Tuberculosis (TB) has been number one killer of women in general and in their reproductive age group in particular for almost two decades. Women are most vulnerable to TB infection as they only are health care providers in the family for the ailing in-laws, husband and children afflicted with TB. Prompt medical care to women infected with TB is not available in rural areas and urban slums, as seeking medical help and diagnosis is delayed usually. With delay in diagnosis there is delay in starting treatment as well. Unwillingness to spend on continued treatment for the entire 6 month period of the course is yet another major barrier to their cure. It is not unusual to find that when women get infected, they are sent back to their parental home for treatment or deserted in many cases. Besides neglect by family members, she neglects herself as well.
In the present DOTS treatment, diagnosis and treatment of TB pose another problem for women as they need to leave home, travel to a health centre escorted by a male member incurring expenditure on travel and medicines. These clinics are not opened at convenient timing i.e. early morning or late evening when bread winner can spare some time for women. Thus, women fail to obtain quality care in the absence of a support system at home to care for the children and financial capacity to meet the high cost of medicines. Not being in a position to make decisions on financial resources of the family, they postpone or deny themselves urgent health care.
Social isolation of TB patients occurs on the belief that tuberculosis is hereditary or infectious. Non-pulmonary TB, can cause infertility, which is usually difficult to diagnose and even when diagnosed, remains untreated. Women suffering from infertility are invariably deserted or ostracised by family.
Till now, it was felt that overpopulation, poverty and tuberculosis go hand in hand. But TB has crossed all barriers of rich and poor, north and south. It affects everybody. Younger lots of upper class families are especially vulnerable to this disease due to low resistance. You name some celebrities, significant number of them have had this disease. One good point of this disease is that it can be diagnosed and treated provided one follows doctor’s instructions.
In the year 2000, it was estimated that there are 11 million Indians suffering from TB with 3 to 3.5 million being highly infectious. Each year 2-2.5 million are added to the TB pool.
Government of India figures for 2007 are that TB infects eight lakh new people every year . But according to the Indian Medical Association (IMA) experts, it seems grossly underestimated.
According to the death estimates, country was losing 5,00,000 cases every year (data of year 2000) from tuberculosis i.e. one death every minute. This year the Government of India plans to bring down the deaths by TB i.e. 3,30,000 per year. In other words two death every three minutes.
The National TB Control Programme was initiated in 1962. We are still far away from national goal of putting stop to new TB infection. It is estimated that 25 to 38 per cent of all women and men are infected by tuberculosis at one or the other stage of their life. The ratio of persons afflicted with non-infectious (pulmonary and extra pulmonary) tuberculosis to those suffering from infectious tuberculosis of lungs is estimated to be 1.5:1. According to one estimate, the prevalence of active pulmonary tuberculosis is 9/1000 and infectious tuberculosis is 6/1000. This figure seems grossly inadequate.
Studies of National TB Institute (NTI) Bangalore, reveals that 95 per cent of infectious TB patients were conscious of their symptoms in cities and, infact, 50 per cent sought medical help themselves. But public awareness of this disease in slums and rural areas is still non existent.
BCG trials conducted in Chingelpet (Tamil Nadu) by TB Research Center, Chennai showed that BCG vaccination given at birth did not protect children against pulmonary TB. However, the experience of large number of paediatricians showed that BCG did protect them against severe forms of TB (milliary TB and TB meningitis), which take heavy toll of lives. The results of the above landmark studies contributed to shifts in TB care strategies globally. This is indeed a major contribution made by Indian public health experts. This is the very reason the BCG vaccination is still given at birth.
Despite the identification of TB as the major public enemy and the biggest killer of women in the reproductive age group, infection is on the increase. The reasons for this include:
Inadequate budget outlay for TB cure.
Patchy involvement of private sector in TB care.
Inadequate diagnostic and therapeutic facilities for 85 per cent of population belonging to weaker section of the society.
Lack of awareness among patients and inadequate education by the health personnel regarding danger of drug default and emergence of drug resistance.
