A Guide for Counsellors 

INTRODUCTION

    In the year 2000, it was estimated that more than 36 million people in the world were living with HIV / AIDS (PLWHA). Globally, one third of all PLWHA are co-infected with tuberculosis. In India, there are an estimated 3.86 million HIV-infected persons. TB is the commonest opportunistic infection in HIV infected persons. It is estimated that 50-60% of HIV positive persons in India will develop TB in their lifetime.

MAGNITUDE OF TUBERCULOSIS IN INDIA

   Worldwide, 2 billion people are infected with TB. There are 8 million new TB cases each year and nearly 2 million death occur annually. 40% of these people are in SE Asia.

    India accounts for nearly one-third of the global TB burden.

    40% of the Indian population has TB infection.

    Every day in India more than 20,000 people become infected with the TB bacillus and more than 5000 people develop the disease.

    Every year 20 lakh people develop TB in India, of which at least 8 lakh are infectious (sputum positive).

    Every year, nearly 5 lakh die of TB - 1000 deaths per day, one TB death every minute.

    Untreated TB cases spread the infection to others in the community: each infectious patient can infect 10-15 individuals in a year unless effectively treated.

    In India, TB kills 14 times more people than all tropical diseases combined, 21 times more than malaria, and 400 times more than leprosy.

    TB kills more women than all causes of maternal mortality combined.

    The direct and indirect costs of TB to the country amount to Rs. 12,000 crore per year.

WHAT IS TUBERCULOSIS (TB) ?

   TB is an infectious disease caused by the bacterium Mycobacterium tuberculosis.

    TB bacilli mainly affect the lungs, causing lung tuberculosis (pulmonary TB). However, in some cases, other parts of the body may also be affected, leading to extra-pulmonary TB is more common in HIV- infected TB patients.

    Te bacterium is also called as acid fast bacillus (AFB) as it is resistant to decolourisation by acid.

HOW DOES TUBERCULOSIS SPREAD ?

   TB terms usually spread through air. When a patient with untreated pulmonary TB coughs, sneezes, or talks, he involuntarily throws TB terms into the air in the form of tiny droplets. These tiny droplets when inhaled by another person may TB. When patients with TB begin taking effective treatment, they stop spreading the germs within a few days to weeks.

    But unless they take the treatment regularly and complete it, they are likely to develop more dangerous forms of TB, known as drug-resistant TB, which they can spread to others.

    Once infected with M. tuberculosis, a person stays infected for many years, probably for life. The vast majority (90%) of people without HIV infection who are infected with M. tuberculosis do not develop tuberculosis disease. The bacilli remain dormant in their bodies. About 40% of our population is infected with the TB bacillus. Of these about 10% will develop the disease.

    Infected persons can develop TB disease any time. Various physical or emotional stresses may trigger progression of infection to disease. The most important trigger is weakening og immune resistance, especially by HIV infection.

 WHEN SHOULD TUBERCULOSIS BE SUSPECTED ?

Pulmonary tuberculosis

    Symptoms suggestive of pulmonary TV are:

    1.    Cough for 3 weeks or more.

    2.    Rise of temperature in the evenings

    3.    Chest pain

    4.    Weight loss

    5.    Loss of appetite

    6.    Haemoptysis (coughing up of blood in sputum)   

   HIV- infected patients with miliary TB often have fever, night sweats weight loss and anemia without specific symptoms. However, sputum smears are often positive.

EXTRA-PULMONARY TUBERCULOSIS

   A person with extra-pulmonary TB may have the following general symptoms:

        Weight loss

        Fever

        Night sweats

    Other symptoms depend on the organ involved:

        Lymph Node TB - swelling in the neck or armpit with or without discharge.

        TB Meningitis - Headache, fever, drowsiness, confusion, neck-rigidity.

        Spinal TB - Back pain, fever and in some cases swelling of the backbone.

        Pericardia! TB - Chest pain, shortness of breath.

