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:  

Where there's smoke there's fire

A landmark study conducted to study the relationship between smoking and mortality from tuberculosis in India has come out with shocking results. The authors of the study concluded that three-quarters of the smokers who became ill with TB would not have done so if they had not smoked. "Almost 200,000 people a year in India die from TB because they smoked, and half of the smokers killed by TB are still only in their 30s, 40s or early 50s when they die," says Dr. V Gajalakshmi, lead researcher with the Epidemiological Research Center in Chennai, India.

Smoking and tuberculosis "are two huge and two preventable epidemics," says Dr. Thomas R. Frieden, who is credited with kick-starting the Revised National Tuberculosis Control Programme (RNTCP) in India. He and other experts in tuberculosis and public health say that the new findings underscore the need to reinforce the tobacco treaty that the member countries of the World Health Organization approved in May 2003.

Sounding a note of caution Dr. Frieden says that tobacco companies are intensifying their efforts to increase the market for cigarettes in third world countries, particularly among women. "Asian women are the No. 1 target of the tobacco industry," he warns.

Countries like India need to do more in order to ban cigarette advertising, increase cigarette taxes and educate the public about the hazards of smoking. People also need to be informed about the perilous connection between smoking and death due to tuberculosis. Those who manage IEC activities in the Central TB Division cannot afford to disregard the crucial message in a study first of its kind in India. The 'smoke' unquestionably raises an alarm about a raging 'fire' taking a toll of hundreds of thousands of lives every year.

Smoking doubles TB deaths: Indian Study highlights new tobacco peril

Helen Pearson in Nature: Science Updates reports that according to a new study* smoking is doubling the number of people dying from tuberculosis (TB) in India. A similar cloud may be hanging over other developing countries.

The investigation found that about half of the 400,000 men who die from TB in India each year do so because of smoking. Smoking appears to quadruple the risk of falling ill with the disease, by helping dormant TB bacteria blossom into a full-blown lung infection.

The result is the first convincing link between smoking and TB. It also contrasts with the plight of smokers in the Western world, who are more likely to die from lung cancer and heart disease. Smokers in India also have higher rates of these diseases. "It's a surprise," says study member Prabhat Jha of the University of Toronto, Canada.

Researchers fear that tobacco may also exacerbate the impact of TB in Africa, China and in other countries where the disease is rife. Women in India and China, who rarely smoke now, might also become increasingly vulnerable as more take up the habit.

Previous epidemiology hinted that smoking might increase the risk of TB. But the threat has been neglected because most studies were in the West, where the disease is uncommon. "It just got forgotten," says team member and epidemiologist Richard Peto of the University of Oxford, UK.

The group examined 43,000 men who had died in the late 1990s and a further 35,000 still living in the southern Indian state of Tamil Nadu. TB was far more likely to have killed smokers, they found.

Jha reckons that smoking increases people's vulnerability to whichever disease is already widespread in a population, be it TB, cancer or heart disease.

* Gajalakshmi, V., Peto, R., Kanaka, T.S. & Jha, P. Smoking and mortality from tuberculosis and other disease in India: retrospective study of 43000 adult male deaths and 35000 controls. The Lancet, 362, 507 - 515, (2003)

Full text of the story available at: http://www.nature.com/nsu/030811/030811-10.html

TB and Smoking study draws international attention
(Lawrence K Altman, New York Times, August 15, 2003)

The Indian study, which demonstrates that, the combination of cigarette smoking and tuberculosis is far deadlier than previously believed, has evoked a keen interest amongst public health experts the world over.

Smokers are four times as likely as nonsmokers to die of tuberculosis in India, the study found. The researchers estimated that nearly 200,000 people die there from tuberculosis every year because they have been smokers. At every age, smokers in the study had twice the risk of dying as nonsmokers. The study also found that Indian smokers, on average, die about 20 years earlier from all causes than they would if they did not smoke.

Smoking and tuberculosis "are two huge and two preventable epidemics," said Dr. Thomas R. Frieden, who investigated tuberculosis in India before he became New York City's current health commissioner. The two epidemics kill more than five million people worldwide each year, Dr. Frieden said.

