Health Action: Special Issue On TB (March 2013)

Health Action
March 2013
Vol 26 No.3 MARCH 2013
health action
A HAFA NATIONAL MONTHLY FROM THE HOUSE OF THE CATHOLIC HEALTH ASSOCIATION OF INDIA (CHAI) MANAGING EDITOR Rev. Dr. Tomi Thomas, IMS EDITOR-IN-CHARGE N Vasudevan Nair EDITORIAL ASSISTANT Theophine V. John LAYOUT & PAGE MAKE-UP M S Nanda Kishore CIRCULATION SUPPORT
T K Rajendran
Cover : Editorial Team Picture courtesy: Cover and Text: Google.com
Contents
Tuberculosis:what, why and how Dr Anand Das .................................. 4 Engaging communities in the fight against TB Project-Axshya Programme Management Unit....................... 8 Evolving TB control strategies in . India Courtesy: Central TB Division..... 11 Tuberculosis and silicosis at workplace Axshya India team of TB Alert ...... 14 Experiences of Lepra India in TB control in Andhra Pradesh Drs J Subbanna & Aparna S Srikantam .................................. 16 TB in children Dr Shoma A Chatterji................. 18 Social stigma attached to TB Dr G Srinivas Rao..................... 20 Frequently-asked questions on TB Source: TBC India ...................... 21 Knowledge, attitudes and practices on TB Courtesy: The Union ................... 22 World TB day: 24 March 2013 Vinay Kumar G......................... 24 Project Axshya has helped the state in reaching the unreached Interview with Dr S Jayasankar, State TB Officer, Government of Kerala ........................................ 25 Why should BPL TB patients be included in the food security bill?.................... .................... 26 CHAI-Axshya: the global fund round 9 TB project Rev Dr Tomi Thomas, IMS .......... 27 District TB officers speak........ 30 TB patients, communities,RHCP and TB forum members testify................................... 32 Reducing stress in type 2 diabetic patients through yoga Shanthi and Karoline Rajkumar...33 Rediscovering the forgotten millets... for health Aparna Kuna et al ...................... 35 Vaccinaion in children Suchitra B.S............................ 37 Health bits...............................38
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EDITORIAL BOARD Rev Dr Yvon Ambroise Sr Anne Ponnattil Dr B Ekbal Dr Amarender Reddy Dr M V Ramana Rao Dr Ravi DSouza Ravi Duggal EDITORIAL ADVISORY COMMITTEE Dr Sunny Chunkapura Dr S Ram Murthy Dr P Sangram Dr Gopala Krishna Dr Venugopal Gouri M C Thomas Dr P V Sharada Printed and Published by Dr (Sr) Placida Vennalilvally for and on behalf of Health Accessories for All (HAFA) at Jeevan Institute of Printing, Sikh Village, Secunderabad- 500 009 Editorial and Administrative Offices: Post Box 2153, 157/6, Staff Road, Gunrock Enclave, Secunderabad 500 009, AP, India Tel: 27848293, 27848457, Fax: 04027811982, E-mail: hafa@hafa-india.org; healthaction@chai-india.org; directorgeneral@chai-india.org Website: www.chai-india.org; hafa-india.org Articles and statements in this publication do not necessarily reflect the policies and views of HAFA.Information given here is not a substitute for professional medical advice.
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Everything we hear is an opinion, not a fact. Everything we see is a perspective, not the truth. Marcus Aurelius
March 2013 March 2013
EDITORIAL
Improving access to tuberculosis care and control

hen India woke up to her sixty-fourth Republic Day the thought that was uppermost in the mind of an average Indian might have been about the life-situation in the country which is far from what one would wish it were. A Republic of ideas, dreams and imagination has become one of hate and nightmares. Living condition is below mediocre. Unemployment is massive. Healthcare is abysmal. Education is in a shambles. There is massive corruption. There is misgovernance or lack of governance. Assaults on democratic values from within and without and violation of womens rights, dignity and lives are rampant. And costly are the grievous failures to address the inequalities and the mass and multiple deprivation that plague the lives of millions of people. Our national aim should be to transform India into a powerful, secular, industrial or economic powerhouse where everyone can lead a decent and healthy life. In this task each individual has to chip in with their creativity and initiatives. In spite of three decades of high economic growth, social progress continues to elude us. For India to reap rich dividends from its democracy, it requires an educated, skilled and healthy workforce to compete in a global economy. A manifold increase in funding for education and health coupled with copious reduction in expenditure and waste, subsidies and warfare is the need of the hour. India recently marked a major milestone: two years without a single case of polio. The success of fighting polio was the result of a concerted effort that included strong leadership and commitment of the government as well as close partnership between public and private sectors. The world is in the cusp of eradication. We are not yet there. As regards leprosy it is the same story. It was announced that leprosy had been virtually eradicated. But the curse is very much here. In 2010, out of 2,28,000 cases in the world, India accounted for 1,26,000. We need to step up effort to achieve zero-prevalence (Times of India, 29 January, 2013). Indias TB burden is staggering. Every year, 1.8 million people get the disease; and about 800,000 cases are infectious. Until recently, 370,000 died of it annually. An estimated 100 million workdays are lost to it, with the country incurring a huge cost nearly $3 billion. The direct costs are $ 300 million. Since its launch in 1998 through Revised National Tuberculosis Control Programme, more than 14.2 million patients have been treated and 2.6 million lives saved with DOTS.(The Hindu, 21 October, 2012) Around 99,000 Indians suffering from TB become drug-resistant every year. In India, around 3% of all new cases and 12-17% among treatment cases are MDR. In 2010, 2.3 million cases occurred of which 360,000 people died; nearly 1000 deaths per day. (Times of India, 8 August 2012). An easy and effective way to diagnose TB has remained a challenge. Emergence of drug-resistance has made its management more complex. MDR TB is caused by bacteria that are resistant to anti-TB drugs (isoniazid and rifampicin). XDR TB is caused by bacteria that are resistant to isoniazid and rifampicin as well as any fluoroquinolone and second line antiTB injectable drugs. Sixty-nine countries including India have reported cases of XDR-TB. An estimated 25000 cases of XDR TB emerge every year. (Times of India 21, October 2012) Earlier, the focus was on detection to encourage people to go for a check-up and sputum testing. But with Multi Drug Resistant TB cases proliferating, the focus is more on completion of the first course which is the simplest way to defeat resistance. The Project Axshya is a civil society initiative to strengthen TB care and control in India. It is the largest Advocacy, Communication and Social Mobilization (ACSM) initiative supported by Global Fund Round 9 Grant and is being implemented in 375 districts across 23 states by the UNION and World Vision India ably assisted by a network of civil society organizations. The project takes a holistic approach towards improving tuberculosis quality care and control. In its second phase, by the time the project closes, perceptible difference would have been made to the tuberculosis situation in the country. Let us hope our dream of a TB-free India comes true! The Catholic Health Association of India (CHAI), the biggest sub-recipient of the UNION, as part of its advocacy effort, took up with the government the idea of providing additional nutritional support to the BPL TB patients by including them in the Food Security Bill. This will ensure their completion of treatment. This issue deals in depth with the care and control of tuberculosis.
Rev Dr Tomi Thomas, IMS Managing Editor
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Health Action
March 2013
COVER STORY
Tuberculosis
What, Why and How
Dr Anand Das (MBBS, DTCD, DNB)
uberculosis (TB) is a disease of great antiquity. Tuberculous lesions had been found in the vertebrae of Neolithic humans and Egyptian mummies as early as 3700 BC. Today, tuberculosis has become the most important communicable disease in the world. In 2011, there were an estimated 8.7 million new cases of tuberculosis (13% co-infected with HIV) and 1.4 million people died from tuberculosis, including almost one million deaths among HIV-negative individuals and 430 000 among people who were HIV-positive. TB is one of the top killers of women, with 300 000 deaths among HIV-negative women and 200 000 deaths among HIV-positive women in 2011.
in the periphery of the lung. There is a critical diameter range that maximizes the probability of inhalation and retention of infectious particles leading to the establishment of the infection. The diameter lies somewhere between 1 mm and 5 mm. The risk between infection and progression to disease is multifactorial. The risk gets elevated in the first years following infection and then remains low for a prolonged period of time. Other risk factors include HIV infection, lung diseases such as silicosis, carcinoma of the head and neck, immunosuppressive treatment, smoking, diabetes and surgeries like gastrectomy and jejenoileal bypass.
Pathology
Deposition of TB bacilli in the lung alveoli is followed by vasodilatation and an influx of polymorphonucleocytes (PMNs) and macrophages to the area. After several weeks, the PMNs decrease and macrophages predominate. The macrophages crowd together as epitheloid cells to form the tubercle or the unit lesion of tuberculosis. Some mononuclear cells fuse to form the multinucleated or Langhans giant cell. Lymphocytes surround the outer margin of the tubercle and in the centre of the lesion a zone of caseous necrosis may appear that may subsequently calcify. Primary, infection is usually evident as a subpleural tubercle (the Primary or Ghons focus) in any lung zone and drains via lymphatics to hilar lymph node to form the primary complex. Most primary infection heals although haematogenous spread probably occurs via the lymphatics in majority resulting in seeding of the bacilli to other parts of the lung as well as other organs. The primary lesion
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Pathogenesis
Robert Koch first described the tubercle bacillus known as Mycobacterium tuberculosis in 1882. Mycobacteria are known to comprise a large group of acid-fast, alcohol-fast aerobic or microaerophilic, non-spore forming, non-motile bacilli. Of the many different mycobacteria, only M tuberculosis, M bovis and M africanum are recognized as tubercle bacilli, all being sub-species of a single species. M tuberculosis is an obligate parasite that is infectious to humans, other primates and many other mammals.
Transmission
For many years, TB was thought to be transmitted genetically. It is now known that the infection is transmitted through the airborne route and that the unit of infection is a small particle called the droplet nuclei. Successful transmission requires airborne infectious droplet nuclei to be small enough to reach an alveolus
Health Action March 2013
sometimes progresses and the pathological changes are similar to those seen in reactivation tuberculosis. Reactivated pulmonary tuberculosis is most often seen in the upper lung zones and limited to the posterior segment of the upper lobe or the apex pf the lower lobe. The high ventilation-perfusion ratio with alveolar Po2 elevated relative to other zones, predisposes to reactivation at these sites. Proliferation of the bacilli in the caseous centres is followed by softening and liquefaction of the caseous matter, which may discharge into the bronchus with resultant cavity formation. Whereas approximately 104 bacilli per gram are fund in caseous tissue, upto 109 organisms may be harboured in a single cavitory lesion. Fibrous tissue around the lesion, is incapable of limiting the extension of tuberculosis process. Spread of caseous material may result in development of tuberculous pneumonia. Rupture of caseous pulmonary focus into blood vessel may result in military tuberculosis (0.5 to 2mm tuberculous foci) in the lung and other organs. Encroachment of pulmonary or lymph node caseous material on the bronchi may lead to tuberculous bronchitis. Rupture of caseous glands into the trachea or major bronchus may cause collapse of lung or even sudden death by suffocation in young children.
mononuclear phagocytes that ingested and killed TB bacilli in an increased rate compared with normal macrophages. Cell-mediated immunity is alone responsible for this acquired resistance. The immunity transferred by an initial infection is utilized in the form of BCG vaccination. BCG confers immunity by activation of macrophages within the reticuloendothelial cells of the immunized host with resultant limitation of mycobacterial growth on subsequent challenge. The positive tuberculin test is the earliest indicator of infection with TB. However, a negative tuberculin test does not exclude tuberculosis. Negative tuberculin tests may be found in patients with military TB, extensive disease and elderly.
Patterns of presentation (Timetable)

