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Cri Cece PHM Policy Brief: Crisis in Control of Tuberculosis THE PROBLEM "WHO estimates that India accounts for 2:8 milion (27%) of the 10-4 million new cases world-wide, and 29% of the 1-8 million deaths. With close to 5 lakh deaths each year, tuberculosis remained one of the top five causes of death ‘among people aged 30-69 year. The recent declines in the age-standardised tuberculosis death rates in India mostly occurred between 2001 and 2007, with a slowing of the decline from 2008 to 2013 Most tuberculosis deaths in India continue to be among young adults in the ‘economically productive age group, with high economic and social costs." (Madhukar Pai, www.thelancet.com Vol 389 March 25, 2017) The reality of the spread of TB in. India is at its most fearsome in disadvantaged areas of the country- in mining and industrial areas; in urban and semi-urban areas where migrant labourers live in cramped settlements; in Adivasi! Dalit communities where where although roads and electricity have reached but people stil struggle to survive. In the Third World, countries thrive on mining and industrialisation making use of cheap labour. Governments’ economic policies focus on clty-centric development. Populations are being displaced from their own lands or are forced to move out to work as migrant labourers in mines and industries. Young migrants living in temporary settlements in cramped conditions are more susceptible to TB, and HIV transmission due to unprotected sexual contacts in cities away from home, exacerbates the risk even further. Those infected with HIV are up to 50 times more likely to develop TB disease than HIV-uninfected individuals. Further as a consequence of improper and imegular treatment, and persistent social determinants that breed the TB epidemic, strains of TB bacteria have evolved that do not respond to standard first-line treatments. The prevalence of HIV infection has complicated TB control even more. Multidrug resistant TB (MDR-TB) where the bacteria resistant to two important anli-TB drugs is increasing rapidly, and in recent years, an even more serious form of TB, Extensively drug-resistant TB (XDR- TB), has evolved. —XDR-TB is extremely difficult to treat because the bacteria is resistant to both first and second- line drugs. There is now talk of TDR (totally drug resistant) strains too. Access to drugs for more resistant forms of TB are more difficult and less affordable, Urban TB is characterized by disproportionate accumulation of TB in many metropolitan cities. Sometime rates are many times higher than the rural TB rates from the same state. NGOs, Large number of health workers in private & public health facilities are advantages of urban areas. TB treatment is completely free and access to diagnostics , drugs & treatment better than in villages. Notification of the disease is better here. These cases are mainly concentrated around urban slums, resettlement colonies and among homeless people. Prevention and control of TB among these high risk groups is complicated by delayed diagnosis, onward transmission and poor treatment adherence. TB services that are not tailored towards the needs of urban risk groups carry a continuing risk of higher rates of TB and drug resistant strains. These ‘TB cases posses a serious risk of developing into deadly drug resistant TB (MDR,XDR & TDR) espacially in the cities with better access to TB drugs because they are exposed to all most all first & second line drugs. Current scenario of TB in few wards of Mumbai metropolitan city is a good example of problems related with Urban TB. ‘THE REASONS FOR THE CRISIS: Political Statements creating false expec-tations: Elimination has been promoted as a goal to create political and media interest in a neglected disease, but the limitations of what could be achieved has not been adequately communicated. The country is not poised for elimination- both because of a very high prevalence of risk factors and because of weak primary health care — especially in urban slums and tribal areas. Weak public health systems: Primary Health care continues to be non-functional and it has been difficult to make it functional only for a very selective list of services implemented through vertical stand alone programmes. This non-functionality of primary health care has reached crisis proportions in larger urban areas where the National Health Mission has had very little penetration and impact Not enough engagement and regul: Sector practice: Often private practitioners provide non-standard regimes. Often they delay testing for multi-drug resistant TB or are Unable to access these drugs. Most patients are too poorto pay the costs of anti-TB treatment in private sector and discontinue within a month. Many drugs against MDR-TB ivate are not readily available. Contracting in private Practitioners has worked, but only as a relatively minor supplementation, Serious reduction of the disease will remain the task of the general practitioner! family level health provider — majority of whom are in the private sector inindia. Access to Rational TB Diagnosis and Free Rational Medicines? The TB control programme emphasized access to medicines through DOTS providers close to home. But in practice, there are huge gaps - such as closeness to home, convenience of access. By insisting on direct observation of ingestion of medicines, an unreal and unnecessary requirement, the more feasible and essential regular intake of medicines is neglected. TB patients still have to travel 60 KM by trains and buses or hiring vehicles to reach treatment. Intermittent short-course was also inadequate to prevent the development of resistant strains. However the switch over to daily regimes was late