TB does not behave differently in different situations. However, certain settings can facilitate the spread of the bacterium and trigger the progression of TB infection to disease.
Since TB bacteria are transmitted through the air, exposure to TB bacteria increases when a person shares a confined or overcrowded poorly ventilated area, with little sunlight with someone having infectious TB. Such settings occur when sharing cramped living areas with a large transient population. Some examples are prisons, refugee camps, and brothels.
Moreover, prisoners, sex workers and refugees usually belong to the low socio-economic group and therefore have poor nutrition. The enclosed environment would lead them to further nutritional deprivation, which enhances the possibility of developing TB.
Closed environments offer excellent opportunities for effective TB control due to defined and limited area of occupation and increased bonding leading to the formation of a mutually supportive community.
Prerequisites for TB control in closed environments should include:
A clear policy for TB control programme.
Sufficient funding to last for at least 12 months for regular supply of drugs and laboratory materials
A full-time experienced TB coordinator should be appointed with a well-trained TB control team.
Laboratory services for sputum microscopy should be available.
Long term commitment of the parties involved.
Measures to reduce transmission should be taken.
Health education should be imparted to the population.
PRISON:
TB notification rates in prisons are many times greater than that for the general population. TB is considered to be the single biggest cause of death among the world’s prison populations. Despite Tb’s endemic nature in Asia, TB among prisoners is not well documented.
Prisoners are vulnerable to TB because:
prisoners are from the most disadvantaged socioeconomic strata of society, mostly males, 15 – 44 years of age and therefore may enter the prison with a high risk of prior TB infection/disease.
prisoners have poor nutrition, before entering the prison as well as the poor diet inside the prison.
prisons are overcrowded and have poor ventilation.
prisoners may be HIV-positive before due to injecting drug-use. In some countries, up to 70% of prisoners with TB are also infected with HIV. The vulnerability of prisoners to punishment, sexual violence can increase the risk of transmission of HIV, which accelerates the progression to TB disease.
poor health care of prisoners due to low budgetary allocations, poor treatment management
unstable environment with prisoners being transferred or released before completion of treatment
Prisons are reservoirs of TB and threaten not only the inmates, but the prison staff, visitors and community. As with any confined and limited environment effective TB control activities can be initiated.
REFUGEE CAMPS:
Over 85% of refugees originate from and remain within areas of high TB burden, of which up to 50% may be infected.
TB becomes an important health problem in many refugee settings once the emergency phase is under control. Due to the changing nature of low-intensity conflicts in today’s world, complex emergencies are becoming common and refugees are forced to remain outside their countries for prolonged periods of time.
Refugee populations are vulnerable to TB because of:
overcrowding
poor nutrition
high transmission/incidence of HIV
coexisting communicable diseases
high stress
poor health care
unstable environment
As with any confined and limited environment effective TB control activities can be initiated.
BROTHELS:
The conditions that sex workers are forced to live in combine the worst facets of prison life with many of the features of being a refugee.
More than one million children, mostly girls, are forced into prostitution annually, the majority in Asia. Many have been forced into prostitution due to unemployment and abject poverty.
Sex workers are vulnerable to TB because of:
Poor living conditions
Socioeconomic disadvantages
Poor nutrition
Mobile population of clients and sex workers puts them at risk of HIV infection
High rates of HIV
Poor access to health care
Outcast by society and therefore do not come out in the open.
As with any confined and limited environment effective TB control activities can be initiated, however, with a more creative response. In addition to the usual TB control activities, peer as treatment supervisors and health educators would help increase access for TB treatment to this population. The TB control programme should enlist the cooperation of brothel owners.
SOURSE: www.searo.who.int
200,000 TB Deaths Due to Beedi-smoking in India: Report - May 14, 2008
An Indian health ministry report was released on Monday, listing the prevalence of beedi smoking, its consequences - both economic and health wise - and public health policy strategies.
