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  • Tuberculosis

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    Figure: Causative agent for Tuberculosis is Bacillus: Mycobacterium tuberculosis (M.tb)

     

    • Tuberculosis (TB) is a communicable disease that is a major cause of ill health.

    • TB is caused by the bacillus Mycobacterium tuberculosis (M.tb)

    • TB disease typically affects the lungs (pulmonary TB) (80%) but can also affect other parts of the body (extra pulmonary TB) (20%)

    • It spreads when people who are sick with TB expel bacteria into the air (for example by coughing, sneezing, shouting or singing)

    • It is one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent

     

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  • Burden of TB in India

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    TB is one of the top burdensome infectious diseases in India. It is estimated that, around 1/4th (26%) of the world's TB cases are in India, translating to about 30 Lakhs new TB cases emerging each year (TB incidence). Against this estimated incidence the National TB Elimination program reported around 19 lakh new and relapse cases in the year 2021.

    An estimated 5 Lakhs deaths occur due to TB each year in the country, translating to about 1 case of TB death every one-two minutes. Compared to this, there are only about 60 thousand deaths due to HIV and about 77 deaths due to Malaria each year.

    TB diagnosis and treatment services although provided free of cost in the public sector, the cost of accessing these services and related loss of wages drive the affected people with poverty (catastrophic costs). TB also has a huge impact on the world's and the country's economy because of loss of workdays (100 million workdays per year).

     

    Assessment

    Question​ Answer 1​ Answer 2​ Answer 3​ Answer 4​ Correct answer​ Correct explanation​ Page id​ Part of Pre-test​ Part of Post-test​
    What is the estimated number of incident TB cases that emerge each year in India? 35 Lakh cases 26 Lakh Cases 26% of the Global Burden 19 Lakh Cases 2 The estimated number of new and relapse (incident) cases in India that emerge each year is about 26 Lakh ​ Yes Yes
    How many cases of deaths are estimated to be caused by TB in India Approximately One death every 2-3 minutes Approximately 5 Lakh deaths 60 Thousand deaths each year 1 and 2 4 In India it is estimated that there is around one death caused due to TB every one to two minutes, translating to about 5Lakh deaths each year in India   Yes Yes

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  • Evolution of TB Elimination Programme in India

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    The National Tuberculosis Control Program (NTP) of India was launched in 1962. It relied on BCG, X-ray based diagnosis and Streptomycin and INH based treatment centralized at district level.  

    Based on a review of the NTP, and WHO recommendations of the DOTS Strategy, Government of India then revised the NTP and launched new program with the title Revised National Tuberculosis Control Program (RNTCP) in 1997. It used Sputum microscopy at DMC(Designated Microscopy Centres) for diagnosis, and multi-drug Short Course Anti-TB Therapy,  decentralized to the TU (TB Unit) level. 

    In recognition of the rising drug resistance problem the DOTS Plus/ PMDT (Programmatic Management of Drug Resistant TB) was launched in 2006 and scaled up to the entire country by 2012. 

    Further to strengthen the monitoring and supervision system - a case based notification system - Nikshay was introduced in 2012. The same year Tuberculosis was added as a notifiable disease at the point of diagnosis by all health care providers.

    Other key milestones from 2012 to 2020 were the availability of the Standards of TB Care in India (STCI) in 2014, introduction of the Daily weight band wise Fixed Dose combination (FDC) in 2016 and new drugs like Bedaquilline  and Delaminid were started in 2017 and 2018 respectively. 

    To emphasise the commitment of the Government of India and to accelerate the efforts towards TB elimination, RNTCP was renamed as "National Tuberculosis Elimination Programme (NTEP)" in 2020.

     

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    Figure: Key milestones under NTEP

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  • Stages in TB Patient's Lifecycle

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    Those who are suspected of having TB disease are first screened for symptoms like cough and fever for more than 2 weeks, blood stained sputum and weight-loss. If found positive on screening, then TB patients are referred for testing to the nearest health facility. If diagnosed with TB, then they are subsequently initiated on treatment. The TB patients initiated on treatment are regularly monitored with the help of field staff or digital interventions like 99DOTS and MERM (Medication Event Reminder Monitor) technology. NTEP staff also ensures that the TB patients are regularly followed up on monthly basis till their treatment completion.

     

    Figure: Patient Flow

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  • TB Causative organism

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    Figure Mycobacterium tuberculosis

     

    TB is caused due to the infection by a bacterium called Mycobacterium tuberculosis.

     

    Figure: Extra-Pulmonary Tuberculosis

     

    It often affects the lungs, and in such cases it is called Pulmonary Tuberculosis. But, it can affect almost any part of the body (except the hair and the nails), in which it is known as Extra-Pulmonary Tuberculosis.

     

     

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  • Mode of TB Transmission

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    Tuberculosis is transmitted mainly through the air via droplet nuclei generated when a TB patient coughs or sneezes. 

    It is estimated that every sputum smear-positive patient spreads the infection to 10 – 15 persons annually, if untreated..

    Figure: Transmission of TB bacteria through air via droplet

     

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  • Symptoms of TB Disease

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    Active TB disease has 4 major symptoms (the 4 Symptom complex). Presence of any one of these symptoms without any other reason warrants evaluation for TB. These are:

    Figure: Signs and Symptoms of TB

    People affected with TB may experience other symptoms as well. These may be based on the site that is affected with TB or other more non-specific symptoms of an infection. The physician or doctor would evaluate these symptoms in view of diagnosis of TB.

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  • Progression to TB Disease

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    After exposure to infective droplets containing M.TB, only a small proportion gets infected and further progresses to active TB disease.

    • Majority of those that get infected persist in a stage of clinical latency known as TB infection (previously known as Latent TB infection). They do not have TB disease and do not show any symptoms of TB and no evidence of any TB related changes on chest X-ray.
    • A small proportion of those with prior infection may progress to active TB disease due to various environmental/ agent/ host factors.

    Figure: Flow chart for TB disease progression

     

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  • TB Infection Vs Active TB Disease

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    TB Infection Active TB Disease
    May not have any signs & symptoms Has sign and symptoms such as cough for more than two weeks, fever, weight loss and blood in sputum
    Has dormant, contained bacteria is the body Has active, multiplying bacteria in the body
    Doesn't spread TB bacteria to others May spread TB bacteria to others
    Chest X-ray usually normal Lesion in Chest X- ray (usually)
    May advance to active TB. It is estimated that the lifetime risk of an individual with TB infection for progression to active TB is 5–10%. Needs treatment for TB disease

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  • Presumptive TB

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    Presumptive TB case refers to a patient who presents with symptoms or signs suggestive of TB disease (previously known as a TB suspect) and where further diagnostic workup including bacteriological investigation is required.

     Presumptive TB can be categorized into

    1. Presumptive Pulmonary TB (P TB) - Symptoms are directly related to lungs (Cough, hemoptysis)

    2. Presumptive Extra Pulmonary TB (EP TB) - Symptoms/ signs are specific to an extra pulmonary site (example: Lymph node swelling)

    3. Presumptive Pediatric TB - Symptoms of TB in young children are more difficult to identify and can be more general (fever, weight loss) 

     

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  • Prevention of TB

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    As TB is an airborne infection, TB bacteria are released into the air when someone with infectious TB coughs or sneezes. The risk of infection can be reduced by taking simple precautions:

    Figure: Measures for control and prevention of tuberculosis

    TB Preventive Treatment(TPT) also has a very important role in prevention of TB. Presently, household contacts of sputum-positive TB patients are given TPT upon confirmation of TB infection and ruling our active Tuberculosis.

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