to happen and incomplet Failures to Scale Up Systems that can address MDR- TB: It stil takes too long to diagnose MDR- TB- which means that many more persons get infected and MOR TB develops in contacts before the index case is diagnosed. However even existing techniques have not been scaled up adequately. Access to these tests is a major bottle-neck contributing to the spread of MDR-TB. This needs new innovations and better organization of services that reduce the time to diagnosis Social Determinants “TB is clinical manifestation of social disease” aptly describes the problem. Unfortunately over reliance on anti- tuberculous drugs, while ignoring other social determinants of TB are some of the challenges which needs to be addressed urgently. Social determinants are problems like poor housing , overcrowding, congested & Poorly designed colonies with poor light and air circulation, high rates of mainutriion among the poor, drug & alcohol addiction in urban and semi-urban areas. Al these hamper adherence to drug regimen Failure to act on Malnutrition — the most important social determinants: In a recent study, new cases of TB were 12 times higher in people with a low body mass index (BMI<18.5), relative to those with normal BMI (18.5-25) after other factors were adjusted for. Recent study by Doctors For You revealed that providing good nutrition to the MDR-TB patients increased compliance to the medical treatment as well as helped the Cri Coates patients stay alive, gain weight and get cured. The failure rate of government program of MOR TB treatment in India is 54% (as per WHO TB India Report 2016). However, a program run by Doctors For You across 5 states had a failure rate of only 14.5% out of which only 6.5% was because of death of the patients (unpublished data, POSHAN Project 2016-18). This indicated that provision of good nutrition is of utmost importance for the effective treatment of the TB patients. During this study it was also found that many people who have Aadhar cards/Ration cards are not yet getting the Ration they deserve through the National Food Security Act 2013. The PDS shops are {far from households and so the people can'tafford to waste their time and energy standing in the queue for the ration. They prefer to buy from private grocery shops and rather eat less than to lose their daily wages. Also there are people who do not have ration cards at all, or have APL ration cards even though their incomes are meagre and their household condition is well below the poverty line. This indicates that government needs to make its PDS system more robust and increase its outreach. ‘Such malnutrition is due to rising inequality and persisting poverty- and as long as economic policies do not address this, TB will continue to be endemic. Similarly under globalization there has been a great increase in mining operations and hazardous industries (like ship breaking) all over India. In the rapid expansion ~ almost no care has been taken to protect health, and most of the workers are migrant workers living in abysmal conditions with very ‘weak unionization. Persistent TB and the rise of MDR TBs, thus not only a shame for our public health system- it is even more a condemnation of the economic policies of the government. Urbanization High population density in urban colonies with limited number of health workers further reduces the frequency of follow up and monitoring of treatment adherence of the TB patients in these colonies. Many of these patient are daily ‘wage workers and their family economic condition further limits the access to good food and nutrition during the first few months of Intensive phase of the TB treatment. Weaknesses — Limited number of community health workers, Awareness about TB is low, High population density with limited DOTS providers, Many urban settlement are declared illegal depriving them of access to 7B drugs, demotivated DOTS providers, Language & cultural barriers with migrants population Threats — Mult-drug resistance, non-compliance, Latent TB, relapse, alcoholism and drug abuse, old age, excessivelcrash dieting, high mental stress, air pollution, junkfood Zoonotic TB This is recognized by WHO and FAO as one cause for the spread of TB in areas where veterinary health is undeveloped. Bovine TB responds tofirst line drugs except, that Pyrazinamide cannot be used Non TB Mycobacteria ‘A study in Central India showed presence of non TB mycobacteria in soll and water. These can cause infection They are difficult to distinguish from TB by routine tests. They do not always respond to treatment. The Peoples Health Movement calls for urgent government actions on two fronts: A. Improving access to quality primary health care for patients at high riskisuspected /diagnosed as having tuberculosis. 8. Policy interventions on social and environmental determinants of the TB epidemic. A. Universal Access to TB detection and treatment. 