Most primary TB heals spontaneously without residue on the chest film. In some patients there may be sequelae to the primary infection. In children, enlarged hilar lymph node may compress or erode bronchi with resultant lobar consolidation and collapse called epituberculosis. Miliary tuberculosis and tuberculosis meningitis occur usually within 6 months of primary infection and is common among children less than 5 years old. Pleural effusion, due to seeding of the pleura from a lung focus, occurs within 6 to 12 months and is commoner among younger adults. Increasing infiltration and cavitation called progressive primary or post-primary disease occurs 1 to 2 years after the primary infection. Skeletal tuberculosis, most commonly of the spine, could occur 1 to 5 years after primary infection. Genitourinary tuberculosis commonly occurs 5 to 15 years after primary infection.
Immunology
The immune or antimycobacterial response of previously infected individuals to subsequent mycobacterial challenge is mediated by a population of
Today tuberculosis has become the most important communicable disease in the world. In 2011, there were an estimated 8.7 million new cases of tuberculosis (13% co-infected with HIV) and 1.4 million people died from tuberculosis, including almost one million deaths among HIVnegative individuals and 430 000 among people who were HIV-positive. TB is one of the top killers of women, with 300 000 deaths among HIV-negative women and 200 000 deaths among HIV-positive women in 2011.
Epidemiology
Morbidity Age: Median age of TB patients has increased markedly in countries where the risk of infection declined rapidly and thus the infected population segments became increasingly older. In contrast, in low income countries, Tb notification rate still peaks in young adults. Sex: Risk of progression from infection to disease also differs among males and females and varies depending on the age. The M:F (male-female) ratio of 2:1 explains higher prevalence of infection among males. Socio-economic Status: There is a strong association of poverty with the incidence of TB. Low socioeconomic conditions lead to increase in transmission.
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Poverty is also associated with reduced access to health care services. Race and Ethnicity: The decline in incidence in the US has been the greatest among the 5 to 14 year-old, greater among females than males and more pronounced among the white. Migration: High incidence among South-East Asian refugees appears because of high risk of tuberculosis infection in their countries of origin. Population Density: Age-specific prevalence is frequently lower in rural than in urban areas. Marital Status: Highest incidence found in men who were divorced and lowest incidence was found in married men. Single and widowed men had an incidence between the two extremes. Substance Abuse: Despite the long-standing notion between alcohol and other substances and incidence, the epidemiological evidence of a causal association is not convincing. Other Risk Groups: Health care workers are at an increased risk. Impact of HIV Infection: TB and HIV are two conditions that are intrinsically linked as the prevention of TB depends on the integrity of Cell Immune System and HIV destroys precisely that. HIV may alter the epidemiology in three ways: Endogenous reactivation in persons who become HIV-infected Progression from infection to disease in pre-existing HIV-infected individuals Transmission of TB to general population from individuals who developed TB because of HIV infection Mortality Major site of disease: Sputum-positive pulmonary tuberculosis has a higher fatality rate than sputum negative. Delay in diagnosis and treatment: Failure to diagnose may result in death as well as unrecognized transmission to family and friends. Age: Mortality is highest among young adults. Industrialization: Spanning 300 years, the epidemic is
coming to an end. Official estimates: 1.5 million deaths/ year (Difficult to verify) Chemoprophylaxis: Administration of chemotherapy (use of chemical agents to treat or control disease) to prevent the development of tuberculosis disease Primary: Given to individuals who have so far not been infected. Isoniazid is used based on its value in experimental animals. Secondary (or disease): Household contacts, Positive TB skin test reactors with abnormal but inactive X Ray, positive skin test in special clinical situations are given 300 mg INH daily for prevention of development of disease.
Clinical features Symptoms

Symptom-free, discovered on routine chest radiography Persistent cough with or without expectoration Malaise Loss of appetite and weight loss Recurrent colds Low-grade fever, evening rise of temperature and night sweats
Physical Signs
Pallor, hectic flush or cachexia
For many years, TB was thought to be transmitted genetically. It is now known that the infection is transmitted through the airborne route and that the unit of infection is a small particle called the droplet nuclei. Successful transmission requires airborne infectious droplet nuclei to be small enough to reach an alveolus in the periphery of the lung. There is a critical diameter range that maximizes the probability of inhalation and retention of infectious particles leading to the establishment of the infection.
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Miliary tuberculosis and tuberculosis meningitis occur usually within 6 months of primary infection and is common among children less than 5 years old. Pleural effusion, due to seeding of the pleura from a lung focus, occurs within 6 to 12 months and is commoner among younger adults.
Increased pulse rate and respiratory rate (if febrile) Clubbing (Rare) Post-tussive crepitations in upper zones and apices Advanced or pneumonic disease: signs of consolidation Chronic disease: deviation of trachea due to fibrosis Physical signs of cavity: seldom found even with large cavities Localized wheeze: endobronchial tuberculosis
Persistent crepitations Certain radiological appearances: cavity, widespread soft shadows, shadows that extend on serial chest x rays
Clinical features in the HIV-positive patient

When TB occurs late in the course of HIV infection or in patients with AIDS, the features are more atypical: lower zone or diffuse consolidation, mediastinal adenopathy and involvement of extrapulmonary sites like brain, pericardium, bones and gastro-intestinal tract. Cavitation of pulmonary lesions and tuberculin positivity are less common.
Differential diagnosis of pulmonary tuberculosis