Non-availability of anti-TB drugs for weaker sections who do not come to government run clinics or hospitals.
Spiralling cost of anti-TB drugs and medical costs.
No training of private doctors on therapeutic guidelines under the revised National TB Control Programme.
Unfortunately, only 10 per cent of the total health budget was allocated to TB. But in 2007, it has been drastically reduced. Government should seriously think that priority in health sector has to be rationalised to take care of number I, II, III, IV killers of women i.e TB/anaemia/ maternal mortality and suicide.
Major shifts are required in the approach to tackle rampant TB in Indian population in more intensive. No accountability along with budget constraints causes weakening of the public health system.
It is estimated that government agencies cannot reach out to 85 per cent of countries population and people are dependent on private doctors. IMA wishes a TB-free India and expects to upscale government’s effort 5-6 times by involving private sector in a big way in all the states.
The IMA launched major TB project of public-private partnership on March 24, i.e. on World TB Day, to realise its dream to check TB in the country. Every doctor and health professional should spend extra 30 minutes with patient and family to emphasise guidelines adhere to treatment, failing which the disease becomes untreatable and drug resistant.
For tuberculosis we should keep in mind that:
TB is a leading killer of the day.
It is a global emergency of today.
Spreading like wild fire, record says.
India shoulders 1/3 global load now-a-days.
Monster kills more than 1000 lives every day.
How pathetic, need not to say.
Poor, malnourished and HIV infected are its favorite preys.
But wicked hands not leave any one who comes in its way.
If cough clogs the airway for more than 21 days.
Inspite of treatment, it stays and you strive for clear airways.
Then rush for sputum exam and X-rays.
If it comes out to be TB,
Jump on to the treatment, don’t delay.
Forget about coins, you need not to pay.
Now DOTS come with bright rays.
It is a service to patient in direct way.
It ensures cure and reduces the spread rate.
Prompt diagnosis and uninterrupted therapy,
Change the marks of weakness from morbid and gloomy lace.
Gender
in Tuberculosis Research
Research
clarifying the role of gender in tuberculosis
control is concerned with specific
sociocultural, socioeconomic, and
structural barriers affecting men
and women, as distinct from sex-based
differences in the biological vulnerability
affecting epidemiology and pathophysiology
of pulmonary TB. This review examines
various studies in the literature
of health and social science research
and recent innovative studies undertaken
by WHO/TDR.
The findings indicate
that women progress from infection
to active TB faster than men do, but
the reported incidence of pulmonary
TB among women is nearly always lower
than for men.
More
women die each year of TB than
of all maternal mortality causes
combined.
Every
year, 300000
children are forced to
leave school because their parents
have tuberculosis, and 100000
women lose their status as mothers
and wives because of the social
stigma.
Tuberculosis
kills more women than all causes
of maternal mortality combined.
In some areas, women face special
problems of access to tuberculosis
diagnosis and treatment because
of stigma and limitations on
mobility.Source:
World Health Report, 1999
Tuberculosis
is reported to be the single
leading infectious cause of
death in women world-wide, killing
over one million women every
year, mainly between the ages
of 15 and 44. Approximately
half a million female deaths
in the Region in 1997 were caused
by TB [3]. Approximately three
million lives globally are lost
to tuberculosis every year,
including about 750,000 in the
South-East Asia Region. Nearly
two-fifths (38%) of the estimated
eight million tuberculosis cases
worldwide each year are from
countries of the Region. Tuberculosis
poses a particular challenge
because of its rapid spread
in recent years, primarily due
to coinfection with HIV/AIDS
and the emergence of drug-resistant
strains.
Surveys carried
out in many countries around
the world show a higher prevalence
rate of TB for men than for
women. The same pattern was
observed in countries of the
Region for which data were found.
In Bangladesh, data from
a national morbidity survey
(1994-1995) showed a prevalence
rate of 118.2 per 100,000
population for males, and
57.4 per 100,000 population
for females, a sex ratio of
2.1 males to 1 female.
Sri Lanka (1996) and Thailand
(1995) also reported a similar
ratio of 2 males to 1 female
In Bhutan, however, almost
equal numbers of females and
males were reported to be
affected by tuberculosis.