The report highlighted that an estimated 100 million people - mostly from the poor and illiterate section of the Indian population- smoke beedi or hand-rolled cigarettes in India. Smoking beedi caused 200,000 tuberculosis deaths, says the report.
The first analytical, scientific and systematic study on the beedi-smoking trend for the year 2004-05 was sponsored by the Indian Union Ministry of Health supported by the World Health Organization, Center for Disease Control and Prevention in Atlanta and the US Department of Health and Human Sciences.
The study led by Prakash C. Gupta, director of Research at Healis, Sekhsaria Institute for Public Health in Mumbai that supported the study, and Samira Asma observes that though beedi smoking causes the same diseases as cigarette smoking does - lung cancer, oral cancer, heart diseases, lung disease and addiction, it is more harmful than cigarette smoking.
Beedi is the cheaper Asian version of cigarette wherein tobacco is hand-rolled in ‘tendu’ leaves. Smoking beedi is considered more harmful than cigarette smoking because it contains more tar, nicotine, carbon monoxide, carcinogenic hydrocarbons and other toxic and class A carcinogenic substances such as nitro amines (NNN and NNK). However, beedi has less tobacco than cigarettes.
“In India, beedi smoking contributes substantially to death from tuberculosis,” said Health Secretary Naresh Dayal.
He also added, “One million of the estimated two million cases of tuberculosis in India are due to smoking. But beedi smokers with tuberculosis are at three times higher risk of death compared to TB patients who are non-smokers.”
According to the report, about 85 per cent of the world's beedi is produced in India in 290,000 beedi-making units. Beedi-rolling centers are predominantly in West Bengal, Andhra Pradesh, Tamil Nadu and Karnataka where cheap labor is available.
Beedi from India is also exported to the US, marketed in various flavors like cherry, mango, honey, strawberry and chocolate. About 14 brands of filtered and unfiltered beedi brands are marketed to the US of which 5 brands come under the ‘herbal beedi’ tag.
The study titled “Beedi and Public Health” records that there are more beedi smokers than users of any other kind of tobacco products. “Beedi is the most widely used form of tobacco. There are 240 million tobacco users of which 100 million smoke beedi," health secretary Naresh Dayal said.
The habit is found the highest in rural Muslim males and next in rural Hindu males. The habit of beedi-smoking is also found in children who are 8-10 years old.
Beedi smoking is harmful for not just smokers, but in the case of passive smoking in those exposed to second-hand smoke as well.
“Beedi also harms workers rolling beedis through inhalation of tobacco dust, while farmers and farm workers handling tobacco crop also suffer severe health problems,” the report said.
A
survey of tuberculosis hospitals in India.-
2004 Oct
Stop TB Department, World Health Organization,
5th floor, A Wing, Nirman Bhavan, New Delhi,
India. singh_a@vsnl.com
SETTING:
Hospitals with beds for tuberculosis (TB)
in India.
OBJECTIVES:
To assess diagnostic and treatment practices
at institutions offering secondary or tertiary
level care for TB patients, and to determine
the resources being used at these institutions.
DESIGN:
Countrywide cross-sectional survey of TB
hospitals using a mailed semi-structured
questionnaire sent to all 105 hospitals
with 100 or more beds and to all State Directorate
Health Services.
RESULTS:
The 94 hospitals that returned the questionnaire
had 15773 TB beds, one third of the total
TB beds in the country. Nearly 1 million
patients sought treatment in the TB hospitals
and one third were diagnosed with TB; the
ratio of smear-positive to smear-negative
patients was 1:2.7. Sixty-four per cent
of hospitals prescribed unobserved rifampicin
in the continuation phase, and 56% of sputum
smear-positive patients were hospitalised.
The annual expenditure for the TB hospitals
was more than the total annual budget for
the TB control programme of the country.
CONCLUSIONS:
In view of the high number of patients seen
and the suboptimal practices observed, urgent
steps should be taken to ensure implementation
of correct diagnostic and treatment policies
in hospitals with TB beds.
