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Tuberculosis in India – Multidimensional Analysis

Tauseef Ahmad

The problem of Tuberculosis and its rampant elusive spread has shackled the world and particularly India. According to WHO report 2013, out of total number of TB cases 2-2.5 million cases are from India alone.

So it is very important to cover and analyze all the aspects and issues associated with TB in India and world.

Let us connect it with our General Studies paper wise.

Paper 1

  1. Issues associated with Women and their remedies: This topic is very diverse and I think mention of TB affecting women at social and economic level with the efforts to lessen them is worth here.

Here we will look into the affliction of women in TB related issues. There is socio-economic impact of TB on women.

Social Stigma and Economic constraints: Social stigma is pervasive in Indian society, not only TB but with many such diseases. When a person is caught with such disease, they are compelled to live in segregation and societal illiteracy surmounted by negligence creates annihilating atmosphere for them. This cause irreparable damage to their health care and the negligence of society never allow them to open up to the fact of being diseased and share their burden. Women are most prone to such unscientific temper and negligence of society. Indian women, mostly rural populace are more prone to harsh living and as soon as they are caught, they find innumerable alliances against them.

These alliances are twin in nature. First, the disease itself and secondly the pressure due to gigantic responsibility under which they live. The parochial and catastrophic temperament of society for women acts as catalyst under testing circumstances. They find themselves under great stress, mental and physical. Unlike men and children, women in India are preoccupied by many responsibilities and the pressure of being diseased is not borne by their poor family set up.

Gender biasness plays havoc here. Women are more delicate to bear such torments (TB) and the multiple atrocities coupled with social, physical, economical and biological in nature leads to their segregation and moral downfall.

In many places women are also levied for others disease (Superstition). This is most pervasive in tribal and village populace. Family responsibility, poor background, illiteracy and grave superstition have led Indian women to live a life of hell.

The condition aggravates when a women is pregnant. Many a times the threat of physical abuse coupled with superficial care taking is found.

Note: Add the role of NGO and SHG working for the cause. Do add other points of relevance. The issue of social stigma is also related to ethical domain. So connect accordingly. (Hint: Human Rights Issues)

  1. Effect of Globalization on Indian society:

One of the negative aspects of globalization is “Diseases of Globalization”.

Although TB is pervasive in India from ancient time (mentioned in Ayurveda Samhita and Vedas) but ineffectiveness to deal it in contemporary times has some relation to globalizing trend and intermixing of people. HIV and Diabetes needs special emphasis here and these two gives a bigger picture on how globalization of disease has bent the very backbone of citizen’s health issues.

          TB and HIV:

People living with HIV are more likely than others to become sick with TB. Worldwide, TB is one of the leading causes of death among people living with HIV. The main factor is low immunity among HIV patients. India has major patients of TB and HIV aggravates the condition.

Among people with latent TB infection, HIV infection is the strongest known risk factor for progressing to TB disease. A person who has both HIV infection and TB disease has an AIDS- defining condition.

WHO Report on TB-HIV

At least one-third of people living with HIV worldwide in 2012 are infected

with TB bacteria, although not yet ill with active TB. People living with HIV

and  infected with TB  are 30  times more  likely  to  develop  active  TB  disease than  people without  HIV.

HIV and TB form a lethal combination, each speeding the other’s progress. Someone who is infected with HIV and TB is much more likely to become

sick with active TB. In 2012 about 320, 000 people died of HIV-associated

TB.  Almost 25% of deaths among people with HIV are due to TB.   In 2012 there were an estimated 1.1 million new cases of HIV-positive new TB cases, 75% of whom were living in Africa. As noted below, WHO  recommends  a  12-component  approach  to integrated  TB-HIV  services,   including  actions  for  prevention  and  treatment of infection  and  disease,   to  reduce  deaths.


According to the government-run Revised National TB Control Program (RNTCP), people with diabetes have a two-three  times higher risk  of  TB  compared  to  people without diabetes and  about  10  per  cent  of  TB  cases globally   are  linked  to  diabetes. People with diabetes who are diagnosed with TB, an infectious disease of  the  lungs,  have  a  higher  risk  of  death  during  TB  treatment  and  of  TB relapse  after  treatment  is  over. “Diabetes is complicated by the presence of infectious diseases like TB.

The  reason  behind  diabetes  patients  easily   contracting  TB  is  the  low   immunity   in  them  that results in higher chance of infection. Diabetes  can  lengthen  the  time  to  sputum  culture  conversion  and  theoretically   this  could  lead  to the  development  of  drug  resistance  in  TB  patients.

