The title of this article may rather appear weird. However, the annual report released by the Central Government year-on-year on situation of tuberculosis or TB in India is invariably titled as TB India, (with year as the subscript). The one for the current year is titled as TB India 2014. Situation of TB in India and Tuberculosis INDIA: In fact, these two connotations meant to define and express the title completely alter the context and the seriousness that the subject entails. When we look at the situation of TB and its prevalence, we find the title given in the government reports is quite apt. Tuberculosis is no longer a disease afflicted only with poverty. Now its genesis is traced to deprived/distorted lifestyle and that it thrives on the offshoots of the so-called newer arena of development that the country witnesses today. In India, as many as 3.3 million persons are suffering from one or the other type of TB and that annually 276,000 lives are lost due to tuberculosis. As many as 9.4 million cases of TB are detected worldwide every year. India accounts for more than one-fifth of the same at about 1.98 million. Two to three per cent of the newly detected cases are also found to be drug-resistant and when the patients abandon the course of treatment mid-way, this proportion of non-resistant cases rises to the range of 14 – 17%.
The Lancet, which is the world’s oldest and leading medical journal and publishes original research articles on health and medicines, has published an extensive research paper focusing on the spread of infectious diseases like malaria, HIV and TB in the world, in its latest edition on 22 July 2014. It was reported that these three diseases had remained the world’s biggest health challenges in 2013. TB has been the most widespread amongst the three. In the same year, the number of deaths reported in India were 1,16,322 due to malaria and 78,662 due to HIV while Tuberculosis engulfed 5,45,516 people to the death. The research clearly states that identification of people suffering from such a disease is still being overlooked!
TB is no less than a silent contagion one sees its devastating impact on life. Generally, we refer to those persons as TB patients who are infected with it and have visible signs of its symptoms. However, the World Health Organisation informs that one-third population of the world or about 2000 million people carry the Mycobacterium tuberculosis, defined as Latent TB. If the people have a strong resistance to disease, these bacteria remain dormant and do not manifest as infection of TB. The WHO apprehends that the bacteria may become active in 20 million of these people at any time and cause a widespread tuberculosis infection. According to the TB India Report 2012, 40% of its population carries the Mycobacterium tuberculosis (the TB bacteria) in the passive form. Malnutrition plays an important role in activating this latent and passive TB bacteria. This poses a real threat to the 65 million underweight children in the country. The bacteria becomes active in the wake of lowered immunity which is caused by lack of nutritious food intake. The probability of developing tuberculosis amongst the younger children is very high. It thus becomes crucial that a strong action plan is put in place for addressing the occurrence of this disease amongst children under 6 years of age and that the community is engaged in monitoring the same.
It appears that a major change has come about in detection and treatment of tuberculosis cases over the years during the period 1990 to 2012. It is believed that the incidence of tuberculosis has reduced from 216 per 100,000 per year in 1990 to 176 per 100,000 per year in the year 2012 in India[1], the tuberculosis mortality per 100,000 population having been reduced from 38 in year 1990 to 22 in 2012. In absolute numbers, mortality due to TB has scaled down from 330,000 to 270,000 annually. Now the moot question is whether we have really brought the tuberculosis under control. The answer is in the negative. The World Health Organisation says that the incidence of active TB has reduced due to detection and treatment. However, the latent TB stands unabated (490 million people of the country continue to carry the dormant bacteria with them. As soon as the immunity drops, it can lead to the activation of the disease) and that we have not been able to bring its determinants under control. Risk factors[2] including biomedical (such as HIV infection, diabetes, tobacco, malnutrition, silicosis, tumor or malignancy etc.), environmental (indoor air pollution, lack of ventilation etc.) or socio-economic (crowding, urbanization, migration, poverty etc.) lead to progression of latent TB to active disease. World Health Organisation believes that enough work has not yet been done in India to address the linkage between the prevalence of TB and these risk factors.