        Pleural TB - Chest pain, shortness of breath,

HIV -TB INTERACTION

IMPACT OF IV ON TB

   HIV is the most powerful risk factor for progression from infection to TB disease. An IV positive person infected with M. tuberculosis has a 50% lifetime risk of developing TB whereas an HIV negative person infected with M. tuberculosis has only a 10% risk of developing TB. This is especially important in India where it is estimated that almost half of the adult population harbours M. tuberculosis.

INFECTED WITH M. tuberculosis

IMPACT OF TB ON HIV

    TB shortens the survival of patients wit HIV infection.

    TB may accelerate the progression of HIV, as observed by a six- to seven- fold increase in HIV viral load in TB patients.

    TB is the cause of death for one of every three people with AIDS worldwide.

HOW IS TUBERCULOSIS DIAGNOSED?

    Sputum Examination

        Most of the tuberculosis patients present with chest symptoms. Invariably these patients seek medical care. That means majority of the TB patients can be easily detected by screening chest symptomatic. all patients presenting with cough for more than three weeks should be investigated for tuberculosis.

        Sputum microscopic examination should be done in designated RNTCP microscopy centres are established in te RNTCP districts for every one lak population. They are located either in the CHC or in Taluk Hospital or in a TB dispensary. Each centre has a skilled technician, trained intensively for sputum examination. To ensure quality control, a senior TB laboratory supervisor is appointed for every five microscopy centres. The senior TB laboratory supervisor rechecks all the positive slides and 10% of the negative slides of these five microscopy centres. Thus the error in diagnosing a patient is minimized.

        It is essential to examine three sputum specimens of a single patient before a conclusive diagnosis can be made. One sputum sample is not sufficient for diagnosis as the chance of detecting smear positive cases is only 80% as compared to 93% with two samples and 100% with three samples.

        A spot specimen is collected on the patient's first visit. The patient is given a sputum container to bring the early morning sample the next day. When the patient comes with the early morning sample, the second spot specimen is taken. Result of the sputum examination is given to the patient at the earliest.

        Sputum microscopy not only confirms the diagnosis, but also indicates the degree of infectivity and response to treatment.

X-ray 

        X-ray are difficult to interpret. There is a high chance of wrongly diagnosing a patient as tuberculosis if X-ray is used as the only diagnostic criteria. Studies have shown that the inter- observer agreement on an X-ray finding is only 70% inter-observer agreement for microscopic examination. Also the same X-ray read by the same expert at different times shows a variation of 20%. A very large proportion of patients with an abnormal X-ray suggestive of tuberculosis do not actually have the disease. Only 50% of those having X-ray findings suggestive of tuberculosis may actually have the disease. Thus if X-ray are used, over-diagnosis of tuberculosis will occur. The patient will unnecessarily receive drugs, which could have been better utilized.

TREATMENT OF TUBERCULOSIS

        Even in HIV / AIDS patients. TB can be cured.

        Treatment for TB is provided for TB is provided free of cost at all government health facilities.

        Curing TB in HIV / AIDS patients will immediately improve their quality of life and prevent further transmission of TB to other family members.

        Treatment with DOTS (Direct Observed Treatment, Short- course) for has been shown to prolong the life of HIV-infected persons by at least two years. HIV-infected TB patients who received treatment with the same drugs but not in a programme of DOTS had an increased risk of death during treatment and an increased risk of recurrence of TB after completion of treatment.

        DOTS is as effective among HIV-infected TB patients as among those who are HIV-negative

        In non-RNTCP areas treatment in the form of sort course chemotherapy (SCC) is provided and is available at the District Tuberculosis Centres. Whenever possible, direct observation of treatment for the first two months should be done, as this as been sown to decrease mortality, drug resistance and relapse, especially in HIV patients with TB co-infection.

WHAT IS RNTCP?