Paper 2


  1. Government policies and design : National TB Control Program, Revised National TB Control Program : Issues (Major crux)

First let us understand the basics of TB, issues in TB control mechanism and related terms.

In this section we will learn the importance of whole issue involved with TB for which it has been in news from past few months. The reason of course is not good but pathetic.

In 2012, India’s golden jubilee year of TB control, the World Health Organization (WHO) named India the worst performer among developing nations, with 17 per cent of the global population carrying 26 per cent of the global TB burden. In WHO’s Report, 2013, India is lamented as worst performer.

Tuberculosis was very much in news because of:

  1. Shortage of drugs,

  2. Increasing case of Multi-drug and Extensive drug Resistance leading to failure of India’s Revised TB control program and questioning the mechanisms involved to check this menace.

  3. Total drug resistance (TDR) as a veritable death warrant and inefficiency to tap and notify this. Even WHO is yet to notify this in spite of its solid recognition in few nations including India.

  4. Popularly used serological tests for diagnosis being declared worse than useless, TST tests, Gamma ray tests, Blood tests and bottlenecks in them.

  5. A government order for mandatory case notification making TB a notifiable disease.

  6. Private practitioners are legally authorized to treat TB, but without quality check mechanisms.

  7. Volunteers are least expertise and literate to handle the cases legally and ethically.

  8. Pediatric TB and issues associated with it.

  9. Contact screening

          Now let us understand TB


Tuberculosis is caused by various strains of mycobacterium, usually Mycobacterium tuberculosis. It usually attacks the lungs but can also affect other parts of the body. It is spread through the air when people who have active MTB infection cough, sneeze, or spit. In most cases the disease is asymptomatic, latent infection, and about 10% latent infections eventually progresses to active disease. If untreated, it kills 50% of its victims. One third of the world’s population is thought to be infected with M. tuberculosis, and every second a new infection occurs. About 80% of the population in many Asian and African countries test positive in tuberculin test.


Until 50 years ago, there were no medicines to cure TB. Now, strains that are resistant to a single drug have been documented in every country surveyed. Drug-resistant TB is caused by inconsistent or partial treatment, when patients do not take all their medicines regularly for the required period because they start to feel better, because doctors and health workers prescribe the wrong treatment regimens, or because the drug supply is unreliable. A particularly dangerous form of drug-resistant TB is multidrug-resistant TB (MDR-TB), which is defined as the disease caused by TB bacilli resistant to at least isoniazid and rifampicin, the two most powerful anti-TB drugs. Rates of MDR-TB are high in some countries, especially the former Soviet Union, and threaten TB control.


TB that is resistant at least to isoniazid and rifampicin the two most powerful first-line anti-TB drugs are called the Multidrug-resistant tuberculosis (MDR-TB). It develops because the when the course of antibiotics is interrupted and the levels of drug in the body are insufficient to kill 100% of bacteria. This means that even if the patient forgets to take medicine, there are chances of developing MDR-TB.

MDR-TB is treated with second line of anti-tuberculosis drugs such as a combination of several medicines called SHREZ (Streptomycin+isonicotinyl Hydrazine+Rifampicin+Ethambutol+pyraZinamide) +MXF+cycloserine.


When the rate of multidrug resistance in a particular area becomes very high, the control of tuberculosis becomes very difficult. This gives rise to a more serious problem of extensively drug-resistant tuberculosis (XDR-TB). XDR-TB is caused by strains of the disease resistant to both first- and second-line antibiotics. This confirms the urgent need to strengthen TB control. Thus, Extensively-drug resistant TB (XDR-TB) is a sub-set of MDR-TB which is               further resistant to at least two more drugs which are second line drugs and is thus virtually incurable.


Totally drug-resistant tuberculosis (TDR-TB)

It is TB which is believed to be resistant to all the first and second line TB drugs. TDR-TB has resulted from further mutations within the bacterial genome to confer resistance, beyond those seen in XDR- and MDR-TB. Development of resistance is associated with poor management of cases. Drug resistance testing occurs in only 5% of TB cases worldwide. Without testing to determine drug resistance profiles, MDR- or XDR-TB patients may develop resistance to additional drugs. TDR-TB is relatively poorly documented, as many countries do not test patient samples against a broad enough range of drugs to diagnose such a comprehensive array of resistance. The United Nation’s Special Program for Research and Training in Tropical Diseases has set up a TDR Tuberculosis Specimen Bank to archive specimens of TDR-TB.