2, Build in Special Focus on Diagnosis and Management of TBin high risk groups: i. Displaced persons —intemal (dams, industries, land acquisition for industries and development projects, conflicts ) or external (refugees) li. Prisonsand correctional institutions li, Other congregate settings-incudes homes for aged, orphanges, Ashram schools for tribal students, shelters for destitute, women in distress iy, Industries- especially mining related, and where theres known higherrisk v. Tribal communities vi. populations living in high risk slum settiements- special focus on manual labour! industry workers/ scavenging! security guard jobs. All of the above areas need to be assigned to teams of primary care providers who are trained on TB detection and who have access to the tests that are required and have the capacity (time, money, logistics) to make frequent periodic visits and provide the necessary care). Large number of health work force in private, not for profit and public facilities can be involved in health care provision, better access to health facilities, clean and green environment, as well as awareness drives for better nutrition and immunity, 6. — Institutionalize Annual free diagnostic tests for Diabetics, people living with HIV or AIDS. Introduce Nutrition Basket for all TB affected families- especially in contexts of increased vulnerability. There are good models from Kerala Cri Cece (Panchayat based) and Chhatlisgarh-which can be built on. In many cases, urban patients are bedridden and have nobody else to fetch the ration to them, Faclities should be available for Home delivery ofration to such patients. Urban programme - people's participation in decision making, involvement and empowerment of women, increase job opportunities. Inter sectoral action with Smart City and Skill Indiainitiative ‘Access to free tests- Sputum AFB containers can be collected from the ANM and it is checked by microscope in most PHC s. The best new test so far is CB NAAT- one costly imported machine has been given to each district. We really need 3 or more of these CB NAAT machines in different parts of each district Universal Access to Free Rational Medicines: The challenge here is rapidly switching over to a daily regime and in case of multi-drug resistant TB ensuring access to Delamanid, Bedaquiline for those who need them. Levofloxacin is currently stil too easy to buy over the counter without a prescription, and has been used for simpler respiratory infections. Its use needs to be restricted to those TB patients who need it, otherwise resistance will develop very soon. Both Delamanid and Bedaquiline are expensive and under strict regulation. Asmall free supply has been given butt, is very difficult to get permission to use it. Since itis not made in India price may be an issue in future, when demand rises and itis used more widely. In the past India has used compulsory licensing to ensure that life saving drugs that were under patent could be made cheaply and in sufficient quantities in local factories. Improve digitized montoring of TB control activity- especially by retaining and strengthening the Nikshay system and a H1 tracking of prescriptions ‘Scale up counsellors and counselling as part of care provision: for both TB and drug resistant TB. For economies of scale it would require introduction of counselling at block level across all the states and districts and urban areas with high endemicity Ensure supply of C-PAP and Oxygen Concentrators to industrially disabled and those with post- tuberculosis chronic obstructive lung disease (copp) 4. Strengthen research on on prevention, diagnosis, treatment and surveillance, with special reference to multidrug resistant TB, Zoonotic TB and Disease producing Non TB Mycobacteria in Soil, Water, Air. Action on Social Determinants Addressing Psycho-social determinants of TB (Open Jails and better prison conditions: b. Prevent overcrowding, ensure family support, encourage economic rehabilitation in prisons, refugee populations, displaced populations. © Occupational Health Measures- addressed at silicosis, coal workers lungs, cotton workers lungs, sugar care workers and other occupations where chronic lung disease is a major occupational hazard, ‘These are not only related to personal prophylaxis but also to technology choice and mitigation ‘measures against dust pollution in the work place. 2. Measures to reduce air pollution and risks of occupational ung disease: a. Policies that promote clean Energy (solar, wind, mini hydel, linking with grid) and move away from coal based power b. Pollution limitations in allindustry c. Better Personal Protection devices and their use in occupations where risk of lung disease and tuberculosisis higher. 3. Botter Living Conditions and Life Styles: ‘a. Ensuring minimum standards of ventilation and lighting- especially relevant to urban slum development. b. Domestic uel choice that reduce indoor pollution: © Measures against active and passive smoking- and other forms of tobacco use, REFERENCES 1. Fourth World News January 2018 Fourth World Action 41 Cowper Road, Cambridge Cb1 3sl, U.K. E-Mail: fourthworldaction@gmail.com 2. Lénnroth K, Jaramillo E, Williams Bg, Dye C, Raviglione M. Drivers Of Tuberculosis Epidemics: The Role Of Risk Factors And Social Determinants, Soc Sci Med 2009;68:2240-6. Doi:10.1016/J ‘Socscimed,2009.03.041 Pmid:19394122 3. Cegielski Jp, Arab L, Comoni-Huntley J. Nutritional Risk Factors For Tuberculosis Among Adults In The United States, 1971-1992. Am J Epidemiol 2012;176:409-22. Doi: 10.1093/Aje/Kws007 Pmid:22791739. 10. 1, 12 13, 14, 435, 16, a7, 18, Cri nace Anuradha R, Munisankar S, Bhootra Y, Et Al Coexistent Malnutrition Is Associated With Perturbations In Systemic And Antigen-Specific Cytokine Responses In Latent Tuberculosis Infection. Clin Vaccine Immunol 2016;23:339-45. 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Narang R, Narang P, jain AP, Mendiratta DK, Joshi, DasR, Katoch VM, http://www.mmreis.Org.In/Projects/_ Imple- mentation/119-Studying-The-Association-Between- Structural-Factors-And-Tuberculosis-In-The- Resettlement-Colonies-In-M-East-Ward-Mumbai http://www.who.int/Tb/Publications/ Global_Report/Gtbr2017_Annex3,Pdf? U: Madhukar Pal, www.thelancet.com Vol 389 March 25,2017 Urban TB In India (personal Communication) Dr. Ravikant Singh, Dr. Peehu Pardeshi, Doctors For You TB India Report 2016 WHO Unpublished Data, Poshan Project 2016-18 (Doctors For You, Mumbai) https:/iwww.tbfacts.org/bovine-thi JSA & Doctors for You : 2018 Plan For Tuberculosis Directorate

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