According to an epidemiological
trend assessment of tuberculosis
done for the period 1989-1993,
55% of the new cases reported
annually were males and 45%
were females throughout the
five-year period. Hospital
morbidity data (covering 28
hospitals in Bhutan) for 1994-1996
showed an almost equal proportion
of males and females to be
affected
Sex differentials
in the prevalence of tuberculosis
may vary across age groups.
According to population-based
surveys conducted in 119 randomly
selected villages in Bangalore
district in India between 1961
and 1968, there was little difference
by sex in tuberculosis prevalence
rates up to the age of 14 years.
After this age, the prevalence
rates for males were from 20%
to 70% higher than for females.
However, age and sex specific
data on reported cases of tuberculosis
in 28 hospitals in Bhutan showed
a slightly higher proportion
of female than male TB patients
in the 0-14 age group (1 male
to 1.3 females), and a slightly
higher proportion of males than
females in the age group 15
years and above. (1 male to
0.9 female).
Data from Bangladesh
on notified tuberculosis cases
in 1997 also exhibited a similar
pattern, but the ratio of female
to male TB patients in the 0-15
age group was higher, ranging
from 1.6 females to 1 male in
rural areas, to between 1.8
and 2.0 females to 1 male in
urban areas.
Because of
the lower reported tuberculosis
prevalence rates for females
as compared to males, literature
on tuberculosis has in general
tended to assume that gender
is not an issue for tuberculosis
control. However, the prevalence
rates as presented above may
not necessarily reflect the
actual situation. Historical
experience has shown that when
the overall annual risk of tuberculosis
infection was high, women aged
15-35 years had higher tuberculosis
notification rates than men
in the same age group. This
was the case in countries of
Europe and America during the
mid-twentieth century, when
the overall annual risk of tuberculosis
infection was as high as is
currently the situation in many
countries of the Region.
It is possible
then, that in countries of the
Region, the lower prevalence
of tuberculosis in women aged
15-35 years is the result of
under-notification of infected
women. This view is also supported
by a 1998 review which found
evidence of under-notification
of tuberculosis in women in
more recent studies.
Studies
using different methods of case-finding
also suggest the need to examine
whether under-notification may
be contributing to the low reported
prevalence and incidence rates
of tuberculosis in women. In
Nepal (1982), a greater proportion
of infected women were identified
through active case finding
by mobile teams, as compared
to the proportion of infected
women who referred themselves
to health centres and clinics.
The sex ratio in the former
instance was 1.2 males to 1
female, while in the latter
it was 2.6 males to 1 female.
Active case finding also identified
a greater proportion of infected
women above 45 years of age.
In another study carried out
in Nepal in 1993, relatively
more women attended mobile clinics
for sputum checks as compared
to the number of women attending
fixed clinics and health posts.
The
progression rate from infection
to disease appeared to be higher
among women in the 10-44 year
age group as compared to men
in the same age group in the
Bangalore study mentioned earlier.
In this study, a prospective
cohort of infected women and
men who had no symptoms of clinical
disease were followed up for
a mean period of eight years.
The progression rate among those
aged 10-44 years was higher
by 130% for females than for
males. At older ages, men's
rate of progression was two
and one-half times greater than
among women of the same ages.
In
India, tuberculosis was the
leading cause of death of women
in the reproductive age group,
according to data for the 15-year
period from 1981-1994 compiled
by the Registrar General of
India. A 1976 study conducted
in Nagpur, India found mortality
rates (deaths due to tuberculosis
in the population) to be slightly
higher for females in the 5-14
year age group, and 10-36% higher
for females in the 15-34 year
age group. After the age of
35 years, men's mortality rates
were several times higher. The
study was based on cause of
death reporting in vital records.
In
Thailand, the death rate from
tuberculosis was substantially
higher for men than for women,
with 1995 figures showing rates
of 10.0 per 100,000 population
for males in both the north
and north-east regions and 12.1
per 100,000 population in the
central region, compared to
female rates of less than 5
per 100,000 population in these
regions. The rate in the South
was considerably lower (7.2
per 100,000 for males and 2.3
per 100,000 for females).