India started its TB program with National TB Control Project in 1962 and used BCG as its main intervention. Few years later The Expanded Program on Immunization took over BCG vaccination (1978).

This strategy and program didn’t work for India and results were disastrous as BCG trials responded badly and showed no protection against infection by TB bacilli (1979)

It was recognized that TB control project has been out of its reach and needs effective restructuring.

India launched Revised National TB Control Program on the backdrop of WHO recommended DOTS strategy after piloting tests from 1993 to 1996.

RNTCP is a fully Central Sponsored Scheme and works for free from diagnosis to treatment. It uses DOTS strategy of WHO and all component of STOP TB strategy of WHO.

It had two phases. First phase was from 1998 to 2005 where focus was on ensuring expansion of quality DOTS services to the entire country. The second phase (2006-2011) concentrated on extensive services and set target to detect the rate of new smear positive cases (70%) and maintain a cure rate of at least 85%.

DOTS: Direct Observatory Treatment Short-course

It is a key component of the WHO campaign to Stop TB strategy. India’s RNTCP is premised upon DOTS. It involves the volunteer’s (trained health professionals) based health services to patients, drugs and services are provided at the doorstep of patients and service provider keeps a track on the diseased.

Key elements:

  1. Sustained political and financial commitment

  2. Diagnosis by quality ensured sputum-smear microscopy test

  3. Standard short course anti TB treatment given under direct and supportive observation

  4. Regular and uninterrupted supply of anti TB drugs.

  5. Standardized treatment and reporting

As a part of DOTS strategy health workers counsel and observe their patients swallowing each dose of powerful combination of medicines and keeping track on their complete drug usage.

In 2012, WHO’s Annual Report on TB reported that though DOTS saved lives from TB mortality but has failed to control TB.

Why this happened?

The Revised National TB Control Program (RNTCP) achieved country-wide coverage in March 2006 and achieved 86 per cent treatment success rate in recent years. More than 15,000 suspects are examined for the disease every day and about 3,500 patients are started on treatment. And to its credit, for the very first time in 2007, RNTCP achieved the global target of 70 per cent case detection (53 cases per 100,000 populations per year).

Despite these impressive achievements, India has the highest TB burden in the world — 3.5 million active TB cases. The number of new active TB cases detected every year is over two million; it was 2.2 million in 2011. And the disease kills two people every three minutes. Incidentally, the incidence and prevalence figure is not a true indicator of the ground reality reason being the number of patients treated by the private sector is not known.

But why is India continuing to record the most number of TB patients in the world every year? A closer inspection reveals that the program is far from perfect and may require a thorough re-examination of both design and implementation. The massive country-wide drug stock-out crisis that played out recently is, but, just one of the malaises that the program faces.

Issues in RNTCP

The national TB control program (RNTCP) uses a passive system for diagnosing TB patients. The design of the system is such that it waits for patients to walk into the centers to get tested. It is well known that patients walk into these centers quite late in the day. And in the process, they end up infecting many people. That a single active TB patient who is not on treatment is capable of infecting 10 or more people in a year shows how badly our RNTCP program is in need of a reorientation. It has to necessarily shift gears and seriously consider changing its strategy from the current passive case-detection system to an active mode of detecting cases.

For those with extra-pulmonary TB, a sputum test will not help in diagnosis. RNTCP is not interested in them as they do not spread TB bacilli. So, the project illustrates incomplete health care and inadequate public health.

“Control” is a defined term in epidemiology — the disease burden should be reduced to a pre-stated level, within a stipulated period of time, and proven to be due to intervention and because of a “secular trend.” As socio-economic status increases, TB should decline even without specific interventions that is a “secular trend.” RNTCP has not set control targets in terms of a time frame and disease burden. It is not measuring a secular trend. Thus, the “control” in RNTCP is not epidemiologically sound.

The Centre, in line with WHO recommendations, had sent an advisory few months ago, to discontinue serological (or blood-based) tests to diagnose TB, as its results aren’t accurate. But serological tests continue to be used in labs across the India, for economic reasons, say several studies done by TB experts. It doesn’t have the stigma and low-margins of a sputum-smear microscopy — the basic TB test. And it is as expensive as a liquid culture test.

Private practitioners are legally authorized to treat TB, but without quality check mechanisms. They often bypass the prescribed treatment protocol, while MDR, XDR and TDR result from non-protocol drug treatment. They also encourage serological tests which are banned.

