Tuberculosis (TB)

It is a disease caused by the bacteria, Mycobacterium tuberculosis.

(Mycobacterium tuberculosis was discovered by Robert Koch and for this discovery; he was
awarded Nobel Prize in physiology or medicine in 1905)
It typically attacks the lungs, but can also affect other parts of the body.
It spreads through the air when people who have an active TB infection cough, sneeze, or
otherwise transmit respiratory fluids through the air.
Each year about 9 million people develop TB disease and 2 million people die of TB.
Who are prone to TB?
Individuals with diabetes and HIV, alcoholics, smokers, those under physical and mental
stress, those who are malnourished and individuals taking long term steroid medications
Two TB-related conditions exist: latent TB and TB disease/active TB.
TB INFECTION/ LATENT TB
TB bacilli spread through the air we
breathe in. Everyone is at risk of infection
After infection, the majority remains well,
but the bacilli stay alive, latent or dormant
in body tissues for life. They have no
symptoms and are not sick.
They cannot spread bacteria to others.

ACTIVE TB
Only some 10 per cent among the infected
ones will develop TB disease some time in
adult life.
After infection only when a persons
immune system becomes weak for some
reason, active TB is developed. They have
symptoms of TB disease.
They spread the bacteria to others.

TYPES:
PULMONARY TB (PTB)
Affects the lungs.

80% cases have PTB

It is given priority in public health agenda.

E.g.: RNTCP

They spread TB bacilli.

Sputum test helps in diagnosis of the
disease.
Symptoms: Bad cough that lasts longer
than three weeks, pain in the chest,

EXTRAPULMONARY TB (EPTB)
It is also known as disseminated or miliary
TB. TB outside lungs. It occurs in the
central nervous, lymphatic, or genitourinary
systems, or in the bones and joints.
15- 20 % cases have EPTB. More common
in immunosuppressed persons and in young
children.
It is not given high priority on the public
health agenda is probably that it does not
contribute significantly to the transmission
of the disease
They dont spread TB bacilli.
Sputum test will not help in diagnosis of the
disease.
Symptoms: Can be same as PTB but there
can then be specific symptoms relating to

coughing up blood or phlegm from deep

inside the lungs, fatigue, fever, weight loss

the particular site or sites in the body that

are infected.

Drug Resistance TB

To treat TB four drugs are commonly used, Rifampicin, Isoniazid, Ethambutol and
Pyrazinamide, in different combinations for six months. These are also called as first line
drugs. Injectible drug Streptomycin is used in some cases.
Drug-resistant TB occurs when drugs are not properly taken, like incomplete treatment,
wrong dosage, wrong length of treatment, wrong combination, unavailability of drugs or
poor quality drugs.
MDR, XDR and TDR result from non-protocol drug treatment.

TYPES:
Multidrug Resistant TB (MDR TB)
It is caused by bacteria that do not respond to at least Isoniazid and Rifampicin,
the most powerful anti-TB drugs.
Its diagnosis and treatment is difficult.
The second line drugs used to treat MDR TB are 300 times costlier than the first
line drugs. These are ofloxacin/levofloxacin, ethionamide, cycloserine,
pyrazinamide, ethambutol and kanamycin.
These drugs are used for 24 months in different combinations and have severe
adverse events.
The government of India started DOTS Plus services for diagnosis and treatment
of MDR TB in 2007.
Extensively Drug-Resistant TB (XDR TB)
It is defined as TB that has developed resistance to at least Rifampin and
Isoniazid, as well as to any member of the fluoroquinolone family and at least one
of the aminoglycosides or polypeptides (second line drugs).

Regular TB and even MDR TB progress relatively slowly, XDR TB progresses

much more rapidly and can be fatal within months or even a few weeks.

Totally Drug Resistant TB (TDR TB)

It is TB which is believed to be resistant to all the first and second line TB drugs.
It is sometimes referred to as extremely drug resistant, or XXDR TB.
It is extremely difficult, although not always totally impossible to treat.

Diagnosis
1. Tuberculin Skin Test (TST)

Also known as the purified protein derivative (PPD) test.

