Last week, readers got a glimpse of the dreaded Tuberculosis, its worldwide spread and its symptomatology. Those who couldn't get their hands on it, may press here to read last week's blog post by Dr S.K. Sharma.
How is TB diagnosed?
Since the time of Robert Koch's discovery of the TB bacillus and Wilhelm Konrad Roentgen's discovery of the X-rays, a lot of advances have been made in the field of Tuberculosis (TB) diagnostics. Diagnosis is easy in pulmonary TB but difficult in EPTB (Extra Pulmonary TB).
History taking and clinical examination are of prime importance. Endoscopy procedures (bronchoscopy, colonoscopy, laparoscopy, among others) have helped in localising where the disease is. Imaging methods, including plain X-ray, ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET) -CT, PET-MRI have been helpful in demonstrating where the disease is and what is the extent of the disease.
Obtaining sputum, body fluids like cerebrospinal, pleural, peritoneal, pericardial, synovial fluids, image-guided/ operative tissue specimens (e.g. lymph node, pleura, intestines) facilitates microbiological (staining, mycobacterial culture and drug-susceptibility testing), histopathological, cytopathological and molecular testing including cartridge-based nucleic acid assays (CBNAAT) to ascertain the diagnosis of TB.
Upfront diagnostic testing with CBNAAT allows identification of drug-resistant TB as well.
Rapid tests are also available now. Rapid and early diagnosis can be done by MGIT or Mycobacteria Growth Indicator Tube test.
How is TB treated?
- General measures - Careful attention must be paid to general measures like tobacco smoking and alcohol intake cessation, building up the nutritional status, adequate treatment of co-morbid conditions like diabetes mellitus, human immunodeficiency (HIV) infection, acquired immunodeficiency syndrome (AIDS).
- Anti-TB drug treatment - TB disease can be fatal without treatment. Mortality is higher in extremes of age (children and the elderly). Institution of regular, complete adequate anti-TB treatment with first-line or second-line anti TB drugs cures TB and can be life saving. Multiple drugs are used to treat TB. While the duration of treatment of drug-susceptible lung TB is 6 months, some forms of drug-susceptible TB like bone and joint TB, TB meningitis can be up to 9 months to 1 year or sometimes longer. Treatment of drug-resistant TB (DR-TB), especially multidrug-resistant TB (MDR-TB) and extensively drug-resistant TB (XDR-TB) multiple drugs for much longer duration.
- Pill burden - To reduce the pill burden, the NTEP uses fixed dose combinations (FDCs) to treat TB.
- Monitoring for adverse-effects - The patients receiving anti-TB treatment should be carefully monitored for adverse effects like liver, eye toxicity, among others.
Social aspects of TB
TB is considered a social evil and a cause of ostracization. Social stigma still persists among the general public ("TB ho gaya hai ise"). Divorces can occur due to TB as women don't conceive because of infertility.
One should not keep on googling symptoms as it may lead to unnecessary delays in diagnosis. If diagnosis is delayed, then complications like permanent vision loss, paralysis and intestinal obstruction, rarely perforation or even death may occur. Because of delay in diagnosis, TB can spread to multiple organs and lead to complications, treatment may not be effective and disease may continue to spread unabated.
If the patient does not take proper treatment, there is a delayed response to treatment and if the patient defaults treatment then drug resistant TB (MDR-TB, XDR-TB) may develop which are difficult to treat, require different treatment with second-line drugs for at least 18 months.
Government of India provides free diagnosis and treatment services for TB across the country. These are available in nearby designated microscopy treatment centres and DOT centres (Directly Observed Therapy centre). For DR-TB, District Centres have these facilities and medical colleges are well equipped with diagnosis & treatment facilities.
Google maps on any smart phone shows locations of nearby DOTS Centres.
The treatment schedule for Pulmonary TB was around 2 years when we joined the medical college. With a multi drug regime, it was reduced to 18 months. Presently it is 9 months, though a cure may occur in 6 months. Quest is on for better drugs with shorter treatment span and fewer side effects.