Pneumonia: sputum-positive for TB and radiographic opacities not improving in 2 -3 weeks Carcinoma of the bronchus: Consolidation distal to a proximal carcinoma particularly may be cavitated and mimic TB. Sputum examination and CT, FNAC and transbronchial biopsy may be done. Lung abcess due to Staphylococcus pyogenes and Klebsiella: Acute severe illness with marked leucocytosis and organism readily isolated from blood or sputum Pulmonary infarcts: Upper zone infarcts with cavitations may mimic TB. Routine investigations, deep vein thrombosis and improving serial x rays help differentiate Other pulmonary diseases: Atypical mycobacteria is a frequent source of confusion.
Diagnosis
Sputum smear examination: ZN staining LED FM Microscopy Culture : Solid and LPA Xpert MTB/RIF (MTB integrated cartridge-based automated nucleic acid amplification test (CBNAAT) that uses a common platform to diagnose both TB and Rifampicin resistance), which has a sensitivity and specificity equivalent to that of solid culture, while providing the results rapidly within 2 hours. Bacteriological examination of samples other than sputum: Gastric aspirate, Laryngeal swabs, Fibreoptic bronchoscopic specimens (bronchial washings, brushings or transbronchial biopsies), Transtracheal aspirates, FNAC etc. Radiology: Opacities mainly in upper zones, patchy or nodular opacity, presence of cavity/cavities, calcification, bilateral opacities in upper zones, opacities that persist even after several weeks.
Complications
Pleurisy : a classical pleural rub may be heard Tuberculous empyema: Following artificial pneumothorax therapy and can present thirty years after therapy. Could result from the rupture of a cavity in the pleural space. Chemotherapy, tube suction and decortication may be needed. Tuberculous laryngitis: Laryngoscopy and biopsy may be needed to establish diagnosis. TB of other organs: Testes in males and urine examination should be done. Chronic obstructive airway disease: May result from a severe fibrotic pulmonary disease. Corpulmonale: Distortion of pulmonary parenchyma, emphysema and airways obstruction.
(*Technical Officer, International Union Against Tuberculosis and Lung Diseases, The Union South-East Asia Office, C-6, Qutub Institutional Area, New Delhi 110 016. Email: ADas@theunion.org)
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Assessment of activity
It is often difficult to decide whether a particular lesion should be treated or merits further assessment. The following may give some guidance: Bacteriologically positive patient indicates activity and is an absolute indication for treatment Symptoms such as cough, hemoptysis, tiredness and weight loss are suggestive that a lesion demonstrated radiologically is active
evised National Tuberculosis Programme (RNTCP) was initiated in 1997 and expanded at an unprecedented scale to cover the entire country by March 2006. During this expansion phase (called phase 1) the programme, focused on enhancing political and administrative commitment, establishing quality diagnostic and treatment services through public health facilities, systematic supervision and monitoring and accountability towards TB care and control. In the years to follow (2006-11) the programme focused on universal access to TB services, in line with the Millennium Development Goals, with DOTS strategy at its core.This strategy also took cognizance of six key strategies proposed by the global Stop TB strategy of WHO (2006-2015) to have World Free of TB. Strengthening involvement of civil society through NGO and Private Provider schemes, Advocacy, Communication and Social Mobilization (ACSM) began to appear on the programme agenda in this phase. Currently, the proposed National Strategic Plan (NSP) document for Phase III (2012-17), emphasizes early case detection and improved diagnosis of all TB patients with better outreach, increased case finding, involvement of private providers and community-based supervision, monitoring and accountability to TB care and control. Early case-detection and ensuring complete treatment of sputum-positive TB clients has always been a major public health challenge for TB control programme. The programme strategies adopted were able to cater to only those clients who visited public health institutions or those who were identified by community-based healthcare workers. Clients outside the public health network continued to go undiagnosed and untreated thereby increasing the TB burden in community. Thus community engagement strategies were to be developed to create awareness about TB care and control. In the process, Project Axshya evolved with objectives to expand reach, visibility and effectiveness of RNTCP by engaging community-based providers to improve TB
Engaging communities in the fight against TB R
COVER STORY
services, especially for women and children, marginalized, vulnerable and TB-HIV co-infected populations. The Union, being the oldest organization working in TB care and control with a mission to bring innovation, expertise, solutions and support to address health challenges partnered with RNTCP, World Vision India to implement the largest ACSM project Project Axshya. The project supported by Global Fund Round 9 grant, is implemented by the Union in 300 districts
across 21 states of India through a network of partners from nine civil society organizations. Over a period of two years, the project has been able to network with over 1200 NGOs and 3000 CBOs who are involved in the implementation of ACSM activities at the community level. Activities listed in the table are all interlinked to
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engaging communities advocating for TB care and rights and responsibilities through Patient Charter (e) control (identifying symptomatics, sputum collection and support TB patients in social acceptance eg. To transportation, referrals, treatment adherence, overcome stigma, (f) support treatment adherence etc. completion, default retrieval etc); Informing Nearly 36,000 such meetings have been conducted communities through communication tools about TB, across 21 states of India. In addition to GKS, Axshya rights and responsibilities of patients through patient village concept is implemented. This intervention is charter, and service availability at health facilities; aimed at community awareness, engagement and Mobilizing communities to advocate for political and empowerment on TB care and control. administrative commitment in ensuring services at health Communities in India access private health care facilities and also for creating awareness about TB providers (~90%) for any type of illness. Private more specifically to reduce TB stigma. Community providers often are the first-point of contact, and engagement involves people from all sectors of the awareness about TB among them is most important for society. In Project Axshya through GaonKalyan Samitis the focus has been Table 1 Activities of Project Axshya (a) to involve members of Village Thematic areas Activities Health Sanitation and Nutrition Committees (VHSNCs), Self-Help Community Engagement Community Group Meetings Groups, Panchayati Raj Institutions, (GaonKalyanSamitis) other influential people through Engage/Train Community community group meetings. (b) to build Volunteers capacity and sensitization of local health Mass Media Campaign care providers - Rural health care (Bulgam Bhai - campaign) providers (RHCPs), Ayurveda, Yoga Mid Media Activities and Naturopahty, Unani, Sidha and Axshya Village (TB Free Villages) Homeopathy (AYUSH) providers, soft Empowering TB-Affected Communities Dissemination of Patient Charter skill training for health staff and other District TB Forums private providers in referrals/ management of referrals. (c) to build Sensitizing people affected by HIV capacities of volunteers in hard-to- Engaging Healthcare Providers Engaging Rural Healthcare Providers reach areas, marginalized and Engaging AYUSH Providers vulnerable populations (eg. HIV Health Systems Strengthening Sputum collection and affected, tribal, naxal affected areas, transportation slums etc), for identifying Human resource development symptomatics, collection of sputum and component transportation to nearest DMCs and Health infrastructure support support the system/programme in component tracing lost to follow-up of patients on Default retrieval treatment.
Gaon Kalyan Samiti

Gaon Kalyan Samiti (GKS) meetings are organized by volunteers of partner NGOs at village level and or at ward level (in Urban areas). During the meetings, (a) the members are sensitized about TB care and control, (b) information is provided about Other Advocacy Efforts availability of services eg. Name of the DMC, TU, etc (c) facilitate volunteers in identifying TB symptomatics in community (d) inform about patients
Sensitization of NGOs on RNTCP scheme Technical support to CTD, State TB cell in areas of ACSM Capacity building of program staff on MDR TB, OR, Epidemiology and Health Management Enhancing political and administrative commitment. Engaging professional associations Supporting national partnership for TB care and control.
rights to get free diagnosis and treatment and other benefits under the existing social welfare schemes.
Health systems strengthening

The cycle of community engagement would be incomplete without Health System support/ strengthening. Health System support/strengthening for Axshya comes from partnering with Central TB Division, Ministry of Health and Family Welfare. The Union has extended support to CTD in terms of providing technical support in areas of ACSM, PP and Monitoring and Evaluation (M&E).ACSM support is also provided to RNTCP in six states namely Karnataka, Maharashtra, Madhya Pradesh, Uttarakhand, Uttar Pradesh and Punjab through the 6 Union consultants. At the district level, activities are focused at sputum collection and transportation in areas of vulnerable/ marginalized/hard-to-reach, poor case detection etc. Secondly to support DTCs in default retrieval through the network of volunteers established under project Axshya. Thirdly, soft-skill training has been provided to health staff to impart communication and counselling skills, improve Inter Personal Communication (IPC) which helps in better patient-provider communication and building healthy relationships. Fourthly, in many states, Designated Microscopic Centres (DMCs) have been supported through providing quarterly preventive maintenance of the binocular microscopes thereby ensuring quality sputum microscopy and hence, better diagnostic care to TB patients. These are some of the major areas of support provided through Project Axshya. The District Tuberculosis Officers (DTOs), State Tuberculosis Officers (STOs) and many health officials, are extending support and guidance to project Axshya at various level of implementation.
TB care and control. Limited knowledge or lack of knowledge has been found to contribute to poor adherence to treatment regimen prescribed under RNTCP. As a result of non-adherence to treatment regimen, the burden of multi-drug resistant form of TB tends to increase in communities. It was therefore envisaged under Project Axshya to engage private providers most importantly RHCPs (unqualified providers) in the identification of symptomatics, referrals, treatment (completion) and default retrieval. Currently, about 17,000 RHCPs have been sensitized under project and are referring TB symptomatics, engaged in sputum collection and transportation and are recognized as DOT providers under RNTCP. DCs and the other project staff have strongly advocated for the involvement of these unqualified practitioners in referrals & DOT provision as they are usually the first point of contact for the community members.
Empowering TB communities
Empowering TB communities through TB forums is an innovative approach. TB forums aim to serve as a platform to share the experiences of TB patients. Formation of this forum is facilitated by the project at the district level ensuring representation from TB affected patients (cured/on treatment) and civil society members journalist, lawyers, NGO representatives, Opinion leaders etc. to discuss the overall experience of TB-patients and suggestions to improve TB care services. The forum meets regularly with DTOs/other officials to brief them about the issues and challenges faced by the patients. Through Project Axshya, TB patients have also been made aware of their Rights & Responsibilities by means of Patient Charter. This is a tool that informs TB patients about TB disease per se, patient entitlements, responsibility of patient towards community and family members.TB patient representation in TB forums, also discuss about their
Holistic approach
Project Axshya envisages a holistic approach towards TB care and control. It does so by engaging communities through a strategy of Advocacy, Communication and Social Mobilization. This model of Community engagement aims at the impartation of knowledge about Tuberculosis and services. This thereby generates a demand for services from communities. On the other hand, it also supports health systems in catering to the service demand that is thus generated. The Union has partnered with multiple stakeholders the Government of India, politicians, community members, civil society organizations and many others, who are willing to contribute for a cause that is to have a TB - Free society.
(Project Axshya-Programme Management Unit, The Global Fund Round 9 TB Project, The Union South-East Asia Office,
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COVER STORY
Evolving TB Control Strategies in India

(Universal access to early quality diagnosis and care of tuberculosis)
he National Strategic Plan for TB Control for 2012-17 developed by the Union Ministry of Health and Family Welfare has raised the bar for tackling the fast- growing TB epidemic in the country. Revised National TB Control Programme has made historical achievements in the recent past years and the programme stands at the point where achieving the ambitious goal of Universal Access to TB Care is in sight. The programme has been continuously been innovative and progressive in addressing issues related to TB control in the country. The National Strategic Plan (2012-2017) was prepared through a consultative process involving a wide cross-section of stakeholders and experts in the programme. Innovation and consensus were the highlights of the process adopted for development of the National Strategic Plan.
DOTS services Further strengthening and aligning with health system under NRHM Deploying improved rapid diagnosis at the field level Expanding efforts to engage all care providers Strengthening urban TB Control Expanding diagnosis and treatment of drug resistant TB Improving communication and outreach Promoting research for development and implementation of improved tools and strategies.
Strategic vision to move towards universal access

