Context
The public health issue posed by extrapulmonary TB (EPTB) may exceed the current assessments of Tuberculosis in India.
Tuberculosis (TB)
TB is an infectious disease that most often affects the lungs and is caused by bacteria, Mycobacterium tuberculosis.
- Transmission: It spreads through the air when infected people cough, sneeze or spit.
- Prevention: TB is preventable and curable. It is usually treated with antibiotics and can be fatal without treatment.
- The most common antibiotics used are: isoniazid, rifampin, pyrazinamide, ethambutol and streptomycin.
- In certain countries, the Bacille Calmette-Guérin (BCG) vaccine is given to babies or small children to prevent TB, which prevents TB outside of the lungs but not in the lungs.
- Existing Forms: The disease exists in both latent and active form.
- Latent Form: The latent type does not express any symptoms and is not transmissible unless it develops into the active type.
- Active Form: This form expresses symptoms such as chronic cough and bloody mucus.
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Tuberculosis Infections
- Non-Pulmonary Tuberculosis Infections: While pulmonary TB, affecting the lungs, is the most common form of tuberculosis (TB) infecting the lungs. However, around 20% of TB infections develop in the lymph nodes, brain, gut, eyes, or other organs.
- Underestimation of TB Infections: Similar to the underestimation of individuals infected with TB, the public health issue posed by extra-pulmonary TB (EPTB) may exceed our current assessments.
- The World Health Organization (WHO) reports over 10 million new cases of TB every year and India alone accounts for 27% of the global TB burden.
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Extrapulmonary Tuberculosis is tuberculosis outside of the lungs.
- EPTB includes tuberculosis meningitis, abdominal tuberculosis (usually with ascites), skeletal tuberculosis, Pott’s disease (spine), scrofula (lymphadenitis), and genitourinary (renal) tuberculosis.
- Diagnostic Challenge: The burden of Extrapulmonary Tuberculosis is hard to estimate. EPTB is often stain-negative i.e., it is not detectable on regular TB stain tests.
| INDEX-TB: It was developed in 2014 as a collaborative effort involving experts from various health institutions nationwide, as well as the WHO and the Cochrane Infectious Disease Group, resulted in the development of INDEX-TB. |
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- The infection may surface in any part of the body and present itself like other non-TB conditions. Many cases of EPTB may not have a corresponding lung infection.
- So, EPTB’s true prevalence in society remains hidden.
- Impact of TB Underdiagnosis: The underdiagnosis of EPTB leads to irreversible damage to infected organs, potentially resulting in complications such as vision loss or blindness.
- Hence, it is imperative to address tuberculosis comprehensively, acknowledging its various complexities.
- Knowledge Silos in Extrapulmonary Tuberculosis (EPTB) Management: As TB can be present in multiple organs, the lack of formal and functioning protocols to exchange information between doctors in multiple specialities leads to silos of knowledge.
- Infection Spread and Organ Interactions: Key aspects of EPTB, including the mechanisms of infection spread and the TB bacterium’s interactions with our organs, remain under-explored.
- Persistent Disease Markers in EPTB: A troubling aspect of EPTB infection is the prolonged presence of disease markers even after the infection is resolved with treatment.
- Some EPTB patients who complete anti-TB therapy may still find themselves affected by the disease.
- For example, In the eye, an autoimmune response to antigens triggered by the original infection can lead to persistent intraocular inflammation even after appropriate anti-TB therapy.
- Immunological Persistence: There could be additional immunological mechanisms at play in other organs impacted by Extrapulmonary Tuberculosis, potentially extending the duration of the disease even after the bacteria have been eradicated from those organs.
- This occurrence results in considerable distress for individuals with EPTB and represents a focal point of ongoing research.
Way Forward
- Common Approach to Extrapulmonary Tuberculosis Management: It needs to be done to be fostered, especially in a high TB burden country like India.
- Enhancing Data Collection: Equipped with guidelines and practice points, the hospital systems need to generate better data on EPTB.
- Presently, EPTB statistics primarily rely on the TB departments of major public hospitals.
- Specialist departments for each organ are the primary centres forExtrapulmonary Tuberculosis management. Their data practices are diverse and do not become part of the aggregate numbers for Extrapulmonary Tuberculosis prevalence.
- These departments must capture patient data and share it with the National TB Control Programme.
- Their action may help reinvigorate Ni-kshay, the national patient management portal for TB control, which has incomplete and missing data on TB patients insofar as EPTB patient data are concerned.
India’s Efforts to Eradicate Tuberculosis:
- Nikshay TB Program: It is a TB control programme, to monitor and track services and status related to screening, diagnosis, treatment and follow-up of TB cases. Alerts to TB patients regarding medication, follow-up alerts to the patients and providers etc.
- Nikshay Poshan Yojana (NPY): The NPY was launched in 2018 by the MoHFW to support every TB patient by providing a Direct Benefit Transfer of Rs 500 per month for nutritional needs.
- Nikshay Mitra: It is a nutrition support programme for consented TB patients.
- The Saksham Project: It is a project of the Tata Institute of Social Sciences (TISS) that has been providing psycho-social counseling to TB patients.
- It focuses on supporting and strengthening national response for both HIV and TB without creating parallel structures.
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- Unraveling Immune Mechanisms in Extrapulmonary Tuberculosis: Collaborative efforts across various EPTB specialties, coupled with the utilization of advanced immunological tools like single-cell RNA sequencing, hold promise for explaining the immune mechanisms underlying the disease.
- Without a thorough understanding of these mechanisms, physicians may persist in administering prolonged courses of anti-TB therapy under the assumption that the infection persists within the organ.
- However, this approach not only proves ineffective in resolving the disease but also subjects the patient to the prolonged anti-TB therapy.
- Updating INDEX-TB guidelines: The INDEX-TB guidelines require updating based on the most recent data and experience as they were developed more than ten years ago.
- Additionally, they must be multidisciplinary and gain from the contributions of several specialized health care fields.
- Establishing Diagnostic and Therapeutic Protocols for Extrapulmonary Tuberculosis: There are no established diagnostic or therapeutic procedures for all organs impacted by EPTB. To formulate them, high-quality data from clinical trials will be required.
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May 15, 2024