PMID: 15527159 [PubMed
- in process]
KNOWLEDGE,
ATTITUDES, AND BEHAVIOR: Care-seeking behavior of
chest symptomatic studied
Tuberculosis Week - July 28, 2003
Tuberculosis specialists in India conducted
a study to "identify the factors
that influence the care-seeking behavior
of chest symptomatic in urban and rural
areas in South India."
Data were collected from interviews of
310 urban residents in Tamil Nadu, Madras,
in South India, and 339 inhabitants of
rural parts of the region.
G. Sudha and colleagues, Indian Council
of Medical Research, Tuberculosis Research
Center, said that 80% of the urban dwellers
they interviewed and 63% of those in rural
areas had sought care (p<0.01). And
most of these didn't delay too long: 93%
sought care within a month of onset of
their symptoms.
"Private health care facilities were
the first and preferred point of contact
for 57% of urban and 48% of rural participants;
the major reasons were proximity to residence
and their perception that good-quality
care would be available there," Sudha
and associates said.
Three factors were cited as main reasons
that symptomatic did not seek care:
they thought their
symptoms were not severe enough (51%)
they couldn't afford
care (46%)
they didn't have
time to seek care due to work pressures
(25%)
Sudha and colleagues reported that "socio-economic
factors such as literacy and family income
significantly influenced care-seeking
behavior."
The researchers summarized: "Our
results indicate that most chest symptomatic
seek care promptly; their initial response
is to go to the nearest private health
care facility, shifting to another if
they are dissatisfied. Fifty percent of
the participants who did not seek care
felt that their symptoms were not severe.
Sudha and coauthors published their study
in Tropical Medicine & International
Health (Factors influencing the care-seeking
behaviour of chest symptomatic: a community-based
study involving rural and urban population
in Tamil Nadu, South India. Trop Med Int
Health, 2003;8(4):336-341).
Additional information can be obtained
by contacting G. Sudha, Indian Council
Med Research, Tuberculosis Research Center,
VR Ramanathan Rd., Spurtank Rd., Madras
600031, Tamil Nadu, India.
The publisher of the journal Tropical
Medicine & International Health can
be contacted at: Blackwell Publishing
Ltd., 9600 Garsington Rd., Oxford OX4
2DG, Oxon, UK.
The information in this article comes
under the major subject areas of Tuberculosis,
Risk Factors, Behavior.
TUBERCULOSIS
RESEARCH CENTRE
Chennai, India
WHO Collaborating
Centre for Tuberculosis Research & Training Research Activities at the Tuberculosis
Research Centre
The Tuberculosis Research
Centre (TRC) is a leading research institution
in the field of tuberculosis. The Centre
is a permanent institute of the Indian Council
of Medical Research (ICMR). It is globally
recognized for its contributions in the
field of tuberculosis. The strength of this
institution lies in its ability to identify
and carefully characterize various populations
of patients with tuberculosis and follow
them up for periods as long as 5-10 years.
This has been possible due to the excellent
teamwork that has been built up over the
last 4 decades. The Centre has on its staff
well-trained clinicians, epidemiologists,
biotechnologists, social workers, health
visitors and bio-statisticians to carry
out these studies.
National
Tuberculosis Institute, Bangalore
WHO Collaborating Centre for Tuberculosis
Research & Training
The NTI is designated as
WHO Collaborating
centre for TB research & training
since June 1985. The activities as a collaborating
centre are as follows
To organise training activities in
TB control for medical and paramedical
personnel, in policies and Procedures
consistent with the WHO-recommended
DOTS strategy.
To monitor and supervise the TB Control
programme in the country.
To plan, coordinate and execute TB
research in epidemiology, surveillance
of drug resistance and operations of
control strategies relevant to regional
and national programme delivery.
To augment the dissemination of information
on TB and its control by tapping the
potentials of the existing Library and
Information Dissemination Services.