The vision of the Government of India is for a TBfree India with reduction of the burden of the disease until it is no longer a major public health problem. To achieve this vision, the programme has now adopted the new objective of Universal access for quality diagnosis and treatment for all TB patients in the community. This entails sustaining the achievements of the programme to date, and extending the reach and quality of services to all persons diagnosed with TB. The objectives of the programme proposed in the plan are: To achieve 90% notification rate for all cases To achieve 90% success rate for all new and 85% for re-treatment cases To significantly improve the successful outcomes of treatment of Drug Resistant TB Cases To achieve decreased morbidity and mortality of HIV associated TB To improve outcomes TB care in the private sector PROPOSED STRATEGIES IN THE NATIONAL STRATEGIC PLAN 2012-2017:
National Strategic Plan (2012-2017)

With progress in achieving objectives in the 11th FiveYear Plan and defining newer targets of Universal Access to TB care, newer strategies have been developed as a comprehensive National Strategic Plan under the 12th Five-Year Plan of the Government of India. The following thrust areas were identified: Strengthening and improving the quality of basic
The rich technical and managerial capabilities of the programme with the support from all stakeholders aiming towards Universal Access to TB Care will ensure that the programme is able to overcome all challenges successfully and will contribute to developing a healthy and economically productive population.
Case-finding and Diagnostics:

Early identification of all infectious TB cases. Improved integration with the general health system,
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and leverage field staff for home-based case finding. Improve communication and outreach Screen clinically and socially vulnerable risk groups for TB. Develop improved sputum collection and transportation systems. Deployment of higher-sensitivity diagnostic tests for TB suspects (and incorporate new tests) and decentralized DST services Catch patients already diagnosed through notification from all sources, improved referral for treatment mechanisms, and deployment of Laboratory & Private Provider notification
The vision of the Government of India is for a TB-free India with reduction of the burden of the disease until it is no longer a major public health problem. To achieve this vision, the programme has now adopted the new objective of Universal access for quality diagnosis and treatment for all TB patients in the community.
Integration with Health Systems:
Integrating the RNTCP with the overall health system will increase effectiveness and efficiencies of TB care and control which has been depicted in the picture. In rural areas, the RNTCP can focus integration through the National Rural Health Mission. In urban areas, the RNTCP can integrate through the private sector and the evolving National Urban Health Mission.
Patient-friendly Treatment Services

Promptly and appropriately treating TB, increasingly guided by DST. Making DOTS more patient-friendly through increased communitization of DOT; pilot incentives/ offsets for patient costs to help patients complete treatment and better monitoring through Information Technology. Improving partnerships between public and private sector Establish Indian Standards for TB Care which can be used to engage providers using existing private treatment and improve care with some public sector support and supervision. Research will guide improvements in regimens and delivery systems. National Treatment Committee/TWG for regular review of regimens, all treatment- related technical guidance
Engagement of Private Sector:

Private sector engagement essential for universal access and early detection RNTCP set norms and conduct surveillance while maintaining some flexibility Move from sensitization model today to output- based contracting of services through interface/ aggregators States need to experiment with innovation and scaleup of those models that are successful Inclusion of private laboratories and pharmacists to detect patients at earliest points of care Technical working group (for guidance, policy advice) Technical support unit (for assistance to States for contracting) Accreditation and innovative financing
Scale-up of Programmatic Management of Drug Resistance -TB

Developing network of C&DST Laboratories and Strengthening of Reference Laboratories Decentralized DST at the district level for early MDR detection Improved information system for PMDT Humanpower support for additional workload by aligning with NRHM health blocks and rationalization of number of patients per STS Improved drug management of second-line anti-TB drugs (22% of budget, even at low GOI procurement cost)
Human Resource Development

The goal of RNTCPs HRD strategy is to optimally utilize available health system staff to deliver quality TB services, and to strengthen the supervisory and managerial capacity of programme staffs overseeing these services. RNTCP will align more effectively with health system under NRHM to leverage field supervisory staff more effectively, and increase capacity building of staffs to equip them to handle multiple tasks of DOTS, MDR-TB, TB/HIV. Support cells at State and District levels will be
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Scale -up of Joint TB-HIV Collaborative Activities:

Activities will aim at early, rapid TB diagnosis with high sensitivity tests for HIV-infected TB suspects & ART for all HIV-infected TB patients, with transport support.
Conduct or commission priority research Rapidly translate lessons into innovative policy and practice Web-based application for faster feedback to the Principal Investigators and facilitate monitoring of the process of proposal submission and the decisions of respective committees
Key Interventions:
Strengthening and improving the quality of basic DOTS services Further strengthen and align with health system under NRHM Deploying improved rapid diagnosis at the field level Expanding efforts to engage all care providers Strengthening urban TB Control Expanding diagnosis and treatment of drug resistant TB Improving communication and outreach Promoting research for development and implementation of improved tools and strategies.
strengthened to increase administrative and managerial capacity, creating space for local programme managers to focus on supervision and quality of services. Web based application will be developed for creating dynamic HRD database to assist better planning and facilitate faster communication.
Advocacy, Communication and Social Mobilization:

Generating demand for earlier diagnosis and treatment Community ownership, participation and involvement are essential for universal access. Enhancing the ACSM capacity of service providers to improve the quality of service delivery. ACSM can reduce stigma which is critical for universal access. Increased coverage can be achieved by focusing on at risk and clinically, socially and occupationally vulnerable populations.
What will NSP achieve?

Control TB: compared to todays activities, success will : Accelerate decline in incidence and prevent 22 lakh TB cases Reduce TB deaths by 75%, and save 17 lakh lives from TB Contain MDR TB: avert 1 lakh MDR cases and reduce incidence by 50% Return on investment: For each additional $1 1$ buys quicker diagnosis of more TB patients, more effective treatment ~14$ gained [ongoing analysis being done here] in future direct economic expenditure on TB cases prevented and Leadership for India: Sustain Indias global leadership in TB treatment and control The rich technical and managerial capabilities of the programme with the support from all stakeholders aiming towards Universal Access to TB Care will ensure that the programme is able to overcome all challenges successfully and will contribute to developing a healthy and economically productive population.
(Central TB Division, Ministry of Health and Family Welfare, Government of India)
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Monitoring and Evaluation, Surveillance and Impact Assessment:

Case-Based Web-Based application will be developed for real time data entry to enhance programme management and better decision-making. Relevant, timely and accurate data collection at each level of programme and the healthcare system. Analysis of these data is critical for ensuring continual programmatic improvement.
Research to inform TB Control policy and practice:

Operational research will be promoted to optimize TB control Priority research agenda to be developed.
COVER STORY
Tuberculosis and Silicosis at Workplace

A Situational Analysis Study in seven districts of Axshya India Project in Andhra Pradesh
ndia has the highest TB burden in the world, accounting for one-fifth of all new TB cases and two-thirds of the cases in South and South-East Asia. While India has made great strides in addressing TB, many challenges remain to expanding case-detection and treatment. Involvement of the private sector in case-detection, TB awareness and prevention, and promotion of safe and effective TB treatment practices is vital to the continued success of Indias Revised National TB Control Programme (RNTCP). Workplace interventions could be one potential private-sector entry point for reaching the unreached clients at workplace for TB diagnosis, treatment and care. The World Economic Forum reports that managers around the world are more ill-informed about tuberculosis (TB) in their workplaces than about HIV and AIDS. 63% of firms in low-income countries expect some impact from TB in the next five years compared to 46% of all firms expecting some impact from HIV/ AIDS. Prevalence of TB is about 3 times higher among smokers. TB Alert India initiated TB workplace interventions in ACSM project supported by USAID and World Vision in October 2008. During the project period (Oct 2008 Sept 2010), TB Alert India with its local partner organizations carried out 68 sensitization workshops at workplaces and reached out to more than 3000 employees in 5 districts. The project facilitated in placing TB workplace Policy and Commitments from the 25 Industries. The workplaces included Tobacco companies, Steel factories, Stone crushing units, Granite companies, Cargo company/Mosquito coil companyHealth Action March 2013
NET Slab Industries,Rice Millers Association. TB Alert India continued TB workplace interventions in Axhsya Project from October 2010 with the support of Global Fund through World Vision in reaching out to more than 1600 employees in 40 Industries. Secretary, Labour Employment Training and Factories Department (LET&FD) & State TB Officer identified 6 vulnerable segment industries which are prone to chest diseases. These vulnerable segment industries are Stone Crushers, Cement Companies, Jute Mills, Brick Kilns, Quarries and Mines. A situational analysis study was taken up by TB Alert India on the suggestion of Secretary, Labour Employment Training and Factories Department (LET&FD) and State TB Officer. Assessment was taken up under New Initiatives of TB Alert India under AXSHYA India Project supported by World Vision & Global Fund.
Situational analysis study

TB Workplace Intervention Situational Analysis Study carried out by TB Alert India in identified 54 industries (Stone Crushing Units(25), Brick Kilns (11), Cement Making Unit(3), Glass Manufacturing Unit (3), Foundries(12)) in 7 districts (Hyderabad, Ranga Reddy, Medak, Nalagoda, Chittoor, Prakasham, Khammam) of Andhra Pradesh State. The study was carried out with 528 employees and 41 focal persons (Owner/CEO/Director/ Sr. Manager) in the industry. The objectives of study were to assess awareness levels of employees at workplace on tuberculosis and silicosis; to understand attitudes of employees at workplace towards TB and silicosis and to
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assess the interest of stakeholders of workplace in becoming part of TB and silicosis control.
Major findings of the study