In young children, infection can rapidly lead to disease, called childhood TB, which can be serious and life-threatening. BCG fails to protect against infection by TB bacilli, but protects against infection progressing to childhood TB. Thus, universal neonatal BCG vaccination saves thousands of lives and huge costs for diagnosis and treatment. Childhood TB is not infectious so, treating childhood TB has no role in TB control. So RNTCP is far from recognizing the menace of Pediatric TB which is a major issue.

Historically, though, there has been less investment in TB medicines, because majorities of the affected were poor, and therefore, there was little market incentive for the industry to invest in this area.

Note: Kindly address the missed issues of relevance!

DOTS Plus Strategy: For addressing issue of MDR-TB ( Add your points )

2. Role of NGO and SHG

Vasavya Mahila Mandali (VMM), a city-based NGO, has brought into play the ‘Snakes and Ladders’ board game to educate TB and HIV-afflicted unlettered patients in the community on the series of ‘Do’s’ and ‘Don’ts’.

The board used by the NGO reads “ART & TB DOTS (Direct Observation Therapy Short Course) Medicines – Good Practices.”

Such initiatives and many more for awareness and proper implementation of government policies, we need a huge back up from our civil society and voluntary organizations.

The role of NGO’s and SHG is very important in effective policy implementations of government plans and policies. We already learnt that how lack of awareness and proper care taking is done. NGO and SHG may be capitalized by government to provide health care system with volunteers to work for government plans at ground level.

Note: Add the case studies by specific NGO’s and SHG’s whereby volunteers work for government plans under PPP and contractual basis.

3.Vulnerable sections: Children- Pediatric TB

According to WHO, the risk of developing the disease is “much greater” in infants and those below five years who have been infected than those above the age of five. In infected children below five years, if the disease does develop, it usually does so “within two years of infection.” But in the case of infants, the disease can set in within a matter of 6-8 weeks of infection.

How far we are from even contemplating a radical change in our case-detection approach can be assessed by looking at how the WHO-recommended, RNTCP-approved contact screening of children below five years in households where an adult has been recently diagnosed with active pulmonary TB (sputum smear positive) is carried out. Children below five years from such households are most vulnerable to getting infected and probably developing active TB.

As a preamble, one has to only examine the differences between the WHO guidelines and the RNTCP guidelines to understand the extent of disconnect. While the WHO recommends contact screening in children below five years, RNTCP has it as below six years. This is the major issue of concern =D

Screening children would help in diagnosing those who have already developed the disease (active TB) as well as those who have been infected but yet to develop the disease.

While treatment for those who have developed the disease would be through the routine multi-drug regimen. Children who have been infected but have not yet developed the disease are ideal candidates for a preventive therapy.

Contact screening of young children combined with chemoprophylaxis (preventive drug therapy) would go a long way in breaking the TB transmission cycle and reducing the case load by preventing the number of people who would become TB patients.

Contact screening does not require many additional resources and can be implemented through the existing system if compliance is ensured through adequate monitoring and supervision.

Indian Scenario:

As per 2008 survey, Only 14 per cent of children aged 6-14 years were screened for TB and only 19 per cent (16 of 84 children) of children below six years were initiated on preventive therapy. There was no difference between urban and rural areas in terms of preventive therapy initiation. It has not been prioritized by RNTCP. No reporting of this activity is required.

Health care workers (HCW) in rural areas were themselves less aware of contact screening and preventive therapy in young children. Awareness level among HCWs that immediate family members are more susceptible to infection was “significantly lower” in rural areas. Only one-third of parents in rural areas were aware of contact screening and the need for preventive therapy in children below five years.

The DOTS -TB treatment card of the adult (index patient) has no provision for documenting the details of contact screening, preventive therapy, follow-up and treatment completion.

As a follow up, some improvements like all the health workers, medical officers to DOTS workers were provided basic training on all aspects of contact screening and preventive therapy. And a separate preventive therapy register and card were also introduced in line with the WHO recommendations. After this, 2013 study in same area reveals that the results were quite dramatic. The health workers were able to identify 82 per cent of child contacts. Sixty-one per cent (53 children below six years) were screened for TB disease and put on preventive treatment. Of the 53 children, 74 per cent (39 children) completed the treatment. This is a huge improvement compared to just 19 per cent children who were even initiated on treatment in 2008.

Issues in diagnosing TB in Children

It’s a fact that diagnosing TB in children less than five years is a challenging task. As WHO’s “Roadmap for childhood Tuberculosis, has pointed out, there are no “effective diagnostic tests.” Unexplained loss of more than five per cent of the highest weight recorded in the past three months, or fever and/or cough for more than two weeks make TB more likely, especially when the child has been in contact with an infectious pulmonary TB patient in the same household. Yet, diagnosis cannot be made on the basis of clinical symptoms alone.