"It's a dynamite study," said Dr. Lee Reichman, a leading tuberculosis expert at the University of Medicine and Dentistry of New Jersey. "Everyone knows that cigarette smoking is bad and causes all sorts of terrible things," Dr. Reichman said, "but none of us thought that it could be stretched to enhance an infectious disease like tuberculosis, especially one that is responsible for so many deaths."

Developing countries account for about 95 percent of the world's tuberculosis cases, said Dr. Marcos A. Espinal, the acting director of tuberculosis control at the World Health Organization. China and India head the list of 22 countries that account for about 80 percent of all the cases.

"We are far away from conquering tuberculosis" in the world, Dr. Espinal said. But India is one country where the situation seems to be improving.
"India is well on its way to controlling tuberculosis, if the AIDS epidemic does not take off," Dr. Frieden said in an interview. A new control program (RNTCP) in India "is drastically reducing deaths from TB," Dr. Frieden said. But smoking is a different matter.

Tobacco companies are intensifying efforts to increase the market for cigarettes in third world countries, particularly among women. In India and elsewhere in Asia, the vast majority of smokers are men. "Asian women are the No. 1 target of the tobacco industry," Dr. Frieden said.

There are about a billion women in Asia, where about 30 percent of men smoke, Dr. Frieden said. If cigarette companies could get the same smoking rate among women, "that's another 300 million smokers and a lot of money," Dr. Frieden said.

Dr. Frieden and Dr. Espinal said there were methodological problems with the Lancet study, which could affect the figure for the death rate from smoking. But they said they agreed with the authors of the study, who said, "Smoking is a cause, and an important cause, of death from tuberculosis."

Illness Fund may bring happy tidings for TB patients
(Times of India, New Delhi, August 19, 2003)

HYDERABAD, India-Underprivileged patients with multi drug-resistant tuberculosis (MDRTB) may get financial assistance if a proposal to divert funds allotted to the Government Chest Hospital, Erragadda, wins approval. At the Erragadda hospital, 10 percent of the TB patients are diagnosed as MDRTB cases. On average, 10 MDRTB patients are admitted to the Government Chest Hospital every month and most cannot afford the expensive drugs that must be administered for up to two years. MDRTB patients are prescribed a three-drug therapy, and in the case of HIV-positive patients, therapy can include up to five drugs. A MDRTB committee has been established at the Erragadda hospital to address these issues.

(Source: CDC HIV/STD/TB Prevention News Update Week of August 24 to 30, 2003)

TB is Enemy No. 1 for India's health: WHO report says more than 45 million people in India are suffering from the disease
(Toufiq Rashid, The Indian Express, New Delhi, July 16,2003)

If you thought AIDS would be India's Enemy Number One, think again. A World Health Organisation (WHO) report released in Paris in July this year says more than 4.5 million people in India are suffering from Tuberculosis, making it home to the highest number of TB cases reported in the world.

With about 1.8 million new cases detected every year and about 460,000 deaths so far, there seems to be no end near to the disease in the country. Though the report credits India with having the most rapidly developing free DOTS (Directly Observed Therapy) programme in the world, it rues the fact that about 900 million people in India and China do not have access to the programme. Only 55 percent Indians were covered by DOTS in 2002, says the study WHO Stop TB initiative that recommends DOTS as the ideal mode of treatment.

Calling India the most-challenging environment for implementation of DOTS, it identifies the massive intra-country migration levels as the single biggest hurdle. ''They come here from other cities, other villages, looking for work. Many find employment in the textile industry, thousands work as porters or vegetable-sellers. These people stay together in groups, live in congested and unhygienic environments and stand a high risk of contracting TB,'' the report quotes Jayashree Parab, who runs KARM, an NGO in Mumbai.

WHO squarely blames India's healthcare sector as 'under-funded,' and notes: ''Unless both public and private doctors participate, the disease will continue to spread. Patients pay for any medication they are given, which means private practitioners may see DOTS as a threat.''