Majority of permanent employees constituted Cement, Glass Manufacturing Industries and Foundries (90 %( 162), 83%(55), 76%(77)) respectively. Temporary employees were those from brick kilns and stone-crushing units. Employees of stone-crushing units and brick kilns are not enrolled with ESI. More number of employees enrolled under ESI are in Foundries 60%(61) followed by Glass Manufacturing 37% (25) & Cement Industries 18%(32). About 37% of the respondents, who are at the risk of getting TB have not heard of TB. However, among the respondents who are aware of TB, only 32% have listed out correct symptoms of tuberculosis, further only 10% of the respondents who have listed correct symptoms of TB know that DOTS is the treatment for it. Percentage of respondents with TB in family stands at 11% among total respondents questioned. However, stigma attached to TB is less where 60% expressed that they will feel compassionate to TB patients. Employees expressing the need to carry out more health camps at workplaces stands at 50%. Health awareness programmes are a necessity which should cover TB/Silicosis, other non-communicable diseases at workplace. As large as 55% of employees across the industries are of the opinion that their industries have a role in the prevention of TB, and silicosis at their workplace. Health awareness programmes which include TB, HIV, Malaria and other diseases like BP, sugar, and cancer should be carried out.
TB Officer, there is a need to talk to managements of industries and plan a cascading model of sensitization programmes to employees (From top management to worker level) on TB, HIV, Malaria, Silicosis, and Lifestyle Diseases. Sensitizing ESI hospital / dispensary staff on RNTCP is crucial for enhancing outreach activities. Establishing/strengthening linkages between District Inspector of Factories, District Health Authorities, Labour Department and ESI Hospital / Dispensaries is an important aspect to be taken up immediately. Where large numbers of employees are present, there is a need for establishment of SputumCollection Centres/DMC/ICTC at workplace. Employee workforce services can be utilized for spreading disease awareness, referral services and follow-up of patient, advocating with workplace management for workplace policy on health (TB, HIV, Malaria, Silicosis, Lifestyle diseases) using IBA materials.
Conclusion
For better health of employees, interventions need to be identified to raise awareness about TB, HIV, HIVTB co-infections, silicosis, non-communicable diseases (lifestyle diseases like Hypertension, Diabetes, Cancer, Heart diseases) on symptoms as well as availability of treatment facilities. As health activities of industries are limited to mere health camps, the scope of diseases and frequency of health activities need to be increased. There is a greater need to establish linkages between workplaces and Government health services. Further efforts need to be made to rope in industries and volunteers at workplace for facilitation of disease-specific policies at the industry level by establishing linkages with district health authorities. There needs to be sustained effort and greater involvement of industries in carrying out healthrelated activities at workplaces. There is also a greater need for tripartite linkages as well as effort industries, Department of Factories/ Labour and State District Health Authorities.
Interactions with focal persons at industries

About 41 focal persons at the industries were interviewed by TB Alert India. Out of a total 41 respondents, 83% (34) of focal persons feel that thy need help of NGOs for greater liaison with Government Health Services for better Workplace and Community Health Services. Dispensaries at workplace, doctor visiting the work place on call are the arrangements in some industries to deal with minor alignments. However, as large as 61% of the industries, mostly brick kilns and stone-crushing units dont have any such arrangement at work places. 73% (30) expressed interest in taking up health activities at workplaces with the support of NGOs.
Limitations of study
A number of limitations to the methodological approach were identified which include the following: Available employees in the respective department were called for the study as per the sample The sample group was restricted to 10% based on availability of resources and time Capacity of District staff for efficient translation of questions and interpretation of responses was limited in some areas.
(Axshya India Team of TB Alert India, Hyderabad)
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Recommendations
In liaison with the Director of Factories, Director of Medical Insurance and Commissioner of Labour, State
Experiences of LEPRA India in TB Control in Andhra Pradesh

EPRA Society (India), a national NGO, has field and clinic-based activities for TB control, carried out in partnership with Revised National TB Control Programme (RNTCP). In response to revised NGO schemes, it has further expanded the partnership to offer laboratory services of MDR TB.
COVER STORY
Dr. J. Subbanna* and Dr. Aparna S Srikantam**

In Andhra Pradesh, there are 12 Designated Microscopy Centres (DMCs) including one Tuberculosis Unit (TU) of LEPRA India, which is being implemented in partnership with RNTCP under signed NGO schemes covering a population of 12.3 lakh population.These DMCs are situated in Hyderabad, Rangareddy, Adilabad and Krishna districts. During 2012, the performance of these centres is as follows: The annualized total case-detection is 2262 with ANCDR as 187/lakh of which 1018 were new sputum-positive-cases and all were initiated on DOTS. This includes 110 paediatric cases (4.9%), and 243 TB cases which were found to be HIV +ve (11%). The sputum conversion rate was 93% and cure rate was 88% and defaulter rate 2.9%. 236 children were provided INH prophylaxis 121 new MDR TB diagnosis (for Sikkim) and 3230 MDR TB cases follow-up sputum examinations (for AP and Sikkim) done at BPHRC Three-hundred-and-eighty local private health care providers in the DMCs/TUs were sensitized and involved in referrals of TB suspects and in provision of DOTS. Capacity-building activities in TB was provided to PHC/UHP staff and TB sensitization for involvement was carried out with local private health care providers (380), DOTS providers (1170) and target groups like
TB Patients (Discussions)
LEPRA Indias foray into Tuberculosis Control Programme