Control of TB
Most countries have their National TB Programmes (NTP) for TB. India has the unique distinction of being the first country in the world to start its NTP for TB way back in 1962. After several iterations, the Government of India is aiming for elimination of TB by bolstering and revamping its National TB Elimination Programme."
HIV AND TB - All cases of HIV positive are investigated for TB. Similarly, all cases of TB are tested for HIV. In case both diseases are present, treatment for TB is offered first. Drugs for HIV (anti retro viral) are offered after a 2 weeks interval.
COVID-19 and TB
The recent global pandemic of severe acute respiratory syndrome Coronovrius-2 (SARS-CoV-2) disease (COVID-19) had derailed the efforts at global TB control and the plans laid for ending TB.
But the pursuit is still going on. Bidirectional screening for COVID-19 and TB has been advocated.
How to prevent TB?
- Public Education
- Public Education should cover cough etiquette (how to cough when in publication form); spitting in public places should be avoided. This public education should start right from school days. Also, ensure personal hygiene measures including frequent hand washing.
- Physical distancing and use of face masks - Maintaining physical distance of 2 metres, use of face masks can prevent disease transmission. However, very few patients are capable of spreading disease by touch or cough.
2. Vaccination. In countries like India, the Bacille Calmette-Guérin (BCG) vaccine is given to babies or small children to prevent TB. The vaccine prevents severe forms of TB like TB meningitis and miliary TB, but pulmonary TB still goes on unabated. The quest for a better and more effective TB vaccine is still on. Trials are being conducted in numerous countries, simultaneously and scientists are hopeful that soon the new and more effective vaccine will be available to the world. Experiments are also on for older adults receiving vaccines for minimising disease and deaths due to TB.
3. Nutrition. TB and under-nutrition go hand in hand. After a few trials, the central government has started the Nikshay Poshan Yojana - NPY. Under this scheme a patient under treatment gets Rs 500 per month for 6 months in registered account for additional food as Direct Benefit Transfer (DBT). The patient can call toll free number 1800116666 or log on to National TB Elimination website of Nikshay.
4. Better ventilation and sunlight. Be it a house or the work place, adequate ventilation is an insurance against all respiratory diseases including Pulmonary TB. Ultraviolet rays of sunlight (or via special lamps) kill TB bacilli.
5. Social Stigma. This is so deep rooted that many families do not wish to take a patient for treatment. One cannot get TB from clothes, drinking glasses, eating utensils, handshakes, toilets or rooms where a patient has been to.
The fight against Tuberculosis is a continuous process and needs to move at a faster pace. COVID-19 lockdowns slowed the pace temporarily. This ensured that TB retained its place as the Number 1 killer of infectious diseases. South and South East Asia contribute half the cases of the world.
Progress of TB eradication programs have been hampered by Covid19. P.C.
https://www.ft.com The need is to spread awareness, especially in the under-privileged class around us. Help spread awareness to the home helps (ayah, bai/ male servant), drivers, cools, sweepers and garbage lifters. Guide them to nearest DOTS centre for free testing, treatment and DBT (cash) for food.
Footnote: About the Author
Dr Sharma is an Adjunct Professor at Department of Molecular Medicine at Jamia Hamdard Institute of Molecular Medicine as well as in Jawaharlal Nehru Medical College & Datta Meghe Institute of Medical Sciences (DMIMS), Sawangi.
Prior to this, he has been Professor and Head of Department of Internal Medicine (WHO Collaborating Centre for Research & Training in Tuberculosis, Centre of Excellence for EPTB, MoH & FW, GoI) & at All India Institute of Medical Sciences; New Delhi 110 029, India.
Dr Sharma is also an Alumnus of the Department of Pulmonary & Critical Care Medicine, Harvard Medical School & Massachusetts General Hospital, Boston, USA.
Professor S.K. Sharma's iconic text book of Tuberculosis has evolved over the last 3 decades as 3 editions, reprints (4th edition is shortly due to be published).
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