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Wednesday, 25 January 2012

Even in 21st century are we loosing the battle against eradication of an ancient oldest bacterial diseases by M. Tuberculosis due to poverty, unemployment, under nutrition, HIV and inadequate free quality supply of ATD drugs, microscopy, [ through DOTS] cultural confirmation ,delay in rapid diagnosis and high tech based confirmation of Mycobacteria and of emerging MDR and even TDR







 Authors *Professor Pranab Kumar Bhattacharya MD(cal), FIC Path(Ind), Professor and Head, Dept. of Pathology, Now in Calcutta School of Tropical Medicine, 108 C.R avenue ,Kolkata-73, W.B , India, In charge Convener DCP &DLT Course of WBUHS; **Miss Upasana Bhattacharya “ Daughter of Prof. P.K. Bhattacharya Mr Rupak Bhattacharya , Mr Ritwik Bhattacharya, Miss Rupsa Bhattacharya,  of 7/51 Purbapalli PO- Sodepur, Dist 24 parganas(north) , kolkata-110 West Bengal, India Mrs Dalia Mukherjee, Miss Oanidrila Mukherjee, Mr Debasis Mukherjee of Swamiji nagar PO_ South Habra; North 24 Parganas; West Bengal India












 Actually in India even after its 69 years of its Independences and 12th such 5th years plan for eradication of poverty and in spite of high economic growth rate near 9 , is probably the highest of killer diseases, like Tuberculosis (M. Tuberculosis) burden country Globally, if the authors is not however wrong, accounting 1/5th of Global incidence of only Pulmonary TB and 1/3rd of in south Asia. According to WHO in 2007, out of total Global 9,3 million cases of TB, 1.4 million cases and 48,000 death is related to HIV and TB co- infections and the epidemiology of MAC TB is modified today by HIV infection which is causing an increase in occurrences of new TB cases and generation of CAT1 & or CAT 2 drug resistances cases(MDR TB) affecting not only individuals but also their close contacts keens and general population of the close community. The Tuberculosis in India and in one of provinces in India like West Bengal ( where Left front party ruled since 1977] are mostly due to extreme level of economic poverty to purchase their minimum required food, lack of necessary calorie, nutrition in the affected family members in low socioeconomic classes , joblessness, lock out in small and medium size industries in the open market mixed economy of India, huge numbers of unemployment amongst economically active youths ( it exceeded more then 1.8 cores general stream graduate level or High school level educated young generation amongst 8.6 cores population in provinces of West Bengal, India census 2001), non workers, laborers, high prices for essential foods purchase , low per capita income in sub urban (bellow poverty line(BPL) Per capita income per month Rs 450 and poverty line people ], urban slum dwellers, colony people, many hawkers maid servants ,watch men and in rural population, illiteracy, and TB is mainly predominant and rampant today within low socioeconomic income group people ( who are the main working /labor forces of the state / India ) of the province of West Bengal, India ( approx.38. population as per author ) and in people BPL (29%) . This ancient Myco Bacterial disease is not usually found in upper middle class and sudden raised middle class and rich class Population with high economic stability (25-30%) having cars, flats with decoration with or without A/c, though other bacterial infections & other diseases for over nutrition { as for example, obesity, metabolic syndrome and sequel, seen in these class. Why?. As the TB is related with CD4 T cell immunity and by delayed type hypersensitivity-Type IV (Th1.and Th2. T cells) which falls with gross level poverty & low calorie consumption for long time. At least, the present first author as a Histo pathologist never encountered in his medical 27 years carrier in hospital’s Lab Set up ,unless that person is some how Immuno compromised for CD4 T cells for some other diseases like Diabetes, taking various kinds of immunosupressive drugs, steroids or under gone any organ transplants or HIV. Nearly 45% population in India is today, affected by TB and in West Bengal alone is house of 1.5 to 3.5 million people per year and in India there are 500,000 deaths occur annually due to TB only?. NTCP followed by RNTCP i.e Revised National TB control program was initiated in the year 1993 by GOI as DOT program strategy. There was political, administrative and organizational commitment too, for short course of DOT (6 months therapy) through which ensuring poor class comprehensive TB control services to reach at Sub center level (SHC) of the country with reliable sputum smear microscopy, good quality anti TB drugs, effective and patient friendly treatment to be given under direct observations and accountability to establish with health care system of the state. Then came revised RNTCP. The objective of revised RNTCP started in 2000, whose objective was to achieve 85% cure rate amongst new/old smear positive cases initiated on treatment and case detection rate raising up to 70% of affected. But there were not really enough existing infrastructure, enough staffs, enough human resources, free essential quality anti TB drugs, human resources to decentralize the activity through creation of Sub-sub divisional level supervisory teams comprising of a senior treatment supervisor, senior laboratory supervisor and designated trained chest Medical officers ,enough reliable microscopy centers with trained persons to examine AFB, free supply of quality Anti TB drugs (CAT-1/CAT-2/CAT-3] and trained personal though some norms and guide line was formulated for these attempts. Result was quite expected and there is raise of TB incidences. TB, HIV, Malaria, MRDM, Diarrhea ARI low birth weight baby and ARI are always diseases