Combatted Well

Tuberculosis is a major threat to public health with new drug resistant cases being detected, however, Kashmir is comparatively faring better in fighting the disease. Syed Asma reports

In India, tuberculosis (TB) is an epidemic and contributes to one-fifth of the total deaths related to it in the world, says a Government of India report. According to the health ministry’s annual report People and Health of 2010, of the 9.2 million TB cases in the world, 1.9 million are in India.

While north Indian states are the most affected areas, Kashmir has done fairly well with better case detection and treatment success rate under the Revised National Tuberculosis Program (RNTCP). The data of the first quarter of 2011 shows Jammu and Kashmir has treated 92 per cent of the detected cases successfully, while 71 per cent of those tested were TB infected.

Critics, however, say that this data only has the details of the patients registered with them and not of the whole valley.

“Reasons which contribute to the lesser prevalence of TB in Kashmir are comparatively less poverty, better sanitation and less prevalence of HIV positive patients,” says Dr Mushtaq Ahmed who is heading the RNTCP program in Kashmir.

Although, the number of patients infected by Tuberculosis is same all over Kashmir but there are some vulnerable sections of society more prone to the disease.

“Gujjar and Pahari population because of their life style is more prone to Tuberculosis than any other section,” says Dr Mirza Muzaffar, Head of Department and Medical Superintendent, Chest Diseases Hospital Srinagar.

“They live in overcrowded places with poor ventilation, in one room they accommodate at least 7 to 8 members” he adds. “If they have a TB patient at home, the risk of others getting infected is 100 per cent”.

Tuberculosis is an infectious disease which spreads through air via droplets from the lungs when a TB patient coughs, sneezes or talks. It can affect any part of the body but mainly infects lungs. Pulmonary (lungs) Tuberculosis is the most commonly prevalent and contagious too. The other type is extra pulmonary tuberculosis which is not considered infectious.

 Tuberculosis is caused by bacterial microorganism – Mycobacterium tuberculosis.  As per RNTCP data 236 suspects were identified per 100,000 in the first quarter of 2011 in Jammu and Kashmir.

Tuberculosis has caused a global emergency because of the increased number of deaths related to it, says Dr Afroza who is presently working with RNTCP, “and mostly what is worsening the scene is the increasing number of HIV positive patients across the world and in India”. Worldwide, HIV-TB co-infection in on an increase.

HIV positive people are immuno-compromised people, have less immunity to fight infections and tuberculosis is considered to be the most opportunist attacking disease, doctors say. HIV positive patients are an easy prey to the TB bacteria.

“A normal population is at the risk of 10 percent with this infection but HIV positive population is at least at the risk of 50-60 percent,” says Dr Afroza who is working in the Sample Examination Cell of RNTCP.

The J&K RNTCP 2011 report says that only one to two percent of the patients are affected with HIV-TB co-infection.

Apart from HIV positive patients, all other sections of the population are equally susceptible to the disease but with a certain life style there is a raised risk of contacting infection.

Doctors feel awareness about the TB control program across the valley has also played its part in maintaining the “good” results. “We have used radio, television, newspapers, word of mouth and street plays to make people aware about this disease and its treatment and it has paid its due,” says Dr Nazir Ahmed from the data section of RNTCP.

And awareness about its treatment has also helped. Treatment like DOTS (Directly Observed Treatment Short-course) and the information that it is free of cost has helped to convince patients go for it, says Dr Afroza.

Doctors say the RNTCP has been immensely helpful in fighting the disease. It was introduced in India in 1993 and covered entire Kashmir in 2005. “RNTCP is so far the most successful program run for TB in the country,” says Dr Afroza.

The RNTCP, over a decade has led to decline of TB prevalence from 586 cases per lakh population in 1990 to 283 in 2007, according to a union health ministry report.

The mortality rates from TB have also declined from 42 deaths per lakh population in 1990 to 28 deaths in 2007, the report states.

The RNTCP was launched after making changes in the earlier National Tuberculosis program (NTP) introduced in 1963. The NTP was the first centrally sponsored scheme introduced to address the epidemic of TB but could not fetch good results, so in 1990’s it was reviewed and ultimately revised into the new scheme of RNTCP.

The new scheme introduced a better diagnosis pattern. The experts say NTP had over-dependence on X-rays which most of the times led to wrong diagnosis. “In case of TB, there are inter reader differences in reading the X rays of TB infected patients, so, many times patients were either under-treated or over-treated,” says Dr Afroza.

The RNTCP introduced sputum examination for diagnosis of TB which helped to detect the cases with more accuracy.

Another change which helped to fight TB in a better way was upgradation of infrastructure. Central government sanctioned one TB unit for a five lakh population but for a topographically complicated place like Kashmir one TB unit was sanctioned for every 2.5 lakh people. Also one DMC (designed microscopic centre) is allotted for the population of one lakh but for hilly places there is a provision of one DMC for 50,000 people.

In Kashmir and Ladakh there are 29 TB units and 92 DMCs across Valley.

Accountability and monitoring is also paid attention in this program. “Patients are made to take medication in front of us, so we have comparatively lesser number of defaulters – those who do not take medication for the stipulated time period later develop complicacies,” says Dr Afroza.

Experts say that defaulters develop a resistance against the drugs which is difficult and expensive to tackle. These defaulters lead to Multi Drug Resistant (MDR) TB or Extremely Drug Resistant (XDR) TB. However, no data about MDRs and XDRs is present in any record books in Kashmir.

 “We are presently coming up with DOTS plus site with the Intermediate Reference Laboratory for culture and drug resistance test (IRLS) lab which will help us to reduce the number of MDRs and XDR,” says Dr Mirza Muzaffar.

The IRLS is a sophisticated laboratory which help to detect if the cells are drug resistant or not and help to make the treatments easier.

“Till now these tests were done privately and on high prices but now once our lab gets inaugurated they will be done on a comparatively lesser price and will be affordable,” says Dr Afroza.

With increase in literacy in Kashmir, the way of treatment of this contagious disease, Tuberculosis, has changed. Before 1950’s Tuberculosis-infected people were made to sit in separate isolated places usually referred to as ‘sanatoriums’. In Kashmir there were two, one at Dalgate which is now a full-fledged chest disease hospital and other was at Tangmarg, says Dr Afroza, this was the missionary approach of tackling the disease.

In these sanatoria, people were left isolated and were given fresh air treatments, as this was the only treatment available around but with passing time and researches, it was studied that this bacillus is an oxygen dependent microbes and thus grows in fresh air, says Dr Mirza. “Now TB patients are kept as other patients in wards, with full precautions, and dealt with same care and affection as any other patient. The stigma associated to it has also reduced manifolds”.


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