TB
is a killer, but Pune is fighting it
Pune, August
23: After a long wait on the steps of the
entrance to the Department of Chest and
Respiratory Diseases at Sassoon General
Hospital (SGH), a listless Nathu has been
told at the OPD that he has to be admitted
for treating Multi-Drug Resistant Tuberculosis
(MDR-TB). A daily wage labourer from Bhor
(45 km away from Pune), Nathu has been unable
to work for a year. His wife’s salary
as a house maid and from doing jobs fetches
them Rs 400 a month. Two children aged four
and six miss school most days. And Nathu
has already spent close to Rs 10,000 for
the “right treatment” for curing
TB.
Twenty-two-year-old Ramesh from Parli village
in Beed district (350 km from Pune) hasn’t
been able to attend classes at the Nehru
College for a year. A TB patient, he underwent
the Directly Observed Treatment Short Course
(DOTS) for six months, but he is a likely
patient of MDR-TB. He boards his bus at
9 pm from Parli and reaches Pune at 7 am
the next day to see doctors at Sassoon and
KEM Hospital. There are no facilities for
treating him at Parli and now Ramesh needs
to be admitted.
Nathu and Ramesh are tell tale cases of
TB patients who have to depend on the treatment
facilities in Pune. In Pune district, there
are 5,755 patients receiving Directly Observed
Treatment Short Course (DOTS) at 1,199 DOT
centres and 100 designated microscopy centres
(DMC).
The DOTS programme ensures the patient adheres
to the treatment. “Even if one misses
a dose, he/she is traced and given the dose
the next day,’’says Dr S R Karad,
Pune District TB Control officer. In fact,
DOTS programme has contributed immensely
for the success of the Revised National
Tuberculosis Control Programme (RNTCP) of
the Union health ministry since it keeps
a tab on each and every patient under its
regime.
Today, more and more TB patients are being
identified. Outlining the DOTS methodology,
Karad said before a patient is put on the
anti-TB drug regimen, his/her address is
verified. And if someone misses a dose,
they are called from their homes and referred
to the nearest DOT centre where community
workers and senior supervisors ensure the
patient takes the medicine in their presence.
Normally, the tendency is not to come back
for treatment as patients often start feeling
better after two months. “But our
staff ensures they are back,” says
Karad pointing to Suresh Sarode from Solapur
who is now a “relapse case”
who has had to be admitted at Sassoon.
But treatment and admission pose their own
set of problems for TB patients. For instance,
at the government Sassoon General Hospital,
the department of chest and respiratory
diseases is located bang opposite the morgue
and several proposals to build a compound
wall between them have yet to see the light
of day.
“We have to live with the stench.
Patients cover their faces and look at the
mournful faces around. This is a daily occurrence
for the last 50 years,’’ adds
Karad.
Moreover, if a patient has to be admitted,
he/she has to go to the Pune Chest and General
Hospital at Aundh, which is almost an hour
away from Sassoon which has no ward to isolate
and treat TB patients. So Sassoon’s
patients are being accommodated at the Aundh
hospital.
But aren’t there facilities at Sassoon?
Karad’s reply is a replay of a familiar
story. “There is a proposal to construct
a new building to admit patients and include
the OPD at Sassoon hospital. But nothing
has happened.”
At the Aundh hospital, 120 of the 400 beds
have been reserved for TB patients who,
normally, have to stay on for at least three
months paying a paltry Rs 10 per day. But
despite having segregated the TB ward, the
hospital doesn’t attract “general
patients”, says medical superintendent
Saroj Maheshgauri.
Built originally for “keeping TB patients
in isolation”, the hospital was packed
to capacity during the 70s. Eventually,
the success of the RNTCP saw the number
of patients come down drastically. But the
stigma of being a “TB hospital”
prevents it from being a fully functional
general hospital.
Killer TB
TUBERCULOSIS kills more adults than any
other infectious disease. It is curable,
yet it claims the lives of more than four
lakh people in India every year. Every day
more than 20,000 people become infected
with TB bacillus and about 5,000 develop
the disease. Untreated pulmonary TB cases
spread infection to others in the community
— each infectious patient can infect
10-15 persons a year unless effectively
treated.
