Amitabh Bachchan poses in his office for TeachAIDS. The actor revealed in December 2014 that he had been diagnosed an treated for TB in the year 2000. Photo: TeachAIDS (TeachAIDS.org)
Tuberculosis (TB) is one of the deadliest communicable diseases worldwide, and in India it imposes an especially heavy burden, both in the number of deaths it causes and the toll it imposes on patients and families. Here are five important things to understand about TB in India. To understand what tuberculosis is and how it spreads, read FamiLife’s guide to TB.
- Prevalence
India has the largest absolute number of people with tuberculosis (TB) disease in the world. That may be expected because of the size of the population, but India is overburdened on a per-capita basis as well. In 2013, the latest year for which the World Health Organization (WHO) has published statistics tuberculosis globally, India had an estimated 17.5% of the world’s population, but 23.6% of the world’s existing TB cases and 23.3% of the new cases.
Data source: WHO Global Tuberculosis Report 2014
- TB affects everyone
TB disease occurs in all genders, socio-economic groups, regions and residential areas of India, although prevalence is higher in men, the poor, the North-Eastern and central band of states and the people living in rural areas. A door-to-door research study with a large number of respondents was conducted to ask adult men (aged 15–59 years) and women (aged 15–49 years) about their experience with TB. Some of the findings are shown in the charts below. Note that these are self-reported survey numbers and not from a government source. For simplicity of presentation, only the averages are shown.
Prevalence numbers are per 100,000 population. Data source: BMC Infectious Diseases
- Tuberculosis carries a social stigma in India
Tuberculosis carries a strong and well-documented stigma in India, and many of those who have the disease do not disclose the information to relatives, friends or work colleagues for fear of being shunned or cast out. Women, especially, feel the brunt of this. There have been cases of husbands leaving, divorcing or abandoning their wives who fall ill with TB. Fear of such consequences can lead to women delaying seeking diagnosis or treatment, which lowers the chances of recovery. In the survey mentioned above, an overall 15.6% of respondents said that if a family member got tuberculosis they would want to keep it a secret from their neighbours. Part of the stigma may be due to misconceptions of how TB spreads. Only 55.5% knew that TB spreads through the air when someone with active TB coughs or sneezes. Most frequent among the other (incorrect) methods were “Through food” (32.4%), “Through sharing utensils” (18.2%) and “Through touching a person with TB” (12.3%).
Aishwarya Bachchan at a movie opening. Photo: Wikimedia Commons/Mark B.
Consider the story of the February 2010 rumour in Mumbai Mirror of Aishwarya Rai Bachchan undergoing treatment for stomach TB. This provoked a furious response and vehement denial from Amitabh Bachchan, her father-in-law, and Abhishek and Jaya, her husband and mother-in-law. Amitabh Bachchan wrote on his blog, “I am too incensed and angered by the contents!” Aishwarya Bachchan wrote, “I am shocked, appalled and extremely upset with the contents of this article. I completely deny the report.” Jaya Bachchan characterized the report as “maligning” Aishwarya Bachchan.
The Mumbai Mirror made several other assertions that the Bachchans objected to, and much of the anger from the male members was expressed in terms of protecting the women. Yet the reactions appear very extreme. It is ironic, then, but also of note, that in December 2014 Amitabh Bachchan publicly acknowledged that he had been treated for TB in 2000, fourteen years earlier. The admission also came 8 months after he had agreed to be an ambassador for the Brihanmumbai Municipal Corporation’s anti-TB efforts.
- Treatment outcomes are improving
The good news is that India has drastically improved its TB mortality rate and is on track to meet the Millenium Development Goal of cutting the TB mortality rate in 2015 to half of what it was in 1990. It didn’t always seem like it would and for a few years after the goal was set in 1993, India’s mortality rate stayed flat. However, also in 1993 the Indian government initiated the Revised National Tuberculosis Control Programme (RNTCP), a major overhaul of the country’s existing TB programme, which, according to the government, “suffered from managerial weakness, inadequate funding, over-reliance on x-ray, non-standard treatment regimens, low rates of treatment completion, and lack of systematic information on treatment outcomes. Programme review showed that only 30% of patients were diagnosed and only 30% of those treated successfully.” Initially a pilot project in limited areas, it was scaled up to cover the whole country geographically and in terms of population between 1998 and 2005. As the charts below show, the changes in prevalence (cases of active tuberculosis per 100,000 population) and mortality (tuberculosis deaths per 100,000 population) are impressive. Between 1995 and 2005 India improved the treatment success rate from 30% to over 85% and in 2012 the success rate was 88%, higher than the global average and better than the Millenium Development Goal of 85%.
Data source: Government of India TB Control Annual Report 2012
- Drug resistance is increasing
Until about 10 years ago, it was possible that people with TB disease could be completely cured if the illness was diagnosed early enough and the patient adhered to the treatment plan completely till the end. Many people did still die, but the medications worked. However, now an ever increasing number of people are getting sick with multiple-drug resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB). MDR-TB is defined as tuberculosis that is resistant the drugs isoniazid and rifampicin, which are called first-line medications. If the disease is also resistant to second-line drugs of the fluoroquinolone group and other injectable drugs, it is classified as XDR-TB.
The growth of resistant tuberculosis is a great worry to the TB control community. In 2005 and 2006 there were just 34 and 33 known positive cases of MDR-TB in India. By 2013 the number had grown exponentially to 25,244. Some of the growth may perhaps be a result of better tracking and notification processes, and estimates are that up to 55% of MDR-TB cases are not being caught. At the moment only 2.2% of new incidences of TB are MDR cases, but TB epidemiologists are concerned that if MDR-TB is not properly managed, it could lead to an uncontrolled XDR-TB outbreak.
The diagonal dashed line is an approximation of the rate of growth in recorded MDR-TB cases and shows that if the current growth rate continues, there will be a million new cases reported in 2018. Data source: WHO TB Data