Tuberculosis: The lethal dose

Tuberculosis (TB) has spread its tentacles across the globe and according to WHO estimates it is a major public health problem in India. India accounts for one-fifth of the global TB incident cases and has acquired a deadlier edge with the emergence of drug resistant strains. Express Pharma, in association with Majestic MRSS, gives an idea about the awareness level about the deadly disease among the medical fraternity and patients and the myths related to it

Tuberculosis (TB)is a major health menace in India. The air-borne disease caused by Mycobacterium tuberculosis (MTB) is a pathogenic bacterial species in the genus Mycobacterium and the causative agent of most cases of TB. Though Government of India has come out with a number of initiatives like DOTS or Directly Observed Treatment Short course, which is the internationally recommended strategy for TB control and has been recognised as a highly efficient and cost-effective strategy, the country still lags behind in completely eradicating the disease. According to statistics received from Ministry of Health on TB statistics, it has been revealed that two people die every three minutes due to TB and it accounts for over three million deaths every year. However, there has been some hope, as Government of India’s initiative to control the disease has yielded some fruitful results.

History

Around 17,000 years back, MTB was found in the remains of a bison. Skeletal remains of pre-historic humans (4000 BC) show that they had TB and researchers have found tubercular decay in the spines of Egyptian mummies dating from 3000-2400 BC. Robert Koch, a German physician and scientist, first discovered the presence of Mycobacterium tuberculosis, which causes tuberculosis on March 24, 1882. Every year March 24 is celebrated as World Tuberculosis Day.

WHO estimates

The World Health Organisation had declared TB as global emergency. Apart from Mycobacterium tuberculosis, there is one more type of bacteria, Mycobacterium bovis, a slow-growing bacteria, which causes TB in cattle and can jump the species barrier and cause TB in humans. According to WHO estimates, India had an estimated 63,000 cases of notified multi-drug resistant tuberculosis (MDR-TB) in 2010, the highest in South East Asia in 2010.

What is MDR-TB?

MDR-TB is defined as tuberculosis that is resistant at least to isoniazid (INH) and rifampicin (RMP), the two most powerful first-line anti-TB drugs. The main reason for patients not being totally cured is that they miss the medicine doses or sometime fail to complete the treatment. Multi-drug-resistant tuberculosis can be cured with long treatments of second-line drugs, but these are more expensive than first-line drugs and have more adverse effects.

Average percentage of patients who do not receive treatment in India

MDR—TB statistics in India

As mentioned earlier, India in 2010 had an estimated 63,000 cases of notified MDR—TB, the highest in the South East Asia region. Recent country-level data shows that about five per cent of TB patients are HIV-positive. National surveillance has shown that the distribution of HIV among TB patients is highly heterogeneous and is closely correlated with the distribution of HIV infection.

The MDR-TB prevalence is estimated to be 2.3 per cent among new cases and 12-17 per cent among re-treatment cases. However, due to the size of the population and the number of TB cases reported annually, India ranks second among the 27 MDR-TB high-burden countries worldwide after China.

The most common clinical symptoms seen among Indian patients are

• Fever
• Persistent cough
• Thick phlegm with blood
• Loss of weight and appetite leading to low energy levels

Majestic MRSS’ survey comprised 30 GPs and chest physicians, six each from Delhi, Mumbai and Bangalore, and four each from Kolkatta, Hyderabad and Chennai.

According to physicians and chest physicians interviewed in the survey, felt that the most common organ infected is the lungs, followed by the lymph nodes, spinal cord, intestine, brain, bones (most commonly hip bones). A Mumbai-based physician said, “Other than nails and hairs, all organs are at a risk of being infected by TB.” Out of all the patients surveyed, an average of 80 per cent had the active state of the disease and the remaining 20 per cent had the latent state.

A chest physician in Kolkata mentioned that most patients come as referrals. While suffering from cough, these patients usually go to the family physician or their neighbourhood chemist. When there is no improvement and relief, they come to us and by then the damage has been done.

A Delhi-based physician said, “Anyone and everyone is at a risk of acquiring TB.” However it is seen there are a number of factors which increase the level of risk, like weak immune system due to HIV, heamato-oncological disorder or diabetes, malnutrition, living in unhygienic crowded places. The most common and important factors were seen to be compromised immune system, alcoholism and malnutrition. One of the biggest risk factors are myths and lack of education. According to another chest physician, “I have seen women who are afraid to reveal their problem, because they  think that TB is a social taboo.”

Doctors look to pharmaceutical companies in order to help in controlling the disease. Pharma companies can assist in spreading an awareness about the treatment and the importance of completion of drug course. As per a pulmonologist in Bangalore, “In most cases, compliance is the main issue, as most of the patients do not take the full course of their medication”.

A Chennai-based pulmonologist said that apart from providing medications, pharma companies can issue booklets which gives due importance to complete the course of medication in time. According to a general physician in Bangalore, pharma companies should work in tandem with the Government, since the Government has plans but requires support to put them in place. Besides, pharma companies should provide low cost drugs with shorter dosage schedules, which most doctors agreed upon.

During this survey, one major problem faced by the doctors were the blind beliefs, myths and old wives tales, which were deeply embedded within the patient’s mind.

Some of the common myths were:

1. TB only occurs in people of the lower socio economical class
2. TB can cause lung cancer
3. TB is hereditary
4. TB is is caused by smoking

Despite a number of initiatives taken by the Government of India, a lot more still needs to be done in order to eradicate the deadly disease. Experts believe that TB eradication has a long way to go, with challenges such as lack of diagnostic centres, delay in diagnosis, break in DOTS treatment, the social and mental trauma that comes along with TB and inadequate drug support to HIV patients who are most likely to get the disease because of their weak immune system. However, with collaboration of private and public sector, India can control the dark
shadow of TB.

Reference:- (Dr Ranjita Shegokar, Freie Universität of Berlin, Institute of Pharmacy, Department of Pharmaceutics, Biopharmaceutics & NutriCosmetics, Kelchstrasse 31, 12 169 Berlin, Germany; Email: [email protected])

Disclaimer: Statements and opinions expressed in this article are those of doctors (General Physicians Chest Physicians Pulmonologists) across urban cities(Delhi, Mumbai, Hyderabad, Chennai, Kolkata, Bangalore). While every care has been taken in the compilation of this information, the authors will not be responsible for any claim, loss, damage or inconvenience caused as a result of any information within these pages