LEPRA Indias participation in tuberculosis control programme has been justified by a combination of factors: The expertise that has been built in the field workers all through the years needed to be channelled. Also, the reappearance of tuberculosis as an epidemic and the similarity in diagnosis and need of regular treatment in both tuberculosis and leprosy warranted participation in tuberculosis control programme. In addition, field-level education and counselling that LEPRA India is equipped with could be utilized to create an impact on allied areas like TB and HIV/AIDS. LEPRA Indias Participation in TB control programmes is in five different ways: Direct participation in TB control Capacity-building Advocacy, Communication and Social Mobilization (ACSM) Research activities Field / laboratory Publications
Private Practitioners (Sensitization)
TB Forum Members (Discussions)
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March 2013
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self-help groups, youth clubs, AWWs, village volunteers, tribal leaders, teachers, students, local NGOs/CBOs/ FBOs and VHSC members. Community awareness programmes consisted of film shows, group meetings, observation days, folk art /stage plays by local artists. Supported the DTCS in implementing tribal action plan and participated in monthly and quarterly review meetings with the staff concerned and DTCS. Support was provided to DTCS in implementing awareness programmes with LEPRA IEC vans. LEPRA India is the NGO member in the District TB Control Society (DTCS) and State TB Control Society in the implementing states and districts.
LEPRA India-Blue Peter Public Health and Research Centre (BPHRC) has undergone a
formal accreditation process between 2007 and 2009 and entered into a memorandum of understanding (MoU) with the State TB Control Programme of the Government of Andhra Pradesh. Microbiology Division of BPHRCwith a provision for BSL III and accredited to the Central TB Division, GoI, has been taking part in the MDR case-detection and monitoring from 2009 onwards. The laboratory caters to the diagnostic needs of patients from BPHRC, other LEPRA field projects, RNTCP-DOTS plus phase-II districts of AP (E. Godavari, W. Godavari, Guntur & Krishna), Sikkim and AP Chest Hospital (for extra pulmonary TB patients).
The laboratory performs about 2000 cultures each year. Since 2009, the lab confirmed the MDR status of around 500 out of 1200 clinically suspected patients through these lab tests. Diagnosis of extra-pulmonary TB is of special focus covering specimens like fine needle aspirates, urine, endometrial aspirates and pleural fluids for diagnosing TB. The laboratory recently was accredited to perform line probe assay for rapid detection of MDR TB. Operational research on second line anti-TB drug resistance and genotyping has been undertaken in the division in collaboration with and funding from AP State TB office. Current research interests of the division include diagnosis and epidemiological features of drug resistance in TB (such as geography-related prevalence and correlation with treatment outcome); diagnosis, epidemiology and pathogenesis of extra pulmonary TB. (lymph node TB) and molecular epidemiology of TB. Attempts are being made to identify potential new diagnostic markers specific to Mycobacterium tuberculosis. At present, in BPHRC there are 5 PhD students pursuing work in TB and TB-HIV 6 ongoing research projects in TB and TB-HIV During the last couple of years, 6 research papers on TB and TB-HIV from BPHRC were published in various international journals.
(*Director- LEPRA India BPHRC; ** Group LeaderMicrobiology Division, LEPRA India BPHRC)
Case-Studies
Mr. Kamruddin, a 50-year-old male, and resident of Bhavaninagar, was suffering with persistent cough and fever. He approached a private doctor, who diagnosed it as TB and started Anti-TB Treatment (irregular treatment/doses) for 9 months. Even after 9 months, the symptoms persisted. After that, he went to Osmania General Hospital. In the DMC, they did sputum examination, and the result was positive (3+). They referred (transferred) him to DMC Bhavaninagar for Anti TB treatment and he was put on DOTS (Cat II, Relapse as per the transfer letter by the Medical Officer - DMC Osmania General Hospital). After three months follow-up of sputum test the result was positive and was given prolonging pouches for one month. Thereafter, the sputum test result was negative. During his phase of treatment, he refused to continue treatment (defaulted-5/6/2009). In one months time, he became serious and was admitted to AP Chest Hospital on 8/7/2009. After two months follow-up, sputum test was done. The result was found positive (2+). Later in the last follow-up, sputum test was found positive (1+). He was suspected of MDR TB and his sputum sample was sent to AP Chest Hospital for diagnosis. They confirmed it as MDR case and started DOTS PLUS treatment and completed successfully. Arshiya, 16 year-old daughter of Mr. Khamruddin, was suffering from stomach pain, cough, fever and she went to Osmania General Hospital. Sputum examination was done and the result was found positive (2+). They referred her to DMC Bhavaninagar for DOTS, LEPRA registered her and put on Cat I (new case) on 19/10/2009. Sputum examinations were done in a routine manner and all the results were negative. Completing treatment she was declared as cured. She came back to the DMC Bhavaninagar with cough, fever and body pains again and her sputum examination result was positive (2+). She was put on DOTS as Cat II (Relapse). The same day she was suspected for MDR TB and the sputum sample was sent to AP Chest Hospital for diagnosis of MDR. She was diagnosed as MDR TB at AP Chest Hospital and put on DOTS Plus treatment and is continuing treatment. (DJS & DAS)
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COVER STORY
TB In Children
An Avoidable Problem
Dr Shoma A Chatterji
uberculosis (TB) is one of the most underreported and underrated chronic diseases of children across the world. Although childhood TB has been receiving attention from global health experts, it still remains a major cause for illness and death of children. TB is preventable, treatable and curable. Children generally contract this disease because they are in proximity to elders who are already affected by the TB bacterium such as a nanny, mother, the caregiver or other infected family members. Children are the prime targets as their immune systems are not fully developed. Children with TB are often poor and live in vulnerable communities where there may be lack of access to health care. According to the Stop TB Partnership, newborn infants of women affected with TB are at increased risk of contracting TB. Children living with adults suffering from TB can become ill with the disease even if they are vaccinated with the BCG vaccine. Tuberculosis among children is often overlooked due to non-specific symptoms and difficulties in diagnosis such as obtaining sputum from young children.
It goes without saying that the more costeffective way is to prevent the disease than to cure it. The most effective way to prevent childhood TB is to stop it from spreading. This can be done through what is known as the three Is (i) Intensified Case-Finding, (ii) Isonaizid Preventive Therapy or IPT and (iii) Infection Control.
TB preys on vulnerable children
The World Health Organization (WHO)s Global Tuberculosis Control Report, 2012, estimates that 490,000 children fall sick with TB every year and nearly 70,000 of them die. Experts, however, maintain that these are gross underestimates. TB preys on the most vulnerable children the poor, the malnourished and those living with HIV. This leads to an unimaginable burden on children and their families. In a Papua New Guinea village, a two-year old orphan who was infected and whose mother died of the disease, was taken up for adoption by a school teacher. But all stories do not end happily. Another adult patient, who later died of multidrug-resistant TB (MDR-TB), had told me that he was tormented by guilt because there are no resources to help them care for their children while they are being treated at a hospital or at home. In another case, a stock-out of anti-TB medication in Southern Romania prevented one 14-year-old boy from leaving the Bucharest hospital to take his high school exams, says a Ph.D. student of Medical Anthropology of the City University of New York. The only TB vaccine that exists, namely the BCG (Bacillus Calmette-Guerin), was invented in 1921. In most countries across the world, BCG is mandatorily
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Health Action
March 2013
given at (or soon after) birth to infants to protect them from the most severe forms of TB including TB meningitis. But few are aware that (a) BCG does not protect children from the most common form of TB TB of the lungs and (b) the effect of the vaccine wears off as children grow in age. Besides, children with HIV cannot receive BCG because it can make them sick. Scientists are working on developing new vaccines that address these drawbacks. A dozen new vaccine candidates are currently undergoing clinical studies. Results of a study of a preventable TB vaccine, that enrolled nearly 3000 infants in South Africa, were published very recently in 2013, and were disappointing because the vaccine did not significantly protect children against TB. Collaboration between the public and private sectors is urgently called for to ensure adequate investment to develop and deliver a new safe and effective TB vaccine soon.
The World Health Organization (WHO)s Global Tuberculosis Control Report, 2012, estimates that 490,000 children fall sick with TB every year and nearly 70,000 of them die. Experts, however, maintain that these are gross underestimates. TB preys on the most vulnerable children the poor, the malnourished and those living with HIV. This leads to an unimaginable burden on children and their families.
spread of the disease. These methods, endorsed by the WHO, can prove to be very effective in reducing childhood TB. It is also necessary to train health workers to address childhood TB and TB services which need to be incorporated into the Integrated Management of Childhood Illnesses (IMCI) a broad-based childhood health strategy. It is also important to link TB services with maternal health care to prevent mother-to-child transmission of HIV and TB. All children living with HIV must be screened for TB regularly,, and vice versa during visits to the medical centre.
Investing in safe and effective vaccines

Evaline Kibuchi, from the Kenya National Aids NGOs Consortium (an ACTION partner) says, The Ministry of Health needs to increase contact tracing for adults with TB. It is the best way to find children who have been exposed and it is not happening enough. It goes without saying that the more cost-effective way is to prevent the disease than to cure it. The most effective way to prevent childhood TB is to stop it from spreading. This can be done through what is known as the three Is (i) Intensified Case-Finding, (ii) Isonaizid Preventive Therapy or IPT and (iii) Infection Control.
Addressing poverty
In order to end childhood TB, we must address poverty. Child health is directly linked to povertya major risk factor for TB which in turn, is a big driver of poverty. This functions like a vicious circle leading back to where it began. Children living in poverty are more likely to be undernourished, lack access to medical care and live in crowded homes with little ventilation and poor hygiene. Their parents are also likely to be ignorant about medical treatment, importance of hygiene and preventive and curative health strategies in daily life, which in turn makes such children more vulnerable to TB than others. Then again, people living in impoverished conditions often cook indoors which creates an environment of thick smoke for the child that weakens their lungs. A study in Bangladesh found that children who completed primary school were less likely to develop TB.
(The author is a freelance journalist, film scholar and writer based in Kolkata, India, and has authored 17 books)
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Intensified Case Finding implies that when an adult member in the family is diagnosed with TB, all close contacts and family members, including children must be screened for TB. If symptomatic, they should be provided appropriate diagnosis and treatment. IPT prevents children from developing the active disease which is also important in the case of children living with HIV. Children with HIV are 20 times more likely to develop TB than children with healthy immune systems. Infection Control covers high burden areas where children are more likely to be exposed to the TB bacteria such as health care facilities, crches, homes, schools and other community settings that need to be made TB-safe. This includes separation of patients who are coughing from those who are not; providing them with masks; opening windows and doors to establish natural ventilation all of which can prevent the
COVER STORY
Social Stigma Attached to TB

Dr G Srinivas Rao, MD
lthough TB is a completely curable disease, there is still considerable social stigma attached to the disease. Some of the basis of this stigma is related to the perception that tuberculosis is a disease that is related to being unclean, poverty or even hereditary. There is also a misperception of risk of transmission to their contacts at home or work even though the patients are on regular treatment.
celebrities affected by TB and individuals who have successfully completed their treatment constitute another useful strategy that can be used to destigmatize the disease.
Familys support
At the personal level, joint counselling of the individual and the family members will go a long way to dispel misperceptions that sleeping together, sharing cutlery and socializing spread the disease. It should be clearly stated that the risk of TB transmission is minimal after being diagnosed and started on treatment. It is to be emphasized that the greatest transmission risk is BEFORE the patient is diagnosed and hence the need for contact examination.
Social impact of TB stigma

The social stigma related to TB leads to a situation wherein patients refuse to seek treatment till at an advance stage, and discontinue treatment, stop going for work and get ostracized by the family and community. Women are prevented from getting married or are divorced by husbands.
Overcoming stigma
The main strategy to overcome the stigma is to give education that is tailored to the community and the patients/ family in particular. At the community level , constant emphasis that TB is another airborne disease that is not related to a persons hygiene or economic status is an important step to address the communitys anxiety. Apart from this, the emphasis that TB can be completely cured if detected early and treated effectively is a major positive point that should be highlighted constantly. Public testimonies by community leaders /
Employers support
If deemed necessary, the employers should also be counselled in a similar way so as to reassure them that the patient is no longer a health risk to his co-workers and to ensure that his employment status is not affected by being treated for TB. Laws are available to prevent workers from being unfairly dismissed for being treated for curable diseases such as TB.
Communitys support
Recognizing the great impact social stigma can have on the effectiveness of the National TB Control Programme, AXSHYA has taken several community initiatives such as disseminating correct technical information on TB, printing educational pamphlets and organizing community shows, exhibitions and talks to reduce the stigma of being diagnosed with TB. Medical staff treating TB patients are also sensitized to be aware of the possible social stigma attached to being diagnosed with TB and actively enquire about the issues and manage them effectively, if recognized.
(National Manager, CHAI Axshya Project, The Catholic Health Association of India, Secunderabad))
Health Action
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COVER STORY
Frequently-Asked Questions on Tuberculosis

What is tuberculosis?
Tuberculosis (TB) is an infectious disease caused by a bacterium, Mycobacterium tuberculosis. Tuberculosis is one of the leading causes of mortality in india. It kills more than 300,000 people in India every year.
How is tuberculosis caused?