The
1961-1968 Bangalore study is
among the few to examine tuberculosis
case fatality by sex. The study
found 119 deaths over three
years among 628 culture and
x-ray positive cases. Females
aged 5 to 24 years had a case
fatality rate which was 27-41%
higher than males of the same
age group. Above 25 years of
age, there was not much difference
by sex in the case fatality
rate
A
number of factors may contribute
to women having poorer access
than men to tuberculosis diagnostic
services and to effective treatment.
Among these are lack of time
and resources and lack of decision-making
power, which affect women's
access to health services in
general. More specific to care-seeking
for tuberculosis, are poor knowledge
of the disease and poor interpretation
of its signs and symptoms by
the women themselves as well
as by the health workers, the
social stigma associated with
being diagnosed with tuberculosis,
and the financial and time costs
of the prolonged course of tuberculosis
treatment.
Evidence
of sex differentials in health
seeking behaviour and utilisation
of services is mixed. A study
of 297 new sputum positive cases
in Nepal (1982) found that women
tended to delay seeking care
much more than men. The mean
reported duration of cough before
diagnosis was 27 days for men
as opposed to 49 days for women.
In
Bangladesh, India and Nepal,
there was no difference by sex
in attendance of tuberculosis
patients at general health facilities.
In Hyderabad, India, while the
sex ratio of patients seeking
care in a private trust hospital
was 1 male to 0.8 female, the
sex ratio of patients referred
by private practitioners was
1 male to 1 female, and that
of patients referred by female
private practitioners, 1 male
to 2 females. This suggests
that women tended to seek help
from a female private practitioner
when they first became aware
of the need for treatment of
their symptoms.
The
higher rate of progression from
infection to disease and the
higher case fatality in women
during childbearing years may
not be attributable to a higher
biological risk during pregnancy.
Studies to date suggest that
if effective chemotherapy is
given, tuberculosis need not
be any more risky during pregnancy
than it would be otherwise.
However, the effect of pregnancy
on untreated or inadequately
treated tuberculosis is still
an open question. No data were
found on the incidence of tuberculosis
in pregnant women or on its
effects on the outcome of pregnancy
and on maternal and infant health.
Tuberculosis of the genitourinary
tract, which is often difficult
to diagnose, can cause infertility
in women. This type of tuberculosis
has potentially serious consequences
for women's lives. A 1993 study
in Darjeeling, India carried
bacteriological and histological
investigations of endometrial
curettings of 800 non-pregnant
women between 15 and 60 years
of age. The women complained
of infertility (47.5%), abnormal
uterine bleeding (30.8%), amenorrhoea
(11.3%), leukorrhoea (6.3%)
and other gynaecological problems.
The incidence of endometrial
tuber-culosis was found to be
11.8%. An earlier study also
in Darjeeling, India (1987)
found that about 52% of women
with genital tuberculosis had
a history of previous extra-genital
TB.
Impact
and Consequences
Social
consequences on women affected
by tuberculosis have been examined
in some studies in India. A study
in one district of Maharashtra
(1996) found that conjugal families
showed an inability or unwillingness
to support the women. According
to another study in 1997, afflicted
men worried about loss of wages,
financial difficulties and reduced
capacity for work performance
at jobs, and consequences of long
absence from work. Women had to
worry about rejection by the husband,
harassment by the in-laws and,
if unmarried, reduced chances
of marriage. The tendency was
therefore to conceal the disease
for as long as possible.
Tuberculosis
and Pregnancy
FAQ on TB and Pregnancy
What tests are done if my doctor suspects an infection and I'm pregnant?
The Tuberculin skin test is a relatively safe and reliable test for pregnant women -- it will not harm you or your baby. This test is also called PPD (Purified Protein Derivative) or Mantoux. This test identifies if you have been exposed to TB bacteria. PPD is not a vaccine.