Navi Mumbai is the hope that WHO identifies as a model for India. Citing it as an example for how attitudinal changes can make a difference in the implementation of DOTS, it says: "Here the health authorities are more people- and service-oriented. The doctors practising in the slums are DOTS providers. There's an indirect benefit to these private doctors involved in the programme, the patients whom they help combat TB become their regular patients and go to them for other ailments.

TB Control Programme to cover entire state by Year-end
(The Hindu (Chennai, India), August 22, 2003, By Nagesh Prabhu)

BANGALORE, India-The Revised National Tuberculosis Control Programme (RNTCP) will be extended to cover the entire state of Karnataka by the end of 2003. This extension will make Karnataka the 10th state in the country to be fully covered under the comprehensive TB prevention program. Currently 22 districts are covered under the program. The Central TB Division approved the extension of RNTCP to Haveri, Uttara Kannada, Udupi, Kodagu, and Chamarajanagar districts. Upgrading of laboratories, training for volunteers and Health Department officials, installation of equipment, and civic works are ongoing. The World Bank-assisted RNTCP was launched as a pilot project in areas covered by the Bangalore Mahanagara Palike (BMP) in 1994, and has gradually extended to other parts of the State. A total of 77,782 TB patients have been treated through the RNTCP since 1998, and 22,611 patients have been administered drugs during the past six months.

(Source: CDC HIV/STD/TB Prevention News Update Week of August 24 to 30, 2003)

National AIDS Control Organization prepares a Draft on Guidelines for Management of TB in HIV Infected

National AIDS Control Organization (NACO) has prepared a draft on guidelines for management of TB and HIV infected and has invited comments and suggestions from members of public, public health experts and clinicians. This initiative deserves to be applauded and supported.

The draft proposes that in view of the fact that tuberculosis is one of the commonest infectious disease seen in HIV infected individuals, there is a clear case for active collaboration between the HIV and TB control programmes to ensure the early diagnosis and successful treatment of tuberculosis and extending adequate care and support facilities to People Living with HIV/AIDS (PLHA).
TB shortens the survival of patients with HIV infection and accelerates the progression of HIV as observed by a six-to seven-fold increase in the HIV viral load in TB patients. In fact TB is the cause of death for one out of every three people with AIDS worldwide.

In order to ensure optimal synergy between the NACO and RNTCP the draft guidelines put forward an 'Action Plan for Co-ordination'. It calls for service delivery coordination and cross-referral at local level and joint efforts at IEC particularly with regard to de-stigmatization.

The draft makes only a passing reference to the delicate issue of Voluntary Counseling and Testing (VCT) for diagnosis of HIV infection in a tuberculosis patient. This vital issue needs to be discussed threadbare so that clear-cut guidelines can be framed and passed on to health care providers in the field.

The draft guidelines can be accessed at NACO website at the following URL:
http://www.naco.nic.in/announcements/tbhiv.zip

Web Call: A visit to Joint Effort to Eradicate Tuberculosis web site

OurJEET.com (Joint Effort to Eliminate Tuberculosis) is a website hosted by the trans-national pharmaceutical giant Novartis through its Indian offices. A number of common facts on the disease, its pathogenesis and epidemiology both in the global and Indian context are provided. The association of TB with HIV and diabetes is explored through separate links, as are the connotations that the ailment has in context to special circumstances like poverty, women in children. DOTS is explained on another link in a rather elementary manner for professionals. The pages that are meant for patients are well designed and easily readable but are heavily biased in favour of an urban audience. Novartis, in a page highlighting its products could have added FAQs regarding drug therapy and its pitfalls, which would have enhanced the usability of the link. The banner and other messages displayed throughout the website aim to shock rather than allay doubts; whether this has been done for a certain design is best left to the visitor to ponder upon. The website has certain links which are only accessible from the sitemap and consist of case studies, the facility to upload cases and require a password and login information. On the whole, a useful site to visit if one is looking for variety of information relating to TB.