Tuberculosis is preventable and curable. It is time to act, to find, treat and end this disease at a time when a quarter of the world’s tuberculosis patients live in India.
Tuberculosis bacilli (TB) have lived in symbiosis with mankind since pre-historic time. TB is recorded in Indian, Egyptian, Greek, and Roman civilisation as far as 5000 years ago.
Each year, we commemorate World Tuberculosis Day on March 24 to raise public awareness about the devastating health, social and economic consequences of TB and to step up efforts to end the global TB epidemic. The date marks the day in 1882 when Dr Robert Koch announced that he had discovered the bacteria that causes TB.
TB remains one of the world’s deadliest killer infections. Each day, nearly 4500 people lose their lives to TB and close to 30,000 people fall ill with this preventable and curable disease. According to National TB statistics India 2016 report, it is estimated that about 40 per cent of the Indian population is infected with TB bacteria, the vast majority of them have latent TB rather than active TB disease. The theme of World TB Day 2019 was – ‘It’s time’ – to find, treat and end TB to ensure no one is left behind.
According to a WHO report, one third of the population of the world is infected with TB. Out of this, 95 per cent of the mortality due to TB occurs in developing nations. Twenty five per cent of these deaths can be reduced with proper and timely treatment. The main symptoms of TB are general malaise, weakness, loss of appetite, loss of weight, low grade evening fever and can be associated with cough, bowel disturbances, lymph nodes swelling, pain in joints and back with difficulty in walking etc.
I strongly believe that if the culprit is to be killed then first he should be caught and then be properly identified after investigation. As for identification of the culprit a photograph is needed, it is also required for identification of the diseases. Photo of the disease can be taken with simple test. As every bacterium has a specific character so does the TB bacterium. A drop of TB pus is required to identify TB bacteria or a tiny bit of appropriate tissue is required to find TB granuloma. These tests can be done in most of the labs. The treatment of TB should be started only after confirming its diagnosis. This ensures better treatment of the disease.
Thousands of people were dying all over the world before 1947 because there was no drugs available against TB bacteria. But after the invention of anti tubercular drugs, the numbers of deaths have been significantly reduced. The anti-TB drugs are very effective. The perceptible results can be seen within three weeks. Many patients get symptomatic relief due to which they get a false impression that the diseases has been fully cured and many a time the patients do not re-visit their doctors and stop their medication themselves. However, it is advised that patient should take medication for the entire period (six months to 1.5 years) as per doctor’s advice and should follow up at the required intervals.
If patients break the treatment regime in between, the infection can reoccur and then the same medications are not effective due to drug resistance. They then have to be prescribed secondary line drugs which are more expensive, more toxic and have to be taken for a prolonged time.
In addition to medications, operations are also needed in some TB cases. If operation is needed, it is desirable to consult an experienced surgeon. Surgery is not necessary for every patient. It is needed only in those patients who are on anti TB drugs but are not improving or have deteriorated during treatment, or the patients have the pus formation in spinal TB and have subsequently developed paralysis during treatment.
If a hump has developed in spinal TB, then operation is needed to aspirate the pus and clean the bone and to correct the hump with the help of spinal implants. For correction of the hump, the author has developed a technique in which half of the diseased vertebra is removed and two separate vertebra are converted into one and a half vertebra into a single block. After a proper surgery and completion of tuberculosis treatment the patients can achieve their pre operative status.
In my opinion inadequate investigation, delayed or wrong diagnosis and improper treatment are the main cause of failure of treatment. Doctor can be blamed for empirical treatment / wrong diagnosis but patients are to be blamed for irregular and inadequate duration of treatment.
Inadequate dose for inadequate duration is main cause for multi drug resistance tuberculosis (MDR-TB) or extensive drug resistance tuberculosis (XDR-TB). MDR/XDR-TB is a major problem not only in our country but in the whole world. This is a man made catastrophe. The reason for the inadequate dose could be poverty, non availability of TB drugs, non availability of trained paramedical and medical staff and dis-continuation of TB drugs abruptly.
Some physicians in our country or in the other countries are influenced by whims without any fact which makes them think that every infection in the spine is a TB infection but it is not so. Because of this misunderstanding they treat all patients of spine infections with the anti tubercular drugs. It was found in a research that nearly 20 per cent of the spine infections are due to pyogenic or non tubercular bacteria.
Empirical anti tubercular treatment not only cause unnecessary financial burden to the poor patients but rampant use of TB drugs in non tubercular infection and has caused the incidence of MDR/XDR-TB to rise in our country.
As we know, most of the anti-tubercular drugs are metabolised in the liver and at times this un-monitored drug toxicity can lead to drug induced liver injury which can even lead to the death of the patient. Tubercular infection is considered to be social stigma in our country.
According to the first national anti TB drug resistance survey 2014-16, India recorded more new TB patients annually than any other country, contributing to 27 per cent of the world TB burden. More than a quarter of TB patients in India have drug resistance to one or other anti TB drugs. The treatment success rate among MDR-TB in India about 46 per cent and death rate is around 20 per cent as against the global level of treatment success rate of 52 per cent and death rate 17 per cent. It is said that MDR-TB is 6.19 per cent among all TB patients with 2.8 per cent among new and 11.60 per cent among previously treated TB patients. The incidence of XDR-TB was 1.3 per cent.
(The author is an orthopaedic and joint replacement surgeon based in Dehradun)
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