Your doctor will inject a small amount of the bacterium protein under the skin in the forearm. This area is examined after about 48 – 72 hours. If there is a swelling around the injection area, your doctor will evaluate how large the swelling is. While a small swelling is normal, a large one almost signifies infection but not necessarily illness.
If you have had a positive result in the past you may not need to repeat this test as it usually remains positive for life despite treatment. However it is always safe to follow your doctor’s advice.
The sputum test is also used for detecting TB in pregnant women. But a chest x-ray is avoided because of the harmful effects of radiation to the foetus.
How can TB affect me and my unborn baby?
TB can affect your pregnancy in many ways depending on the extent of the disease, stage of the pregnancy and your nutritional health amongst other things. Many studies show that children born to mothers with untreated TB may have low birth weight or fetal growth retardation and in some cases may be born with hearing defects. TB also increases complications during pregnancy. It can also spread to the foetus through the umbilical cord.
Why should you not give up TB medication midway?
If you do not take the drugs as exactly prescribed, there is a very strong chance of a relapse. You may also end up with drug-resistant variations of the disease which are more difficult to treat. Therefore, you need to regularly take the prescribed drugs right through the treatment cycle.
Medications for TB need to be taken over a long period — anywhere between 4-9 months — depending on the severity of your case. Your doctor will guide you as to when it is safe to stop medication.
Can I feed my baby if I am undergoing treatment?
A small concentration of the TB drugs does get into breast milk, but research indicates that levels are so low that it will not affect your baby. The benefits of breastfeeding far outweigh any possible side effects of medication. Talk to your doctor if you are worried about this.
I’m pregnant and I’ve been diagnosed with TB. How do I take care of myself?
• Ensure you take all your medicines and do not miss even a single dose of what has been prescribed.
• Make sure you don’t miss any antenatal visits and other doctor’s appointments.
• Report any side effects, such as vision changes, headaches, increased nausea immediately to your doctor.
• Maintain good personal hygiene . Ensure that you wash your hands regularly and cover your mouth and nose with a tissue when you cough or sneeze so that you do not spread the germs around.
• Make sure you dispose of your soiled tissues in a covered bin.
It is important to stay positive – it is safer for you and your baby to be aware of the illness and get treated for it than to be ignorant and suffer from failing health and end up in life threatening situations.
Can my baby catch TB from me once he is born?
Once you have been taking medication for two weeks you can no longer infect other people. Your baby will be tested for TB at birth and treated if he has become infected. If he is TB free he will be given the BCG vaccine to help protect him.
Treatment of Tuberculosis in Pregnancy
In almost all situations, tuberculosis discovered during pregnancy should be treated without delay. A pregnant woman with a positive skin test and abnormal chest x-ray findings compatible with tuberculosis should start treatment. Three samples of induced sputum should be submitted for smear, culture, and drug-susceptibility testing. The outcome of these tests will determine the regimen for continuation of treatment.
Drug Treatment for HIV-Seronegative Women with Drug-Susceptible TB
The initial treatment regimen should consist of isoniazid (INH), rifampin (RIF), and ethambutol (EMB)
Pyridoxine (Vitamin B6) is recommended for pregnant women taking INH
Routine use of pyrazinamide (PZA) should be avoided because of inadequate teratogenicity data
Para-aminosalicyclin (PAS) has been used safely in pregnancy but may be poorly tolerated
Avoid: streptomycin (which interferes with development of the ear and may cause congenital deafness), kanamycin, amikacin, capreomycin, fluoroquinolones (ciprofloxacin, levofloxacin, ofloxacin, and sparfloxacin), cycloserine, ethionamide, and clofazimine
Treatment of Latent TB Infection in Pregnant Women
In most pregnant women, treatment of latent TB infection (LTBI) should be delayed until 2 or 3 months after delivery, even though no harmful effects of INH (the standard treatment regimen for TB infection) on the fetus have been documented. However, in some cases treatment for LTBI (INH, 300 mg) should begin during pregnancy for women with a positive tuberculin skin test:
Treatment of latent TB infection should be started during the first trimester of pregnancy for:
Pregnant women who have HIV infection or behavioural risk factors for HIV infection but refuse HIV testing
Pregnant women who have been in recent close contact with an individual with smear-positive pulmonary TB (at the physician's discretion)
Treatment of latent TB infection should be started after the first trimester of pregnancy for pregnant women who have had a documented tuberculin skin test conversion in the past 2 years
Treatment of LTBI, if indicated, should be started 2 to 3 months after delivery for all other pregnant women, including those with radiographic evidence of old, healed TB.