Used to detect TB infection but will not tell whether a person has active TB or
not.
Performed by injecting a small amount of tuberculin into the skin of the arm. The
reaction formed on the arm determines the result of the test.
Useful in diagnosis of infection in children where others methods generally fail.
Problems:
Non-availability of diagnostic tools like tuberculin.
Though infected, TST can be negative in infants because their immune
system is not mature.

2. Smear Microscopy
First diagnostic tool used to microbiologically confirm TB infection/disease.
A very thin layer of the sample (sputum) is placed on a glass slide, and this is

called a smear. A series of special stains are then applied to the sample, and the
stained slide is examined under a microscope for signs of the TB bacteria
Inexpensive and simple
Problems:
Performs poorly in children, especially in those under five years.
Sensitivity is only about 50-60%

3. Culture

Culturing is a method of studying bacteria by growing them on media containing

nutrients.
Culturing and identification of M. tuberculosis provides a definitive diagnosis of
TB and can significantly increase the number of cases found.
It can also provide drug susceptibility testing, i.e. if a person has MDR or XDR.
Problems
It has sensitivity limitations and takes several weeks to yield a clinically
useful result.
more complex and expensive

4. X-rays
Acute pulmonary TB can be easily seen on an X-ray.
The picture it presents is not specific and a normal chest X-ray cannot exclude
extra pulmonary TB.
Problems: In countries where resources are more limited, there is often a lack of
X-ray facilities.

5. Interferon gamma release assays (IGRAs)

A new type of more accurate TB test. Results can be available within 24 hours.
These assays work by detecting a cytokine called the interferon gamma cytokine.
They are performed in practice by taking a blood sample and mixing it with
special substances to identify if the cytokine is present.
Used to detect TB infection/Latent TB but will not tell whether a person has
active TB or not.

6. Xpert molecular test (Xpert MTB/RIF)

An alternative test that is more sensitive than Smear Microscopy and takes less
time than Culture.
WHO endorsed Xpert for rapid diagnosis of drug-sensitive and multi-drug
resistant TB
Xpert can be used as the initial diagnostic test in all children presumed to have
TB.
There is limited number of Xpert diagnostic machines in India and is used for
testing drug-resistant TB.

Note: There are other tests but I have discussed the ones mentioned in Hindu articles.

DOTS

Directly observed treatment, short course.

A key component of the World Health Organization's campaign to stop TB.
RNTCP uses DOTS.
It involves patient case management by trained health professionals.
Drugs are made available on the doorstep by a DOTS provider who keeps track of the
patient.
Important elements of this program:
Political commitment to a National Tuberculosis Control Programme
Microscopy services to detect sputum.
Regular uninterrupted supply of anti-TB drugs.
Direct observation of the treatment for at least initial intensive phase. As a part of
DOTS strategy health workers counsel and observe their patients swallowing each
dose of powerful combination of medicines.

TB in children

Children account for about 12 per cent of the total TB cases in India as per RNTCP
TB disease in children under 15 years of age is also called paediatric tuberculosis.
Unlike adults, children under five years of age may develop the disease very soon after
infection.
This is proved correct in case of those from households where an adult has been recently
diagnosed with active pulmonary TB
Diagnosis is difficult in children because they are unable to produce sputum. A very few
TB bacilli are present in the sputum sample of young children. So there are many
children wrongly diagnosed as disease-free.
Children are less likely to spread TB bacteria to others. This is because the forms of TB
disease most commonly seen in children are usually less infectious than the forms seen in
adults.
Contact Screening of Children: Screening of children under five from households where
an adult has been newly diagnosed with sputum smear-positive pulmonary TB. This is a
new approach to diagnose the disease in children. This approach has twin advantages.
While the diseased would be put on treatment without delay, the asymptomatic children
would end up getting a preventive therapy.
Childhood TB has been ignored for years. In 2012 WHO estimated the global burden of
TB in children was 5.3 million across the world.
Childhood TB is a fundamental indicator of a Tuberculosis Control Program. This is
because almost all children aged under five get infected from a family member.

Indias TB Control Program

EVOLUTION
1950s-60s
1962
1992

Important TB research at National Tuberculosis Institute at

Bangalore and Tuberculosis Research Centre at Chennai
National TB Control Program (NTCP)
Program Review: Only 30% of patients diagnosed and out
of these only 30% treated successfully.