of poverty and should be other indicators of Health structure development of a country, or of a state. It is the matter of shame for a welfare government too that TB is raising in the state. Quite obviously and expectedly , very soon ,West Bengal and India faced the challenges of Drug Resistance TB { for long years continued use of these two drugs ] to first INH and then Refampicin ( two drugs) and the real cause was deficient and detoriating TB control program, inefficient administration of effective therapy at free of cost to poor people, use of substandard quality ATD drugs in hospitals, ignorance of health workers about the disease , inadequate admission facility in govt. hospitals during emergency period, replace of blood during severe Hemoptasis; Interruptions of ATD chemotherapy and non adherence due to various reasons ,side effects of toxic drugs and market costs of Anti TB drugs to those people who can not even earn food for them as prevention of TB or non availability, low nutrition status , may have massive bacillary load and delay in identification of TB and lack of uniform laboratory methodology in the state metropolis, prescribing some times of high tech very costly gadazets like Bachtech and PCR identification of the bacteria. Then came MDR TB in India and in West Bengal too in early 1990s so far author remembers. They are TB which are resistant to two or more effective anti TB drugs available like INH and Refampicin. Those patients who are not MDR TB can be still cured by 6-9 months of treatment if taken regularly. But problem with MDR TB require at least18-24 months treatment and treatment are very toxic for the body itself and are expensive too. In West Bengal, at least stamping a person with MDR TB is equivalent to stamp his death certificate also. The classical threat of TB epidemics started as MDR TB and often that was use or misuse or the antibacterial agents has emerged the evolution towards resistance resulting often treatment failure. There was not stop. There appeared then sporadic XDR TB in India and also in West Bengal . TB in community XDR TB so far authors knowledge is, has been detected in India on an average 1.6% of TB population in India since 2004 to 2007 when MDR was 34% on average. The one possibility of XDR TB may be association with HIV ,though it is only 6% roughly of XDR TB. What about the rest? And now the threat appeared however, Totally drug-resistant tuberculosis (TDR-TB), i.e incurable TB, though are sparse, rare, one or two isolated cases. That are in association with HIV. But so far Knowledge of the author there is no equipped laboratory to diagnose TDR TB except one or two in Delhi. In Maharastra, Mumbai, 2cases of TDR were detected in 2011. Before these Twelve (12) cases of TDR were confirmed. Giovanni Migliori, The Director of the World Health Organization (WHO) Collaborating Centre for Tuberculosis and Lung Diseases in Tradate, Italy, suggests that TDR-TB is a deadlier iteration of the highly resistant forms of TB that have been increasingly reported over the past decade in poor socio economic classes. “Totally resistant TB is so not new at all,” he said. Since the 1960s, two drugs — isoniazid and rifampicin — had been standard TB treatment. Although episodes of resistance cropped up periodically, during the 1990s the incidence of multiple drug resistance (MDR) grew significantly, leading researchers in 2006 to refer to it as extensively drug-resistant tuberculosis (XDR-TB). Surveillance data from the WHO indicated that XDR-TB is present in at least in 58 countries, with an estimated 25,000 cases occurring each and every year. WHO till this date describes TB as a “disease of poverty and extreme level, poverty who have no purchase capacity for minimum basic need to live as human”, drug-resistant varieties might best be understood as resulting from poor treatment. According to a 2011, WHO report, fewer than 5% of newly diagnosed or previously treated patients were tested for drug resistance. And it is estimated that just 16% of patients with drug-resistant TB are receiving appropriate treatment. “The cases are a story of mismanagement,” said Migliori. “Resistance is here man-made, caused by exposure to the wrong treatment, the wrong regimen, the wrong treatment duration .” But for author besides the Statement of Migliori, MDR or TDR molecular studies showed drug resistance in M tuberculosis is mutation in the drug target genes and effector pump “The pharmaceutical industry has scant interest in TB for decades,” together “The industry pretty much concluded it wasnot an attractive market, and there was not enough potential profit.” So the Battle for TB is loosing by us. Control of TB must be governmental programmed and that must be based on program ,objective and effectiveness of interventions and applications of recourses According this author the first priority to cut of chain of transmission of bacilli by giving food and nutrient to people at BPL or PL level, free early diagnosis, quality sputum microscopy, free provisions of quality anti TB drugs through DOTS ,achieving any how 85% cure rate, universal poor friendly access of free DOTS, to reduce morbidity and mortality and secondary priority expansion of case detection and treatment at free costs in private hospitals, use of free culture for diagnosis of smear negative cases even, formulation of guide line for extra pulmonary cases, identification, surveillance of drug resistance cases at free cost even in private set up hospitals in the country, monitoring of cost effectiveness and rationalizations of care, expansion of tuberculosis packages to care for MDR tuberculosis particularly for immuno suppressive groups and HIV parsons.





























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