Young children will not be able to produce sputum. This is largely because their cough reflex is not fully developed; they tend to swallow the sputum. Sputum is the most basic and important sample for diagnosing pulmonary TB disease.

Even when a sputum sample does become available, it may contain only a few TB bacteria. So it is hard to see a few bacteria under microscopy. So, pediatric TB is called “Pauci-Bacillary disease” (fewer bacilli). The sensitivity of diagnosis by smear microscopy and culture depends on the amount of bacteria present in the sample.

But even in the absence of sputum sample for micro-bacterial confirmation, much information can be gained from tuberculin skin test (TST) and X-ray results. Though infected, TST can be negative in infants because their immune system is not mature. This is where chest X-rays come in handy.

“Positive chest X-rays (e.g. enlarged lymph nodes inside the chest) are also indicative of TB. But X-rays can be abnormal due to many diseases (e.g. bacterial or viral pneumonia, asthma).If X-rays are abnormal, that pushes the diagnosis towards active TB, not latent TB. But X-ray results need to be used along with other tests. A positive TST and suggestive X-ray, plus history of close contact with a TB case in the house, and symptoms (e.g. not gaining weight, fever) are most likely to point to TB diagnosis.”

The recently updated national guidelines on pediatric tuberculosis lay great emphasis on bacteriological confirmation using sputum samples even when chest X-ray is suggestive and TST is positive, and the child has received a complete course of antibiotic treatment.

In cases where sputum is not available for examination or sputum microscopy fails to demonstrate, alternative specimens (gastric lavage, induced sputum, broncho-alveolar lavage) should be collected, depending upon the feasibility, under the supervision of a pediatrician.

Facilities to collect sputum using the two different lavage methods from those under five years are available only in the tertiary centers in the urban areas. So what percentage of children from the rural areas would end up getting correctly diagnosed and treated, is a question to be addressed? Incidentally, RNTCP aims to achieve “universal access” to quality assured TB diagnosis and treatment during 2012-2017. But near future and present status abhor all these claims.

That’s a very tall order considering the fact that even tuberculin is often not available in peripheral health facilities.

Treatment and Diagnosis: Issues

  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 and the reaction formed on the arm determines the result of the test.

Useful in diagnosis of infection in children where others methods generally fail.


  •  Non-availability of diagnostic tools like tuberculin.

  • Though infected, TST can be negative in infants because their immune system is not mature.

  1. 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


  • Performs poorly in children, especially in those under five years.

  •  Sensitivity is only about 50-60%

  1. 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.


  •  It has sensitivity limitations and takes several weeks to yield a clinically useful result.

  •  more complex and expensive

  1. 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.


  • In countries where resources are more limited, there is often a lack of X-ray facilities.

  1. Interferon gamma release assays (IGRAs)

A new type of most accurate TB test through which results can be available within 24 hours and 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.

  1. 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.

Introduction of newer diagnostic tests such as Xpert MTB/RIF which can detect MDR-TB from the sample as well as resistance to rifampicin, a surrogate marker for MDR-TB, in less than two hours has become important to rapidly diagnose MDR-TB.

Earlier Solid culture method result can be obtained only after 4 months, Liquid Culture method result in two months, Line Probe Assay test single MDR sample result obtained in two days, Now Gene Xpert result can be obtained within two hours.

Problems with Xpert MTB

Need for a constant supply of electricity, the high cost of the instrument and cartridges. Waste management of cartridges and its utility in extra-pulmonary and smear negative samples has been questionably low.

  1. Issues related to social sectors : Health

Here we shall connect the bottlenecks in India’s health care policies and services. Mention and advocacy of PPP to lessen the burden on government is one way to address the issue in contemporary times. Lack of resources and proper channelization of resources are also important reasons.

Note: Add specific points as per your convenience.

  1. Issues related to Poverty and Hunger (Malnutrition): One of the reasons for ineffectiveness of TB control in India and world.

    Note: I discussed it under economic impact but do make your points and connect


  1. World Health Organization : On TB, Reports on India

        Many of the things have been addressed already.

        WHO response

WHO’s pursues six core functions in addressing TB.

1. Provide global leadership on matters critical to TB.

2. Develop evidence-based policies, strategies and standards for TB prevention,   care and control, and monitor their implementation.