        RNTCP means Revised National Tuberculosis Control Programme. Under the RNTCP, tuberculosis units (TU) are covering a population of five lakh. The TU is based in a CHC, Taluk Hospital or a Block Primary Health Centre (PHC). Each TU has one Senior Treatment Supervisor and Senior TB Laboratory Supervisor exclusively for the RNTCP. A designated Medical Officer - Tuberculosis Control is responsible for all the RNTCP activities at TU. The diagnostic component of the TU is the Microscopy Centre which is also located either in the Microscopy Center which is located either in the CHC, PHC, or the Taluk Hospital. Each Microscopy Centre serves a population of one lakh. Rural hospital, health centres, dispensaries and health facilities within a direct are responsible for providing direct observed treatment services (DOTS). Peripheral health workers, (Multipurpose workers, Trained 'dais', 'Anganwadi' workers, village health guides or community volunteers) oversee the delivery of drugs to the patients and help in retrieval of defaulters.

        There are five components of te RNTCP :

                                                (i)   POLITICAL COMMITMENT

                                                (ii)  GOOD QUALITY SPUTUM MICROSCOPY

                                                (iii)  UNINTERRUPTED SUPPLY OF GOOD QUALITY DRUGS

                                                (iv)  DIRECTLY OBSERVED TREATMENT

                                                (v)    ACCOUNTABILITY

RNTCP sifts the responsibility for cure from the patient to the health care system.

        By late 2001, a population of more than 440 million has been covered in more than 200 districts, and 80% of the country is expected to be covered by 2004. Areas with a high prevalence of HIV infection have been prioritised for RNTCP coverage and most are already implementing the RNTCP.

        Ideally, the RNTCP microscopy and treatment observation centres should be located in the same institution as the voluntary counselling and testing centres. Three sputum samples are tested in each patient.

        Patients with two or three positive smears are started on treatment; those in whom only one is positive undergo chest X-ray. Those with no positive smears are prescribed a course of antibiotics for 7-14 days and if symptoms persist, undergo chest X-ray and are re-evaluated.

        The patient can take treatment from any of the identified DOT centres depending on his choice and convenience.

HOW EFFECTIVE IS DOTS?

       DOTS is the WHO-recommended technical and management package aimed at achieving the twin goals of more than 85% cure rate and 70% case-detection of new infectious cases. If effectively implemented, this strategy should cut the chain of transmission in the community by curing most of the infectious cases.

        Direct observation ensures that patients take the right drugs, at the right intervals, and in the right dosages.

        Direct observation is necessary because it has been observed that many patients do not strictly adhere to the regimen. Many patients naturally discontinue their medication once they start feeling better. Even with excellent health education, at least one third of the patients are likely to stop taking drugs.

        Treatment in the RNTCP consists of 2 phases- an initial intensive phase and a second continuation phase. The total duration of treatment is 6-9 months. Sputum microscopy is done regularly to monitor the response to treatment.

        The intensive phase lasts for 2-4 months. In this phase, a health worker or some other trained person watches as the patient swallows the drugs in his presence. Treatment is given thrice a week on alternate days and every dose is directly observed.

        The continuation phase lasts for 4-5 months depending on the patient's response to treatment. In this phase, the first dose of the medicine every week is taken by the patient under observation, while the other doses are taken by the patient himself. The patient should bring the previous week's blister pack when coming to collect the next week's blister pack.

       It is extremely important that the patient takes regular and complete treatment in order to ensure complete cure and prevent development of drug-resistant  TB. Treatment of multi-drug resistant TB is extremely difficult, expensive and often unsuccessful.

Failure to use DOTS in the face of HIV can lead to explosive spread of TB with cases tripling and drug resistance increasing rapidly.

SCREENING OF CONTACTS

        Any contact of a smear positive case should have three sputum examinations done, irrespective of the duration of his symptoms. This is particularly important for HIV-positive patients, as a higher proportion of their contacts may be HIV-positive and therefore at risk for having TB disease.

        Children below six years of age who are contacts of smear positive cases should be evaluated for TB.

RECORD KEEPING AND REPORTING

        Counsellor should keep a record of the number of persons attending VCTC, number identified with cough for more than three weeks, number referred for diagnosis, number diagnosed as TB and of these placed on treatment.

        The report should be compiled and submitted to the SACS every month.

ROLE OF COUNSELLORS IN HIV - TB CO-ORDINATION

The counselor at VCTC can help in the RNTCP by: 

  Revised National Tuberculosis Control Programme (Manipuri Version)