Mission in 1998. 
Section three deals with research studies carried out by Ramakrishna Mission TB Clinic. Section four contains information about activities of RK Mission centres in TB control in various states. It provides important information from grass root level where the field workers are grappling with TB control on day-today basis.

Section five contains success stories of TB control. This year’s World TB Day slogan is ‘DOTS cured me-it will cure you too’. The inspiring stories of patients who overcame most adverse and disadvantaged situations and defeated tuberculosis provide motivation and fortitude, are very timely. 

The book draws from the experience of leading public health personalities of the country and is an indispensable tool for TB programme managers working at various levels, public health workers, policy planners and all those interested in TB control in India.

You can read detailed information about the book and how to obtain a copy at: http://www.healthinitiative.org/html/books/book1.htm 

Expansion Of The Tuberculosis Programme In India: The Policy Evolution Towards Decentralization And Integration

Author: Dr. A. K. Chakraborty
Published by: Centre For Health Research And Development (CHRD), A Unit Of The Maharashtra Association Of Anthropological Sciences (MAAS) Pune, India.
Pages: 66

The book puts together the results of a study commissioned by CHRD. The funds for the study were provided under TB knowledge development programme sponsored by Department for International Development (DFID), London through London School of Hygiene and Tropical Medicine (LSHTM).

The book describes the lessons learnt through implementation of National Tuberculosis Control Programme and analyses the reasons for its ‘failure’. One must remember that in half of the country TB control services are still being provided through ‘infamous’ NTP. The book then explains strategy behind RNTCP implementation. Experiences world over have demonstrated that when DOTS services are of high quality target cure rate is achievable. The book cautions in no uncertain terms that there is no room for complacency and programme managers and health care providers have their task cut out for them. The book suggests that RNTCP will have to proceed with decentralization of supervisory and control mechanisms to facilitate faster expansion. 

Dr. A K Chakraborty is a well-known epidemiologist of the country and was associated with National Tuberculosis Institute (NTI) Bangalore. He has drawn from his vast experience while preparing this document, which can be called a ‘mid-term evaluation’ of RNTCP. If RNTCP is to achieve its goal it must learn from its successes and failures so far and take corrective steps. 

You can read detailed information about the book and how to obtain a copy at: http://www.healthinitiative.org/html/books/book2.htm 

Web Call: The Journal of the Indian Medical Association: special issue focusing on tuberculosis control in India. 

http://www.jimaonline.org/mar003/toc.html 

The Journal of the Indian Medical Association, which is the official publication of the largest organized body of Indian physicians, has published a special issue focusing on tuberculosis. Dr. L S Chauhan, Deputy Director General (TB), Central TB Division, Directorate General of Health Services and Dr. Reuben Granich, Medical Officer- Tuberculosis (P), WHO, Regional Office for South-East Asia, have been retained as guest editors for this issue. The various articles have been written by experts in tuberculosis treatment and control. The possibility of a public-private mix in implementing the Revised National Tuberculosis Control Program has been explored. This special issue succeeds in addressing the various facets of tuberculosis diagnosis, epidemiology, control, social issues and the various treatment strategies.