3. Provide technical support to Member States, catalyze change, and build sustainable capacity.

4.  Monitor the global TB situation, and measures to progress in TB care,

Control and financing.

5. Shape the  TB  research  agenda  and  stimulate  the  product ion, translation and  dissemination  of  valuable  knowledge.

6.  Facilitate and engage in partnerships for TB action.

The WHO’s Stop TB Strategy, which is recommended for implementation

by  all  countries and partners,   aims  to  dramatically  reduce  TB  by  public  and private actions  at   national  and  local  levels  such  as:

1.  Pursue high-quality DOT S expansion and enhancement. DOTS are a five-point package to:

a.   Secure political commitment, with adequate and sustained financing

b. Ensure early case detection, and diagnosis through quality assured bacteriology.

c. Provide standardized treatment with supervision and patient support.

d. Ensure effective drug supply and management   and

e. Monitor and evaluate performance and impact;

2. Address TB-HIV, MDR-TB, and the needs of poor and vulnerable populations; Most important

3. Contribute to health system strengthening based on primary healthcare;

4.  Engage all healthcare providers;

5.  Empower people with TB, and communities through partnership;

6.  Enable and promote research.

2. Programs and Policies of other International bodies for TB control:  Already covered

3. Lessons for India from other nations: Do some case studies of African nations where the fight for TB with effective policy has been substantial. What India can learn from them?

Paper 3

  1. Issues related to Planning and mobilization of resources for TB: 5YP and Economic implications of TB

Economic Impacts of TB

The development of new and improved TB treatments that reduce the global TB burden could help increase the productivity of entire regions and promotes sustainable and self-determined economies, opening up new engines of innovation, trade, and industry. The concept of health being a necessary precursor to wealth is as true for the world as a whole as it   is for the individual.

TB Impacts:  The World

TB will  rob  the world’s  poorest  countries  of  an estimated $1  to $3  trillion over  the next 10 years . This  will disproportionately   impact  developing countries ,  where 94 percent  of  TB cases  and 98 percent  of  TB deaths  occur.

Particularly   troubling  for  the prospects of  global  prosperity ,  75 percent  of  TB cases  arise during people’s  most productive years , between  the ages  of  15 and 54.

Poor, crowded living conditions increase the risk of contagious infection.  TB and poverty create a vicious cycle, whereby the disease exacerbates poverty, which in turn increases the likelihood of contracting TB.  This is extremely distressing news   for the 2.7 billion around the world who live on $2 per day or less.

TB Impacts: Countries

The World Bank estimates that   loss of productivity attributable to TB is 4 to 7 percent of some countries GDP.  Entire economies are affected by the world’s TB epidemic, stifling human development on a large scale.  Concomitantly , the burgeoning cos t  of  TB medical  care  is  a constant  drain on  those health systems  whose  infrastructures  are  least  able to carry   the  load.  Many TB-endemic nations can’t afford to treat their own patients, leaving donor countries to procure TB drugs for the developing world.  Treatment for drug-resistant TB is financially out of reach for most who suffer from the disease.

Many national healthcare systems are overburdened by the TB epidemic and the infrastructure necessary for TB treatment represents the bulk of their costs i.e about $4 billion annually.  A shorter regimen that eliminates many of the doctor visits could drastically cut those expenses. Funding could then be redirected to basic healthcare and increased resources for TB control. Whole economies would benefit, especially   in nations that bear the brunt of the TB pandemic.

TB Impacts:  Families

TB commonly destroys families where it is prevalent, with women bearing the brunt of   the stigma of   the di s ease.   In TB-endemic regions, the burden of TB is greatest for women in their child-bearing year. Over the next five years, without effective interventions, up to four million women will die from TB and 50 million children will be orphaned.  Further, hundreds of thousands of children will die from TB over the same period.   It is estimated that 250,000 children suffer from TB each year and 100,000 die.  However, TB is notoriously difficult   to diagnose in children and therefore many experts believe the pediatric burden of TB is even higher.

The economic toll on families is also very difficult.  TB treatment  is  often free,  at   least   for drug-sensitive  tuberculosis , but  patients  incur other costs , like  transportation and hospital  costs , at the same  time  they  have  likely  reduced  their working hours  or stopped working completely .  The WHO calculates that   the average TB patient   loses  three  to  four months  of  work-time and up  to 30 percent  of  yearly  household earnings .

A  shorter drug regimen would reduce  lost  work-time and  lessen  the economic  impact  of  TB on  individuals  lives , and in  turn help stabilize  families , save and enrich  the lives of  millions of  children,  and enable a healthier, more productive labor  force  in many  TB-endemic countries.