In the meantime, the International Diabetes Federation has released the estimates of the global burden of diabetes mellitus (DM) vide its 2011 Diabetes Atlas. A study in South India shows that diabetes is an independent risk factor for tuberculosis. Modeling from the study suggests that diabetes accounts for 14.8% of all tuberculosis whereas 20.8% of smear-positive TB cases are traced to diabetes. In the context of health, it is now strongly believed that consequent upon the rapid urbanization and socio-economic development, diabetes mellitus (DM) has been assuming the proportion of an epidemic. Now 61.3 million people in India suffer from this incurable disease. Widespread prevalence of TB is largely owed to person-to-person transmission of infection. Whilst its diagnosis and treatment are underway, it is the other factor of progression of latent TB to active disease which is also of serious concern. Accordingly, it is not necessary that a person shall contract TB from another TB-infected person. A research paper[3] informs that HIV and malnutrition are major population attributable risk factors in progression of latent TB to active disease. The study reveals that population attributable fraction for adults would stand at 16% due to HIV, 27% due to malnutrition, 10% due to diabetes, 13% due to alcohol use (>40g/day), 21% due to active smoking and 22% due to indoor air pollution. It thus brings out clearly that mere diagnosis and treatment would not be able to contain the prevalence of TB. We would need to review our life style and have a relook in to the policies of distorted development.
TB has a straight linkage with poverty and working conditions. With the discontinuity in regularly getting adequate nutritious diet, the immune system in the human body weakens and the TB bacteria proliferate their effect. When the bacillus Mycobacterium tuberculosis (the TB bacteria) are inhaled by the host into the lungs, they start getting multiplied and invade the hilar lymph nodes through the lymphatics. Subsequently, it reaches the kidneys, brain and bones through the blood flow and begins causing its adverse effect on them.
Although the immunisation programme of India includes BCG (Bacillus Calmette–Guérin) vaccination for prevention of TB, there are many issues with regard to the quality of programme implementation. It was claimed that 87% children were administered the BCG vaccination in year 2007. However, since then and over the years until year 2013, the claim status continues to be at 87%! The population wing of the United Nations too has raised questions on these claims. Probably, the problem is that we have reposed so much of faith in BCG vaccination that the attention to diagnosis of TB in children and their treatment has been relegated in terms of importance and priority.
Presently, these days all of us seem to measuring up ourselves in terms of economic indicators (value of money). The TB India Report 2014 informs that the family loses its income in the range of 20 to 30% because of this illness and that the country as a whole suffers huge loss to the tune of Rs.1422, 000 million! The kind of government resources that are being pumped in to the so-called development, it is apparent that the policy making in fact is apparently oblivious to the twin price that is being extracted from the public, namely, economic insecurity and death. Accordingly, whenever next the government seeks to review the status of TB in the country, it should rather examine as to how it would combat the TB arising due to urbanization, malnutrition and air pollution! One should no longer hide the epidemic in the guise of data pertaining to diagnosis centres and number of patients treated.
Child Malnutrition and TB
Specialists at the department of Paediatrics, Shyam Shah Medical College (Gandhi Memorial Hospital), Rewa in Madhya Pradesh had taken up a descriptive study (August 2013, Indian Paediatrics) on children between six to sixty months of age with Severe Acute Malnutrition (SAM). The study revealed that out of 104 SAM children admitted in the Nutrition Rehabilitation Center at the hospital, 23 (22.1%) were suffering from tuberculosis. It is an irony that 14 (61%) of the TB affected Severe Acute Malnourished children were under 12 months age. Likewise, 22 of the 23 children were anaemic. Evidently, TB is now spreading rapidly amongst the younger children and is becoming fatal in ‘collusion’ with malnutrition.
Tuberculosis or TB is one of the 10 major factors for children’s deaths the world over. According to a research published in July 2013 in the International Journal of Scientific & Research Publication, 1 million children are infected with TB every year resulting in the death of 100,000 children amongst them. Generally, the children contract the infection from those near and dear ones within the family/household who are already affected with the TB. As many as 620, 000 children were diagnosed in India to be suffering from tuberculosis during the period 2006 to 2013. Every year, 75, 000 children are added to this disturbing statistics. It is estimated that the children constitute 5% to 7% of all TB patients in India. Whilst at one end of the spectrum, we are witnessing a heightened discourse on the crisis of malnutrition, there is very little attention being given to the dyadic relationship between tuberculosis and malnutrition. Presently, malnutrition is sought to be traced as one of the constituent factors up to a certain limit in a tuberculosis-affected person. Diagnosis of tuberculosis amongst the children afflicted with malnutrition has not yet been seen as a significant strategic need. The reality, however, is that we cannot ignore the impact of tuberculosis when there is such a widespread prevalence of TB amongst the children. Let’s first settle it out whether we recognise TB as a disease for the children or not?
