Abstract
Introduction
Mycobacterium tuberculosis is a respiratory pathogen that primarily affects the lungs. The incidence (new cases per year per million population) of tuberculosis (TB) in India for 2021 is 210 cases per 1 00 000 population. India accounts for 28% of the total new cases worldwide. 1 The highest number of cases are reported from the Delhi region, that is, 747 cases per 1 00 000 population, followed by Haryana (477) and Chattisgarh (451). 2 Persons with immunodeficiency, especially HIV sufferers and intravenous drug user, malnutrition, and residents of nursing homes, or similar institutions, are more susceptible to infection. Tuberculosis infection results in weight loss and debilitation. Tuberculosis may spread from the lungs to involve other organs, including the central nervous and gastrointestinal systems. Multiple-drug-resistant TB (MDR-TB) is an increasing problem for treatment and containment. In India, MDR-TB occurs in 3.5% of new TB patients and 26.7% among previously treated patients. 3 Extensively resistant TB is increasing, and the frequent usage of fluoroquinolones may be a factor. With these challenges, India should improve early diagnosis, treatment, and prevention strategies to reduce MDR spread as it now contributes up to one fourth of MDR-TB cases worldwide. 4
Challenges
Although TB is a preventable disease with a definitive cure, millions of cases still occur. Lower socioeconomic areas with meager resources, crowded living conditions, and poor knowledge of transmission provide opportunities for infection. HIV patients are susceptible to the reactivation of dormant TB. Prevalence is also higher in intravenous drug users and in cases of malnutrition. Social stigma may delay the reporting of new cases, making containment harder. At the community level, the lack of infrastructure and direct observation of treatment centers, requiring long-distance travel, discourage people from seeking treatment. Patients with advanced HIV-AIDS may test negative for TB regardless of the status of the disease. Delays in diagnosis and presentation to receive health care postpone adequate treatment. 5 The longer treatment courses required for advanced cases and resistant mycobacterium increases the risk of dropout, and in turn, noncompliance increases the risk of drug resistance to first-line agents such as isoniazid and rifampicin. Unregulated private prescription of these drugs has led to a rise in resistant forms. More extensive testing for rifampicin resistance is required in today’s world to prevent suboptimal treatment and further evolution of resistant cases. 6 Adverse drug reactions of first-line agents commonly experienced are hepatotoxicity, peripheral neurotoxicity, dermatitis, and gastrointestinal disturbances. These can discourage people from seeking care. The incidence for these drug reactions is noted as 1.48 cases per 100 patients treated for TB with pyrazinamide (95% CI [1.31, 1.61]), 0.49 for isoniazid (95% CI [0.42, 0.55]), 0.43 for rifampin (95% CI [0.37, 0.49]), and 0.07 for ethambutol (95% CI [0.04, 0.10]). 7
Initiatives
The government of India initiated the National Tuberculosis Elimination Programme under the Ministry of Health and Family Welfare. According to the National Strategic Plan, the aim is to eliminate TB by 2025. This program functions on four levels, from a Central TB Division to multiple subdistrict facilities. Laboratory services that operate on three different levels are provided under the program. National Reference Laboratories in coordination with the World Health Organization (WHO) Supra National Reference Laboratory Network provides quality assurance and certification to the culture and drug susceptibility testing laboratories. Ziehl-Neelsen staining for the sputum smear is the most widely used testing method. 8 Rapid molecular testing is used to detect rifampicin resistance. Treatment services depending on the drug sensitivity are provided. A public-private partnership mix is an innovative way of giving private providers incentives for notifying TB cases and ensuring treatment adherence and course completion. 9 Air-borne infection control measures including separate isolation rooms for TB patients, the use of surgical masks if a negative pressure room is not being used, and N95 masks for health care workers are used to contain the spread. Increased BCG vaccination for infants younger than one year will further reduce the number of pediatric cases. 10 Routine vaccination provides significant protection against severe forms of childhood TB including meningitis.
Discussion
Considering the trend of TB cases, especially resistant cases, India needs to improve its marketing, surveillance, and treatment strategies. Mass educating campaigns about the signs and symptoms, the importance of an early diagnosis, and treatment compliance are necessary. Slogans like “two drops for life” used in Polio awareness campaigns delivered a high-impact message to parents. It became an integral part of encouraging individuals to vaccinate their children and helped in bringing down the incidence of Polio cases. A similar marketing strategy for TB could prove beneficial. This could help remove any form of the stigma and encourage people to undergo treatment for TB. Prompt screening and preventive treatment are recommended according to the latest WHO guidelines to contain the further spread of infection. High-risk individuals should be monitored regularly, and if indicated, preventive therapy is initiated. As an alternative to human interpretation of chest radiographs, computer-aided detection is being suggested in individuals aged 15 years or older, but this is yet to be proven in a public health program. Molecular rapid diagnostic testing and a C-reactive protein cutoff of >5 mg/L are other ways of improving screening accuracy in high-risk populations. 11 In health care establishments, the regular disinfection of apparatus should be monitored. Isolating suspects in a negative pressure ventilation room should be ensured, and they should be provided with surgical masks. The WHO recommends installing special ventilation systems to maximize airflow rates or germicidal ultraviolet systems to disinfect the air. 11
Conclusion and Recommendations
On an individual level, we should educate people about appropriate hygiene practices. Cough etiquette involving the use of one-time-use tissue or elbow should be taught. Hand hygiene should be promoted, and well-equipped stations for the same should be installed. This could decrease the aerosol load of pathogens. Adults with signs and symptoms of pulmonary TB, including cough, night sweats, and weight loss, are advised to have their sputum sample tested using Xpert mycobacterium tuberculosis / resistance to rifampicin (MTB/RIF). Children can be tested through a gastric lavage or a nasopharyngeal aspirate. Detection of drug-resistant strains may be done with moderate- and low-complexity automated nucleic acid amplification tests (NAATs). Treatment of drug-susceptible cases using a 4-month regime is being considered by the Guideline Development Group appointed by WHO. This regimen includes rifapentine, isoniazid, pyrazinamide, and moxifloxacin. A shorter 4-month course would be preferable for patients and help decrease noncompliance. Countering noncompliance can be achieved by involving the family members of patients to assist them with adherence to the treatment plan. Multidrug- or rifampicin-resistant cases are usually advised to include bedaquiline in the 9- to 12-month regime. This is beneficial for patients who have not been exposed to second-line TB drugs for more than a month and do not have resistance to fluoroquinolones. Patients with HIV are required to initiate antiretroviral therapy within 2 weeks of starting TB treatment. This would help contain the spread of disease and decrease morbidity in patients. 12 A combined effort by the government, health care providers, and the community is essential to overcome the challenges posed by TB. A discrimination-free mindset toward AIDS and TB patients, refining national policies to ensure that WHO guidelines are being followed, and extensive screening, as well as timely treatment of high-risk individuals, should be our top priorities.
Footnotes
Author Contributions
The manuscript was written by G.K., O.A.S., R.M.F., M.E, and S.O. Review-editing was performed by K.U. and S.O. Referencing and formatting was done by S.O.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethics Approval
Not applicable.