TB is spread through the air by a person suffering from TB. A single patient can infect 10 or more people in a year. What are the symptoms of tuberculosis? Common symptoms of tuberculosis include: Cough for three weeks or more, sometimes with blood-streaked sputum Fever, especially at night Weight loss Loss of appetite
Which is the strongest risk factor for tuberculosis among adults and how does it affect the spread of TB?
The Human Immunodeficiency Virus (HIV, the virus that causes AIDS) is the strongest risk factor for tuberculosis among adults. Tuberculosis is one of the earliest opportunistic diseases to develop amongst persons infected with HIV. HIV debilitates the immune system increasing the vulnerability to TB and increasing the risk of progression from TB infection to TB disease. An HIV positive person is six times (50-60% life time risk) more likely to developing tuberculosis once infected with TB bacilli, as compared to an HIV negative person, who has a 10% life-time risk.
Benefits of DOTS/ Why DOTS?

More than doubles the accuracy of TB diagnosis. Its success rate is up to 95%. It prevents the spread oftuberculosis by prioritizing sputum-positive patients for diagnosis and treatment, thus reducing the incidence and prevalence of TB. It helps in alleviating poverty by saving lives, reducing the duration of illness and preventing new infectious cases. It improves quality of care and removes stigma. It prevents treatment failure and the emergence of MDR-TB by ensuring patient adherence to treatment and uninterrupted supply of anti -TB drugs. It lends credence to TB control efforts and the health care system.
Can tuberculosis be cured in HIV co-infection?

Tuberculosis can be cured, even among HIV-infected persons. TB treatment with DOTS reduces the morbidity and mortality among people living with HIV.
For how long must tuberculosis treatment be taken?

Tuberculosis requires at least 6 months of treatment.
What is multi-drug-resistant tuberculosis?

Multi-drug-resistant tuberculosis (MDR TB) is caused by strains of the tuberculosis bacteria resistant to the two most effective anti-tuberculosis drugs available-isoniazid and rifampicin. MDR TB can only be diagnosed in a specialized laboratory.
What is DOTS that is being implemented?

The DOTS strategy is in practice in more than 180 countries. By March 2006, India had extended DOTS to the entire country.
What is the duration of treatment for multi-drugresistant tuberculosis?

Multi-drug-resistant tuberculosis requires at least 1824 months of treatment with medicines which are 100 times more expensive and often highly toxic.
(Source: TBC India)
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What is RNTCP?
Revised National Tuberculosis Control Programme (RNTCP) applies the principles of DOTS to the Indian context.
How many people die from TB in India every year?

COVER STORY
Knowledge, Attitudes and Practices on TB

From a Baseline Survey conducted as part of Project Axshya
gather baseline information on TB-related Knowledge, Attitudes and Practices (KAP) among the five respondent groups and gain a better understanding of how target groups viewed stigma discrimination and gender. Methodology: The survey was implemented by The Union, South-East Asia Regional office in 30 of the 374 Global Fund project districts. The districts were selected by a stratified cluster sampling technique from the states of the four zones (north, south, east and west) of the country. Nearly 75,000 households were visited covering a population of 374,000 people. Axshya is a Global Fund supported TB project launched in 2010 that is reaching out to 374 districts across 23 states in the country to expand the reach and visibility of the RNTCP through increased civil society engagement at the community and the individual levels with a special focus on marginalized and vulnerable populations.
he core objective of the Baseline Survey was to
Of those who had heard of TB, 69% recognized cough for two or more weeks as a major symptom while 11 % did not know any symptoms of TB 50% knew TB was transmitted through air when an infected person coughed/ sneezed 55% felt sputum examination could help diagnose TB while 60% considered chest X -Ray to be more accurate. Though 80% felt that TB was curable, only 37% knew that TB treatment has to be taken for 6-8 months duration Only 23% had heard of the term DOTS, and less than a fifth (19%) knew that free treatment for tuberculosis is available under DOTS 10% of the respondents had cough of 2 weeks or more in the last 2 months and of them only about 30% had visited any health care provider seeking care
TB diseased persons
As many as 752 TB diseased persons were identified and 609 were interviewed. Among the respondents, around 77% were married, 43% were illiterate and 33% worked as daily wage labourers. Importantly 89% used solid fuel for cooking and 75% were from households with less than Rs 4,000 monthly income.
Key findings
Each respondent group was interviewed through a semi- structured questionnaire.
General population
As many as 4562 persons (2320 males and 2242 females) with an average age of 34-36 years were interviewed. The respondents included labourers, housewives, skilled workers and people engaged in agriculture. Students, petty traders and those in government and private service were also interviewed. 30% of the respondents were illiterate and 60% stayed in semi pucca or kachha (temporary) houses.
Findings
66% patients had cough as a presenting symptom, 47% had fever and 33% chest pain 74% patients were diagnosed with TB within one month of the onset of symptoms 60% were diagnosed in a government hospital 54% were receiving free treatment under DOTS and 46% were taking treatment from non-Government health facilities by paying for their medicines
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Findings
Almost 15% of the respondents had absolutely not heard of TB at all
While 80% were aware that treatment has to be taken regularly, only 55% knew that the duration of TB treatment is for 6-8 months
Health Service Providers (HSP)

About 614 Health Service Providers were interviewed out of which nearly 2/3rds were private practitioners and 1/3rd were doctors in government service. More than half of them (55%) were qualified practitioners of allopathic medicine, 26% were qualified practitioners of Ayurveda medicine, 12% were qualified practitioners of homeopathic medicine and 5% were practitioners of Unani system of medicine and the remaining were not qualified in any of the systems of medicine mentioned above.
Axshya is a Global Fund supported TB project launched in 2010 that is reaching out to 374 districts across 23 states in the country to expand the reach and visibility of the RNTCP through increased civil society engagement at the community and the individual levels with a special focus on marginalized and vulnerable populations.
advocated for DOTS. However, 7% also felt herbal remedies could cure TB, 6.5% viewed Ayurveda as a good option and 4.3% said that they also believe that homeopathy works. Only 1/5th of them had undertaken any activities related to TB control in their community.
Findings
94% HSPs identified cough of two weeks, 64% coughing of blood and 52% pain in the chest as major symptoms of TB 1/5th of the HSPs did not know that patients can be sent to government health facilities for sputum examination Nearly 96% had diagnosed a case of TB of the lungs in the past and 36% mentioned that they had diagnosed TB of other organs as well 88% believed that allopathic medicines were the best form of medicines for the treatment of TB, 10% informed that homeopathic medicines are good for TB treatment, and 2% felt that other forms of medicines work for TB. 80% were aware that the treatment for TB is for 68 months Nearly 1/3rd of HSPs did not advise TB patients to go to government health facilities for availing free treatment 64% were not sure what was multidrug resistant TB (MDR- TB) and how it is diagnosed.
Non-Governmental Organisations/ Community-Based Organisations

As many as 51 NGOs/CBOs were identified in the 300 primary sampling units of the 30 districts. They were selected on the basis of information given by opinion leaders and community members about their presence in their locality. These NGOs/CBOs were working in the area of education (55 sanitation (43%), rural development (33%), domestic violence gender (35%), employment (14%) and environment (4%).
Findings
About 50% were engaged in programmes on TB prevention and control. Of those who were engaged in TB Control, 88% created awareness on TB, 23% reduced stigma and discrimination and provided training on TB health care Nearly, 84% were willing to collaborate with RNTCP whereas only 41 % were involved in any of the schemes 12 % helped in the resettlement of TB patients and only worked as DOTS providers.
Opinion Leaders
As many as 511 leaders were interviewed. Opinion leaders influencers in the community, holding sway over people propagating messages and instilling behaviors through discourses, interactions and exchanges. The respondents manly consisted of members of local self government-Panchayati Raj Institutions (village pradhan, ward member), religious leaders and teachers.
Conclusion
This community based survey provides valuable information on the current levels of knowledge, attitudes and practices of the various stakeholders of the population with respect to TB. This report provides data that shows major gaps and opportunities for enhancing the reach, visibility and access to Government of Indias Revised National TB Control Programme within the framework of the ACSM component of Global Fund Round 9 India TB project.
(For the full text of the report, visit: http://www.axshyatheunion.org/Documents/KAP.pdf.)
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Findings
All of the respondents had heard of TB and 92% knew it, fully curable 91 % knew a person with TB must be referred to government health centre 67% had faith in allopathic medicine while 34%
COVER STORY
World TB Day: 24 March 2013

Theme: Stop TB in My Lifetime
Vinay Kumar G
orld TB Day is an opportunity to raise awareness about the burden of tuberculosis (TB) worldwide and the status of TB prevention and control efforts. It is also an opportunity to mobilize political and social commitment for further progress. Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide due to a single infectious agent. In 2011, 8.7 million people fell ill with TB and 1.4 million died from TB. Over 95% of TB deaths occur in low- and middleincome countries, and it is among the top three causes of death for women aged 15 to 44. In 2010, there were about 10 million orphan children as a result of TB deaths among parents. TB is a leading killer of people living with HIV causing one quarter of all deaths. Multi-drug resistant TB (MDR-TB) is present in virtually all countries surveyed. The estimated number of people falling ill with tuberculosis each year is declining, although very slowly, which means that the world is on track to achieve the Millennium Development Goal to reverse the spread of TB by 2015.
Key facts about TB
treatment by end 2011 this is only one in five of the notified TB patients estimated to have MDR-TB; Provision of antiretroviral therapy (ART) for TB patients known to be living with HIV needs to double to meet WHOs recommendation that all TB patients living with HIV promptly receive ART The African and European regions are not on track to meet the target of halving deaths from TB between 1990 and 2015.
WHO response
WHOs pursues six core functions in addressing TB. Provide global leadership on matters critical to TB. Develop evidence-based policies, strategies and standards for TB prevention, care and control, and monitor their implementation. Provide technical support to Member States, catalyze change, and build sustainable capacity. Monitor the global TB situation, and measure progress in TB care, control, and financing. Shape the TB research agenda and stimulate the production, translation and dissemination of valuable knowledge. Facilitate and engage in partnerships for TB action. The WHOs Stop TB Strategy, which is recommended for implementation by all countries and partners, aims to dramatically reduce TB by public and private actions at national and local levels
(Asst Lecturer, JSS con Mysore)
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TB global challenges
In 2011, there were an estimated 8.7 million new cases of TB and 1.4 million people died from TB; Over 95% of TB deaths occur in low- and middleincome countries. Poor communities and vulnerable groups are most affected, but this airborne disease is a risk to all; TB is among the top three causes of death for women aged 15 to 44; There were an estimated 0.5 million cases and 64 000 deaths among children in 2011; There is slow progress in tackling multi-drug resistant TB (MDR-TB): with 60 000 patients enrolled in
INTERVIEW
Project Axshya has helped the State in reaching the unreached...

