This conference is very special as it celebrates the 90th anniversary of The International Union Against Tuberculosis and Lung Disease (The Union), and marks the 100th anniversary of the death of Robert Koch who was the first person to isolate the tuberculosis bacillus in 1882 and subsequently awarded the Nobel Prize for his tuberculosis findings in 1905.
Despite recent progress, tuberculosis (TB) remains an important global public health problem. One-third of the world's population is currently infected with the tubercle bacillus, nearly 9 million new cases occur each year and close to 2 million of them die due to the disease. All countries are affected, but 85% of the cases occur in Africa (30%) and Asia(55%), with India and China alone accounting for 35% of all cases.
Pulmonary TB is contagious and spreads through the air and if not treated each person with active TB infects 10 to 15 people every year. Multidrug-resistant tuberculosis (MDR-TB) is a particularly dangerous form of drug-resistant TB and is defined as disease caused by TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB are high in some countries and, coupled with the devastating effects of TB-HIV co-infection, threaten to undermine TB control efforts worldwide.
TB is a grave health threat in India, accounting for one-fifth of the global cases of TB, killing two persons every 3 minutes. The country boasts of 2.2 million new cases every year, out of which 1 million are infectious, smear positive pulmonary cases. In fact, a recent study suggests that missed diagnosis of TB in India and China is spurring a global spread of the disease. Overcrowded living conditions combined with appalling sanitation help in the spread of this contagious disease.
DOTS was launched formally as the Revised National TB Control programme (RNTCP) in India to combat TB, in 1997. It was introduced to ensure that every TB patient completes the full six-month course of treatment, typically involving four drugs.
But this much-hyped programme, despite considerable success as reported by the WHO Global TB Control reports periodically in mitigating the impact of TB and reducing human suffering by ensuring the patients the best anti-TB medications free, has actually been less of a success than was previously assumed.
An alarming number of poor and vulnerable people who are at a high risk of TB find that benefits of DOTS are out of their reach, both economically and physically. A number of people like migrant labourers or daily wage workers do not undertake the full programme, and drop out before completing it. Such patients might develop drug-resistant TB - a deadlier form of the disease. Worse, even a single such defaulter can create a significantly large pool of infected people. Unless treatment is made convenient for patients, it will not have the desired results. In DOTS, the patient has to take anti-TB medicines in direct supervision of a health worker (or DOTS provider), or another trained person who is not a family member, at the centre. I personally know of many patients who found it very inconvenient to go to a DOTS centre everyday (or every alternate day where intermittent therapy is provided) to swallow the pills, and hence went on and off the treatment - a very dangerous step indeed, which very often results in relapse or development of drug resistant TB. Perhaps, if a family member is made responsible to administer the drugs every day, the outcome might be better. We probably have a lot to learn from home-based care (HBC) approaches in providing AIDS related treatment, care and support services. Or else the health worker should go to the patient's home to give the medicines - a seemingly impossible task in the Indian health set up which is considerably over burdened. We need to find new ways and means to monitor patients continually, until they complete the full course and recover.
While supervised treatment to ensure the right treatment given in the right way is the need of the hour, it is equally necessary that adequate standards of TB care be applied by all providers, whether public or private. The new International Standards for TB Care is a promising step in this direction.
We also need to promote the empowerment of civil society and communities in this fight against TB. The recent Patients Charter for TB Care, although a wonderful document, is yet to be adopted by national programmes. Most patients (and perhaps even doctors) in India are totally unaware of its contents.
Research on TB, neglected for decades, must be fostered to meet the increasingly pressing needs for new drugs, diagnostics and vaccines. Addressing TB/HIV and MDR-TB requires improved and rapid diagnostics and new classes of drugs. Discussions at the Open Forum 4 meet on 'Critical Path To New TB Drug Regimens' held in Ethiopia (August 2010) have brought forth new promises in this direction, and would hopefully be carried forward by this conference.
The social and economic costs of TB are enormous, as its incidence is concentrated in adults between the ages of 15 and 54, who are the primary wage earners. One estimate projects that the Thai economy will lose the equivalent of USD 7 billion by the year 2015, solely to TB sickness and death. In India, the estimated loss of economic output due to TB deaths reaches more than US$ 370 million every year. The combination of the enormous economic burden of TB and the inconsistent availability of cost-effective interventions, make TB one of the highest priorities for action in international health.
It is hoped that this 41st Union World Conference on Lung Health will greatly motivate participants to discuss the development of new diagnostics, anti TB drugs and vaccines along with further advances in HIV care, Lung Health and tobacco control, with a view to fully fund and optimally implement the revised Global Plan To Stop TB 2011-2015, which, in the words of Dr Mario Raviglione, Director, WHO Stop TB Department, "sets out the direction with renewed intensity in care and control efforts, and new approaches and tools to become available that should take us towards the achievable goal of TB elimination by 2050."
(The author is the Editor of Citizen News Service (CNS) and also serves as the Director of CNS Stop-TB Initiative and CNS Diabetes Media Initiative (CNS-DMI). She has worked earlier with State Planning Institute, UP and teaches Physics in India's prestigious Loreto Convent College. Email: shobha@citizen-news.org, website: www.citizen-news.org)
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