1993
1998
2001

RNTCP pilot began

RNTCP scale-up
450 million population covered

2004

>80% of country covered

2006
2007

Entire country covered by RNTCP

DOTS Plus

National TB Control Program (NTCP)

India pioneered TB control among developing nations. It was started in 1962.
The objective of the program was to identify and treat as large a number of TB
patients as possible so that infectious cases are rendered non- infectious and
reduce the magnitude of TB problem in the country to a level where it ceases to
be a public health problem.
Program activities were case detection, case treatment, health education and BCG
vaccination.
BCG vaccination:
Indias TB control pioneers P.V. Benjamin and Frimodt-Moller introduced
the mass BCG vaccination in the hope that it would protect against
infection by TB bacilli.
An extensive vaccine trial was launched to measure its protective efficacy.
In 1979, preliminary results of a 15-year-long BCG trial showed no
protection against infection by TB bacilli.
The Expanded Programme on Immunisation took over BCG vaccination.
Despite a nationwide network of facilities, NTCP failed to yield satisfactory
results. The situation did not change much.

Revised National TB Control Program(RNTCP)

The WHO-recommended DOTS strategy was launched formally as RNTCP in

India in 1997 after pilot testing from 1993-1996.
From diagnosis to treatment is rendered free of cost to every patient.
Implemented as 100% centrally sponsored program.
All components of the STOP TB Strategy-2006 are being implemented.
First phase (19982005): Focus was on ensuring expansion of quality DOTS
services to the entire country.
Second phase (2006-2011): Widen services and to maintain at least a 70% case
detection rate of new smear positive cases as well as maintain a cure rate of at
least 85%.
RNTCP is far from giving due importance to paediatric TB.

RNTCP- DOTS-Plus Vision

By 2010 DOTS-Plus services available in all states.
By 2012, universal access under RNTCP to laboratory based quality assured
MDR-TB diagnosis for all retreatment TB cases and new cases who have failed
treatment.

By 2012, free and quality assured treatment to all MDR-TB cases diagnosed
under RNTCP (~30,000 annually)
By 2015, universal access to MDR diagnosis and treatment for all smear positive
TB cases under RNTCP.

Current Challenges

WHO estimates that only half of lung TB patients get DOTS.

DOTS saves lives from TB mortality, but has failed to control TB.
The TB control project has failed to address the yawning gap between private sector
health care and TB control.
With the entry of AIDS to India in 1980; HIV infection is a major risk factor of TB.
RNTCP is only interested with PTB and completely ignores EPTB. This project
illustrates incomplete health care and inadequate public health.
Poverty leads to TB and TB worsens poverty. People are still under the impression that
TB is a disease of poor people, mostly of those living in slums.
The annual economic loss to India on account of uncontrolled TB was assessed by the
government at $23.7 billion, while RNTCPs budget is only $200 million.
Unregulated private health care is leading to widespread irrational use of first-line and
second-line anti-TB drugs.
Stock-out of anti-tuberculosis drugs was in news recently. This will lead to more cases of
Drug resistance TB.

How to intensify our fight against this deadly disease?

A comprehensive and effective surveillance system to have correct estimates of

tuberculosis burden.
Integration of tuberculosis control activities with primary health care services.
Enabling and promoting research into TB control activities.
End the shortage of anti-TB drugs in India.
Regulate the rational use of first- and second-line anti-TB drugs.
Existing diagnostic laboratories need to be strengthened with routine training/refresher
courses for the involved personnel for better utilization of these already scarce resources.
Better diagnostic tests for quick screening of this disease at field level should be
developed and made available at the grass-root level.
Vaccination of our livestock against TB and routine screening of livestock should be
made mandatory.
The links between primary health centers and DOTS centers should be strengthened.

References:
The Hindu Articles:

Contact screening: the risk of wrong TB diagnosis

A monster called drug-resistant tuberculosis
Paediatric TB: should Xpert molecular test replace smear microscopy?
Programme to prevent TB in children neglected
What went wrong with Indias TB control
Dont ignore the children
Lets declare war on TB
Why the true burden of paediatric TB remains unknown

http://www.tbfacts.org/index.html
http://mrunal.org/2012/02/science-tuberculosis-and-dots-therapy.html

Name: Divya V Prabhu