  1. Inclusive growth : Bottlenecks in Health sector : Done above

  1. Science and Technology: Development and applications of technology in the field of TB

                Mention of Treatment, Tests and technology as TST, XPERT Gene and

                IGRA etc.

               NIKSHAY: Nikshay, jointly set up by Central TB division and National

               Informatics Centre (NIC) in May, 2012, is an online record system

               Monitor TB patients (Add some your points)

  1. Achievements of Indians and Institutes working for TB control and indigenization of technology related to it.

Note: Do it yourself please:


The Sentinel Project on Pediatric Drug-Resistant Tuberculosis is a  collective power of a global  partnership by  experts and others who  share the same vision of  ensuring  that no  child dies of drug-resistant TB  that  is  curable.

One of the most important contributions of the Sentinel Project’s field guide is its algorithm for managing a child who is in contact with an infectious adult with MDR-TB disease. Though WHO has not come out with guidelines on chemoprophylaxis for children, especially those younger than five years, who are close contacts of MDR-TB patients, several other agencies have come out with theirs.  “The question about chemoprophylaxis is not addressed in the same way among several global guidelines,” Prof. Becerra noted.  “But the aim of the Sentinel Project has been to provide guidance on this and other challenges based on the collective expert opinion and observations of colleagues across the globe.”

There are two instances when children aged younger than five years who are asymptomatic, growing well and have no clinical signs of TB but have been in contact with an adult (index case) would be eligible for preventive therapy.

The first is when the index case is resistant to rifampicin drug alone.  In  such a  case,  the  child needs  to be  treated with  15-20 mg/kg of  isoniazid drug  for  six months. The second instance is when the index case has confirmed MDR-TB but is susceptible to Ofloxacin.  In such cases, the child may be treated as per the National TB Program, or by one of the five regimens listed in the Sentinel Project.

Another  important goal  of  the Sentinel  Project  is  to  come as  close as possible  in knowing  the  true burden of TB disease in children. Since bacteriological confirmation is difficult in  children  younger  than  five  years,  there  is a need to have more data on  the number of  children  suffering  from drug-sensitive TB and drug-resistant TB. (The Hindu)

  1. Biotechnology and its role in TB :diagnosis and treatment

              Done already

  1. Food security related:

One of the major causes of TB is the use of tobacco. Due to its pervasiveness there is ineffectiveness in curtailing TB rise. If somehow there is serious control in sale and production of tobacco then it would advertently affect the food security as well as TB. How?

When tobacco’s production would be curtailed then there will be more land for crop production which means more land to poor farmers and government to work in crop intensive agriculture and in turn more food secure our nation will be.

So with one sword, two strikes.

Paper 4

Ethical incapacity among doctors, family and society to treat the diseased under human dignitaries and the international scenario to fight with this menace is endowed with several other challenges to be addressed.

The consequences of TB have been, and continue to be, enormous. The fact that TB primarily affects the poor raises issues of social justice. The  fact  that drug resistance which exacerbates  the TB  threat worldwide is  largely a product of  the way that drugs are distributed  likewise  raises  issues of justice .  Public health TB  control measures  such as isolation and quarantine,   finally,   raise questions about how  the goal  to protect public health  should be balanced against  the goal  to protect individual human  rights and  liberties.

Very recently it has been compounded that deaths due to TB and AIDS has enhanced drastically. It has also been recognized that TB treatment is much more cost effective than AIDS. Even then the ineffectiveness in dealing with TB issue raises several ethical questions.

Mostly TB cases are found in third world nations and developing nations and in-spite of several technological competence of developed world, the moral obligation to help other nations is still perfunctory.

A final  reason  for  thinking  that TB may be ethically more  important  than AIDS  is  that  the  former,  being airborne,   is both  contractible  via  casual contact and much more  contagious.  While behavior modification  (with respect to drug use and  sexual practice)  can essentially eliminate  the risk of  infection with AIDS,  TB  can be passed  from one  individual  to another  via  coughing,   sneezing and even  talking. In many ways the threat to ‘innocent individuals’ and public health in general is greater in the case of TB and needs to be addressed.

Though bioethics discussion often focuses on health workers obligations and patient relationships, and issues of social/institutional policy gives emphasis on ethical obligations of individuals that is to avoid infecting others and treat patients with complete humane behavior.

It would be unreasonable, for example, to expect that potentially infected persons should  take all possible measures  to avoid  infecting others because  ‘potentially  infected persons’   includes all of us who have been  in  contact with  someone who just might have been  contagious without our knowing  it.