According to a study[4] by DT Nga Quynh, childhood tuberculosis is most common in children in the age 1 to 4 years because its diagnosis with the sputum smear-positive test is rarely conclusive for them. In addition, it is this age when the child needs special attention with regard to its nutritious diet for growth and development which if not met with makes the child vulnerable to contract the infection. Probability of progression from infection to TB disease is higher up to 20% in the under 5 years age children. The study also shows that untidy surroundings marking the poor housing, crowded conditions, poorly ventilated spaces, low income, lack of access to basic medical care services, lack of knowledge of tuberculosis prevention and non-availability of timely diagnostic services have led to the widespread prevalence of the infection. We know that antigens and antibodies protect us against the diseases. In fact it is the proteins which put up a defense shield against the invasion of diseases. Severe Acute Malnutrition uses up the protein reserve in the children resulting in their impaired immunity. Thus, whilst the children already have lesser protein in view of poverty and poor dietary practice, TB infection further diminishes their protein and fat reserves.
Despite the very high prevalence of malnutrition in children, the programmes aimed at combating malnutrition do not have any worthwhile arrangements for diagnosis and treatment of TB. There are as many as 240 Nutrition Rehabilitation Centres (NRCs) being run in Madhya Pradesh. These centres provide treatment to about 40, 000 children every year. Whilst the guidelines stipulate that the children admitted in the NRC will be subjected to Mantoux screening test, the ground reality is that not even basic facilities for conducting the test have been provided for. The Anganwadi Workers and the Health Workers have not been oriented to trace the symptoms of TB in the family members/relatives of the children registered with the Anganwadi Centre, particularly in respect of those children who are underweight and severely underweight. These family members could be the potential source for the child to get infected. TB also inhibits child growth and retards their weight gain. Accordingly, it becomes vital to associate TB prevention and treatment with the community management of malnutrition.
It is well known that cells in our body also protect us from bacteriological illnesses. Cell Mediated Immunity (CMI) renders the principal shield of defense against tuberculosis. Severe Acute Malnutrition affects this CMI. It is thus clearly established that severe malnutrition is rather directly associated with the prevalence of tuberculosis among the children.
We are aware that when the children do not get adequate nutrition, their body cells and tissues start getting broken or damaged. The TB bacteria also make way through the damaged cells and tissues. According to the National Family Health Survey 3 (NFHS 3), 16.4% of under-5 children in India are severely underweight. It means that about 20 million children are highly vulnerable to acquire the TB infection. However, our malnutrition management programme does not give any precedence to this aspect.
An initiative has been taken up for diagnosing children with tuberculosis from the perspective of health. The Revised National Tuberculosis Control Programme (RNTCP) in association with Indian Academy of Paediatrics (IAP) has set criteria and strategy for diagnosis and treatment of TB amongst children, both pulmonary peripheral TB lymphadenitis. Under this, TB diagnosis is based on clinical features, smear examination of sputum where this is available, positive family history, tuberculin skin testing, chest radiography and histo-pathological examination as appropriate.
As for the adults, treatment for children is also proposed in three stages – diagnosis, classification. The entire endeavour emphasizes only upon the medicine and medicine! Whilst the commonsense points towards the lack of nutrition as a factor for TB and highlights the need for nutritious diet during the course of treatment as well as post-treatment, the arrangements in place today appear to be wanting in integrating the malnutrition and TB aspects in regard to children.