If a woman taking INH and/or rifampin for treatment of LTBI becomes pregnant, treatment should be interrupted and started again 2 or 3 months after delivery, unless one or more of the above risk factors are present.
Breast Feeding
Because the small concentrations of anti-tuberculosis drugs in breast milk do not produce toxicity in the nursing newborn, breast feeding should not be discouraged for an HIV-seronegative woman who is planning to take or is taking INH or other anti-TB medications. Furthermore, the low concentration of anti-TB medications in breast milk should not be considered effective treatment for disease or as treatment for latent TB infection in a nursing infant. Women who are HIV seropositive should not breast feed because of the risk factor of HIV transmission to the infant.
Tuberculosis
and Women
This
is the VOA Special English Health
Report.
Tuberculosis
kills about two million people
a year. The international campaign
called Stop TB says this lung
disease kills more men than
women in most of the world.
Yet it says tuberculosis kills
more women than all pregnancy
related disorders combined.
And, in some
cultures, women who get TB face
additional problems. They may
not be able to leave their families
or their jobs to go to a health
center that is far away. They
may be required to have their
husband, father or brother take
them for care. They may also
have to depend on men to get
them medicine.
Women often
get TB during their most productive
years. They are having babies,
caring for their families and
often working in paid jobs.
Most women who die of tuberculosis
are between the ages of fifteen
and forty-four. Often they die
for lack of treatment or because
of poor treatment.
Tuberculosis
is especially easy to catch
in places where people live
close together. Most people
who get infected with TB never
get sick. But mothers who do,
and are not treated, can easily
spread the disease to their
children. The germs are spread
through the air when a person
with TB coughs or sneezes.
People with
active cases of tuberculosis
have a bad cough. Other signs
include pain in the chest and
coughing up blood. Tuberculosis
also produces weakness, increased
body temperature and weight
loss.
Some women
worry about rejection by family
members and employers if they
have TB. The World Health Organization
leads the StopTB campaign. Campaign
officials say there is no reason
to reject someone who has TB.
They say it is important to
know that tuberculosis can be
cured. People must take medicine
for several months. But doctors
say a person taking the medicine
stops infecting others in about
two weeks.
Women may
be concerned about taking tuberculosis
drugs if they are pregnant.
But experts at the American
Centers for Disease Control
advise them to continue treatment.
And the women should get their
treatment from a trained doctor
or health care worker. That
way they know they are taking
the right medicine.
The C.D.C
also says women who take TB
drugs can continue to breastfeed
their babies. This is important
for the development of natural
defenses in babies.
This VOA Special English Health
Report was written by Karen
Leggett.
10
facts about tuberculosis and women
TB is the single biggest
infectious killer of
women.
Over 900
million women
—mainly between
the ages of 15 and 44—are
infected
with TB world-wide,
one million will die and
2.5 million
will get sick this year
from the disease.
TB is the single
biggest killer of young
women.
TB accounts for 9
percent of
deaths among women between
the ages 15 and 44,
compared with war, which
accounts for 4 percent,
HIV 3 percent and heart
disease 3 percent.
Women of reproductive
age are more susceptible
to sickness once infected
with TBthan are men
of the same age.
Women in this age
group are also at greater
risk from HIV infection.
In parts of Africa,
young women with TB
outnumber young men
with TB.
TB kills more women
than any single cause
of maternal mortality.
In some parts of
the world, the stigma
attached to TB leads
to isolation, abandonment
and divorce of women.
In some parts of
the world, women's movements
are leading the efforts
to control TB.