In addition to further analyzing, these issues, ethicists should be raising public awareness about the moral imperative of infection prevention.

Coercive Social Distancing

It is common, at least in developed countries such as the US, to confine TB patients who refuse to take their medicines. To what extent is coercive restriction of movement ethically justified in the name of TB prevention? And who, exactly,   should be confined? It is one thing to confine infectious (i.e. contagious) patients who refuse to take their medication. It is quite another thing to confine noninfectious patients.

Third Party Notification

One of the ethical  issues debated  in  the  context of HIV was  the question of whether or not an HIV  infected patient’s  right  to  confidentiality  should,   if necessary,  be breached  to notify a  third party at  risk of becoming  infected by him. Similar questions arise in the context of TB, and they are especially pressing in the context of XDR-TB.  The ethical question for the physician or other health worker  is whether or not  to warn  close  contacts of a patient diagnosed with XDR-TB or a patient  suspected  to have active illness,  while diagnostic  confirmation  is awaited, especially  if  there  is reason  to believe  the patient has not warned  close  contacts of  the danger of  contagion and/or  is  failing  to  take  sufficient precautionary measures. On the one hand, disclosure would apparently violate the patient’s right to confidentiality.  When a patient presents to health care workers, the implicit or explicit promise is that information regarding his health will be held in confidence. In the above scenario,   then,   informing the third party would involve breaking such a promise.

The third party in this scenario, on the other hand, has rights too.  Her/his right to life is seriously threatened if the patient has infectious XDR-TB. While health workers have duties to their patients, they also have duties to save lives of others when they are in a position to do so. The patient’s right to confidentiality in this scenario conflicts with his/her contacts and right to life.

The third party’s right to protection is more important than the incautious patient’s right to protection. While it  is  common  to  conclude  that a health worker  is ethically permitted to breach  confidence  in a  case  like  this,  many hold  the  stronger position that  the health worker  is not only ethically permitted but also ethically required  to breach  confidence  in order  to protect  the  third party.

Duty to Treat

It is commonly believed that health workers have a duty to care for patients even when this poses dangers to health workers themselves. Facing dangers associated with  caring  for infectious patients  is arguably part of a health worker’s  job—just as  it  is a  fire-fighter’s  job  to  face  risks. Facing  such  risks,  one might argue,   is one of  the  things  that a health worker  commits  to when  she  takes on  this kind of employment.   Some argue that the duty to care is based on a social contract. Society provides privileges by way of exclusive training to health workers—but it then expects health workers to provide health care in return.

In addition to duties to immediate patients, health care workers have duties to others.  They have duties  to other/future patients  that  they would not be able  to  treat  if  they die as a  result of  treating  this patient.  And  they similarly have duties  to  family members  that  they  could not  fulfil  in  the event of death.  Though  such duties may  conflict with  the duty  to  treat  ( this immediate patient) , health workers also have duties  to  their  co-workers that  support  their duty  to  treat  ( this  immediate patient) .  Co-workers are part of a team and each expects the others to do their part. If I refuse to treat this patient,  then  someone else  (who might have a  family and would have  future patients)  will be  called  in  to do my  job.

If too many refuse, then the health care system no longer functions.  Solidarity is, therefore, needed.

If the risks are exceptionally high in the context of XDR-TB, then the safety of working conditions must be improved. If  it  is  reasonable  for society  to expect health workers  to  treat patients,   then  it  is also reasonable  that health workers expect  society  ( or  the health  care  system)to provide  safe working  conditions  insofar as  this  is possible.  This is a matter for reciprocity. Compensation to health worker should be given with due appropriation.

International Justice

As a disease of poverty, TB raises issues of international distributive justice.  Though  sufficient  resources  for health  improvement are  lacking  in poor  countries, there are numerous powerful moral  ( egalitarian,  utilitarian and  libertarian)  and  self-interested  reasons  for wealthy nations  to do more  to help  improve health care  in poor  countries. These issues are complex and intertwined with the above questions regarding liberty-violating public health measures.   If health care provision and thus global health were better to begin with, for example, then the occasions upon which liberty infringing public health measures are called for would arise less often.

Because infectious diseases including drug resistant infectious diseases such as XDR-TB, do not recognize international boundaries, bad health in poor countries threatens global public health in general. The strength of associated  self-interested  reasons for wealthy nations  to help  reduce TB  in poor  countries  ( through  targeted or untargeted  funding)   should therefore,   finally,  be a major  focus of analysis.