Under RNTCP[5], all children less than 6 years of age, contacts of the family member suffering with active TB are screened for TB and provided INH (Isoniazid) chemoprophylaxis once active TB has been ruled out. The implementation is through General Health System, which varies from place to place and the adherence to guideline is less than satisfactory. On analyzing last 10 Central Internal Evaluations conducted in year 2012, it was noted that 35% of children less than 6 years did not receive chemoprophylaxis.
Generally, sputum smear microscopy is used to confirm the bacterial infection. However, it is difficult to do so in case of the children. Less than 15% of cases being sputum acid-fast bacilli smear positive and mycobacterial culture rendering yields at best at 30%-40% in case of children are reported[6].
Where tuberculosis is not endemic, the diagnosis follows three approaches – first – if the child is having continuing cough which is not getting cured with normal course of treatment, second – child’s weight is falling, and third – close contact of the child with an infectious person within the family. In the event of such a situation, chest radiograph is taken to look for suggestive lung abnormalities and then tuberculin skin test or Mantoux test is carried out. In this test, a small amount of TB antigens (called Purified Protein Derivative – PPD -) in a shot is put under the top layer of skin on the forearm using a syringe. In case the child shows swelling on the arm after 2 or 3 days, it is indicative of the presence of TB infection. This test is necessitated because even if the child has TB, the chest radiography may not be able to show the abnormalities in the lungs. Further, carrying out the sputum smear test becomes a challenge because it becomes very difficult for the child to expectorate the sputum from the depth of its lungs which is essential for smear examination. Therefore, in order to do a proper diagnosis and reach a valid conclusion, another method that is used is known as Gastric lavage test in which sample of respiratory secretions is collected by aspirating the contents of the stomach. It can be performed only by trained nurses in the hospitals. The yield of M. Tuberculosis in culture is in the range of 40% to 92%[7] by this test, though it is a difficult and invasive procedure. Likewise, Bronchoalveolar lavage is another method in which water is extracted from the lungs. This test is extremely invasive which can be done only with tertiary care facilities. Despite the widespread prevalence of paediatric tuberculosis, simpler and easier techniques of investigations are not available for diagnosis and detection of TB in children. Despite the recent emergence of 8 newer diagnostic tests for tuberculosis, none of them have been validated for the children.
A National Technical Working Group (NTWG) on Paediatric TB has been constituted to work on the status of TB amongst the children. Its first meeting took place in July 2013. It has recommended for enhanced capacity for collection and processing of samples, standardidising the method of sample collection and conduct of trainings and has called for ensuring that complete regimen of treatment is rendered. This group too has also ignored the need to enhance children’s immunity by way of effectively meeting their nutritional requirements and putting in place a comprehensive malnutrition programme management.
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About the Author: Mr. Sachin Kumar Jain is a development journalist and researcher who is associated with the Right to Food Campaign in India and works with Vikas Samvad, AHRC’s partner organisation in Bhopal, Madhya Pradesh. The author could be contacted at sachin.vikassamvad@gmail.com Telephone: +91 755 4252789.
About AHRC: The Asian Human Rights Commission is a regional non-governmental organisation that monitors human rights in Asia, documents violations and advocates for justice and institutional reform to ensure the protection and promotion of these rights. The Hong Kong-based group was founded in 1984.
[1] ‘TB India 2014’, Annual Status Report, Government of India
[2] TB India 2012, Government of India, Central TB Division, March 2012
[3] Tuberculosis control 2010-2050: cure, care and social change. Lancet 2010 DOI:10, 1016/s0140-6736 (10)60483-7 by Lonnoroth K, Castro K, Chakaya JM, Chauhan LS, Floyd K, Glaziou P, Raviglione M.
[4] Quynh Nga DT, Risk factors for tuberculosis infection among child contacts of pulmonary tuberculosis cases [Dissertation], (Oslo), University of Oslo, May 2009
[5] TB India, 2014, Central TB Division, Government of India
[6] Soumya Swaminathan and Banu Rekha, Paediatric Tuberculosis: Global Overview and Challenges, Clinical Infectious Diseases, 2010:50(S3):S184-S194
[7] Soumya Swaminathan and Banu Rekha, Paediatric Tuberculosis: Global Overview and Challenges, Clinical Infectious Diseases, 2010:50(S3):S184-S194
