UPSC EDITORIAL ANALYSIS : The challenge of extra-pulmonary TB

Source: The Hindu

• Prelims: Current events of national importance(AMR,TB, extrapulmonary TB, National TB Elimination Programme, WHO etc

• Mains GS Paper II: Government policies and interventions for development in various sectors and issues arising out of their design and implementations etc

ARTICLE HIGHLIGHTS

• 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.

• 20% of TB infections develop in the lymph nodes, brain, gut, eyes, or other organs.

INSIGHTS ON THE ISSUE

Context

Tuberculosis:

• TB is caused by a bacterium called *Mycobacterium tuberculosis, belonging to the Mycobacteriaceae* family consisting of about 200 members.

• Some of Mycobacteria cause diseases like TB and Leprosy in humans and others infect a wide range of animals.

• In humans, TB most commonly affects the lungs (pulmonary TB), but it can also affect other organs (extra-pulmonary TB).

• TB is a treatable and curable disease.

• TB is spread from person to person through the air. When people with lung TB cough, sneeze or spit, they propel the TB germs into the air.

• Common symptoms of active lung TB are cough with sputum and blood at times, chest pains, weakness, weight loss, fever and night sweats.

Extrapulmonary tuberculosis (EPTB):

• It is tuberculosis outside of the lungs.

• EPTB includes tuberculosis meningitis abdominal tuberculosis skeletal tuberculosis Pott’s disease (spine) scrofula(lymphadenitis) genitourinary (renal) tuberculosis.

• tuberculosis meningitis

• abdominal tuberculosis

• skeletal tuberculosis

• Pott’s disease (spine)

• scrofula(lymphadenitis)

• genitourinary (renal) tuberculosis.

• Extrapulmonary tuberculosis (EPTB) accounts for 15–25% of all cases of TB.

• HIV patients, especially with low CD4 counts, have higher rates of EPTB.

• Children are more likely to have skeletal TB than adults.

• EPTB is more difficult to diagnose than pulmonary TB It often requires invasive procedures to obtain tissue and/or fluid samples.

• It often requires invasive procedures to obtain tissue and/or fluid samples.

• The symptoms and signs generally relate specifically to the affected organ system.

• Extra-pulmonary infections can persist even after the TB infection in the lungs is resolved.

• The public health challenge of extra-pulmonary TB (EPTB) may be larger than our current estimates.

• EPTB is often stain negative, which means it is not detectable on regular TB stain tests.

INDEX-TB:

• Formulated by a Group of experts from different health institutions across the country, the WHO, and the Cochrane Infectious Disease Group.

• The objective was to provide guidance on uniform, evidence-informed practices for suspecting, diagnosing and managing EPTB at all levels of healthcare delivery.

• The guidelines describe agreed principles relevant to 10 key areas of EPTB which are complementary to the existing country standards of TB care and technical operational guidelines for pulmonary TB.

• These guidelines provide recommendations on three priority areas for EPTB: use of Xpert MTB/RIF in diagnosis use of adjunct corticosteroids in treatment duration of treatment.

• use of Xpert MTB/RIF in diagnosis

• use of adjunct corticosteroids in treatment

• duration of treatment.

• The guidelines were developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria which were evidence based, and due consideration was given to various healthcare settings across India.

• which were evidence based, and due consideration was given to various healthcare settings across India.

What steps need to be taken for better diagnosis of EPTB?

• Armed with guidelines and practice points, our hospital systems need to generate better data on EPTB.

• Specialist departments for each organ are the primary centers for EPTB management. These departments must capture patient data and be ready to 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.

• These departments must capture patient data and be ready to 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.

• which has incomplete and missing data on TB patients insofar as EPTB patient data are concerned.

Variants of TB:

• Drug-resistant (DR-TB)

• Totally drug-resistant (TDR-TB)

• Extensively drug-resistant (XDR-TB)

• Pulmonary TB (P-TB)

• Non-pulmonary TB

Initiatives:

Way Forward.

• 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.

• A concerted effort by different EPTB specialities, and advanced immunological tools such as single-cell RNA sequencing, might be able to uncover the immune mechanisms for the disease. Unless we understand these mechanisms, physicians will continue to treat EPTB with long duration anti-TB therapy (sometimes for even two years or more) assuming that the infection is persisting in the organ. This fails to resolve the disease and exposes the patient to the toxicity of anti-TB therapy. Diagnosis and treatment protocols for all organs affected by EPTB do not exist. We need high-quality data through clinical trials to formulate them. INDEX-TB guidelines were formulated over a decade ago and need to be updated with the latest data and experience. They also need to be multidisciplinary and benefit from inputs from a variety of specialized areas of health care. The needs and the interests of patients and communities must be prioritized within the care paradigm and the health-care system. This principle, echoed by survivors, communities, health experts and policymakers, underscores the need for a person-centered approach to TB care and management. The adoption of AI and digital health solutions for TB diagnosis, adherence and surveillance can revolutionize the way TB care is delivered and accessed in the country.

• Unless we understand these mechanisms, physicians will continue to treat EPTB with long duration anti-TB therapy (sometimes for even two years or more) assuming that the infection is persisting in the organ. This fails to resolve the disease and exposes the patient to the toxicity of anti-TB therapy.

• assuming that the infection is persisting in the organ.

• This fails to resolve the disease and exposes the patient to the toxicity of anti-TB therapy.

• Diagnosis and treatment protocols for all organs affected by EPTB do not exist. We need high-quality data through clinical trials to formulate them.

• We need high-quality data through clinical trials to formulate them.

• INDEX-TB guidelines were formulated over a decade ago and need to be updated with the latest data and experience. They also need to be multidisciplinary and benefit from inputs from a variety of specialized areas of health care.

• They also need to be multidisciplinary and benefit from inputs from a variety of specialized areas of health care.

• The needs and the interests of patients and communities must be prioritized within the care paradigm and the health-care system. This principle, echoed by survivors, communities, health experts and policymakers, underscores the need for a person-centered approach to TB care and management.

• This principle, echoed by survivors, communities, health experts and policymakers, underscores the need for a person-centered approach to TB care and management.

• The adoption of AI and digital health solutions for TB diagnosis, adherence and surveillance can revolutionize the way TB care is delivered and accessed in the country.

QUESTION FOR PRACTICE

Critically examine the role of WHO in providing global health security during the COVID-19 Pandemic.(UPSC 2020) (200 WORDS, 10 MARKS)

Editorial Analysis – 15 May 2024