Dr.S Jayasankar, State Tuberculosis Officer, Government of Kerala, speaks to Joltin Rappai, Assistant Programme Manager, CHAI. Excerpts...
Q: What is the situation in Kerala State in terms of Tuberculosis Care and Control? A: Kerala is a pioneer in tuberculosis control activity in the whole of India and it has the lowest TB examination rate. Our case-detection rate in spite of all efforts happens to be 73% and treatment success rate 84%. Annual risk of TB infection in Kerala is one in 50 per lakh population in New Smear Positive (NSP) cases. Q: What do you see as the greatest challenge to TB Control today? A: High prevalence of Diabetes Mellitus, Hypertension, Cardiovascular Diseases, and Alcoholism in the community pose challenges. Follow-up among migrant labourers has become a great challenge in tuberculosis control in the State. Q: Whats the one thing that could happen tomorrow that would make the biggest difference in the fight against TB? A: TB control programme is going to be incorporated with non-communicable disease (NCD) control programme and this will help in addressing the major challenges that affect the cure rate. The State is preparing to launch Practical Approach to Lung Health (PAL) which will help in strengthening the general health care system. Q: How is Axshya Project supporting the state in the successful implementation of RNTCP? A: Project Axshya implemented by CHAI/UNION in the state of Kerala has helped the state in reaching the unreached through community meetings, NGO/CBO sensitization, other innovative activities, media etc. The state/district level soft skill trainings organized by CHAI/ Axshya helped our staff to rebuild and rejuvenate our RNTCP family. Involvement of Axshya/CHAI has been very useful for the state as well as districts in implementing our Advocacy Communication and Social Mobilization (ACSM) activities. CHAI/Axshya District coordinators are an extended hand of RNTCP DTO in the field. Their wholehearted presence and vibrant enthusiasm in the district as reported by various DTOs motivate us to have more partnership programmes with CHAI in future too. Q: What role does Axshya have in helping to bring about innovations in TB control? A: Axshya has done many innovative activities in Kerala. The Food Security Bill initiated by Axshya is one of the national models. The involvement of other sectors (Ayurveda, Homeopathy) is another model being piloted in Kerala. We have a good Ayurveda-RNTCP partnership built by Axshya in Kollam District which we are going to extend to other districts through Axshya. Through project Axshya, we have conducted sensitization meetings in Jails, police department, tribal department, schools of social work etc. Axshya has linked our TB patients to various welfare schemes like Saink Welfare Scheme for Ex Military TB Patients, Tribal Development Department and various other social welfare schemes. Q: How could you make Kerala a model state in TB Care and Control? A: In Kerala, we have a high level political and administrative commitment in the field of health (Tuberculosis). We have adopted a decentralized monitoring and evaluation approach in RNTCP which helped us to streamline TB care and control activities in the state. Each district is completely equipped with a committed team of RNTCP warriors. Q: What kind of support is being provided by Kerala Government for the welfare of poor TB patients? A: The Government is providing very good support to the RNTCP Programme in the state. There are various welfare schemes in the state through which the poor TB patients are supported. Financial assistance of Rs. 1000/- per month is given to every Ex-Serviceman who is undergoing tuberculosis treatment as an outpatient. Tribal Welfare Department has various schemes for the welfare of tribal patients. Revenue Department of Kerala is giving Rs.525/- to every economically poor TB patient in the State.
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Health Action
March 2013
COVER STORY
Why should BPL TB patients be included in the Food Security Bill?

A joint advocacy initiative by the International Union Aagainst Tuberculosis and Lung Disease (The Union) and the Catholic Health Association of India.
A. Provisions of the Food Security Bill In its present form, the Food Security Bill targets specific weaker sections to ensure their food security. Laudably, these include vulnerable populations such as homeless individuals, migrants, disaster-affected people, destitute including pregnant and nursing women, senior citizens and children. These individuals are also defined very specifically in terms of clear and measurable entitlements. B. Poverty-TB correlation A vulnerable segment of Indian population escapes inclusion in the Food Security Bill: patients affected by tuberculosis (TB) living below the poverty line (BPL). The Revised National TB Control Programme (RNTCP) of India registered a total of 15, 15,872 TB patients for treatment. Further, about 750,000 of the total 15, 15,872 TB patients that India notifies annually for the last 5 years live on an income below Rs 2000 per month. costs India 100 million productive man-days every year. At an all-India level, the loss of productive work-days due to TB-related deaths is estimated to be around 1.3 billion man-days. TB affects women and children too. Women are particularly vulnerable: more women die due to TB than all the causes associated with childbirth put together, according to RNTCP data. 100,000 women are rejected by their families due to TB and parental TB affects children, causing about 300,000 school dropouts. To add to this, lack of adequate food is identified as a major cause for discontinuing treatment course of 6-9 months. Such interruptions in treatment could eventually lead to drug resistant forms of TB and death.
D. Facts about TB in India TB is a serious national problem. Multi-Drug Resistant TB is a more severe and debilitating form of TB which affects an estimated 64,000 Indians every C. Health Implications of Poverty and TB, year. According to recent research conducted by The Union, through a Knowledge, Attitude and Practices and a Way Forward (KAP) study of Tuberculosis in India, it can be safely Illness and poverty worsen the estimated that between 26% CHAI Team led by Director-Gneral meeting with conditions for TB patients. A large Prof K V Thomas, Honble Union Minister for to 44% of all Indian TB amount of scientific evidence Consumer Affairs, Food and Public Distribution. patients live in households shows that supporting TB patients with a monthly income of with access to food significantly less than Rs 2000 per month. improves their treatment outcomes. TB is not just a disease, but Many TB patients simply cannot a real barrier to Indias feed themselves. Nutritional overall socio-economic supplements can effectively assist development. The direct BPL TB patients in recovering their costs of treatment amount to health. TB adversely affects the US$ 300 million per year. poor because TB impacts their TB patients must be ability to work and to be productive. included in the Food Security TB worsens poverty due to the loss of productive workdays. TB alone
(Continued on page 34)

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COVER STORY
CHAI-AXSHYA
The Global Fund Round 9 TB Project
For CHAI, Project Axshya is an extension of its vision of bringing Health for All. The involvement of NGOs & CBOs in the project has helped them to exhibit their sincere commitment towards the society in controlling a dreadful disease like tuberculosis.
Rev. Dr. Tomi Thomas,IMS
he Catholic Health Association of India (CHAI) is one of the largest coalition partners of International Union against Tuberculosis and Lung Disease (The UNION) and Ministry of Health & Family Welfare, Govt. of India (Central TB Division) working in 96 districts of 10 states. The Project Axshya is actively working to improve the reach, visibility and effectiveness of RNTCP through civil society support by engaging communities and community-based care providers to improve TB care and control, especially for the marginalized and vulnerable populations including TB-HIV patients. The CHAI-Axshya project focuses on strengthening Indias national TB control programme and TB services through Advocacy, Communication and Social Mobilisation (ACSM). Activities include high-level advocacy for political and administrative support, implementation of the RNTCP ACSM strategy at the state and district levels, and social mobilisation to garner community demand for TB services. This is largely achieved through empowerment of community groups
through awareness campaigns, community meetings; establishing sputum collection and transport mechanisms and building a team of community volunteers called Axshya Mitras who continue to sustain this fight at the local levels. The creation of District TB Forums has given a platform to voice the needs and challenges of the affected community.
Geographical coverage
The CHAI-Axshya project covered 96 districts across 10 states of India in the last three years comprising underperforming, poor and backward, difficult (Nagaland, Chhattisgarh and Jharkhand), and predominantly tribal districts.
Key project activities State level:

Sensitizing NGOs to register under RNTCP schemes State-level training of TOTs for NGO/PP/CBOs training State-level TOTs for training Health Staff in soft skills
Health Action
March 2013
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Geographic Coverage of CHAI-Axshya Project
Retrieving defaulters Developing and orienting TB forums Facilitating quarterly joint meetings of ICTCs & DMCs
What has been achieved so far

380 NGOs are committed to TB cause working through CHAIAxshya in 96 districts of 10 states Over 23,949 community meetings were conducted and 400,000 people were reached with TB messages Various State level Training of Trainers (ToTs) were conducted for NGOs on TB care & control, facilitated them to apply eligible NGO-PP schemes/Health Staff on communication soft skills/PLHIV networks, in order to engage HIV positive people in TB care and support. Over 13,000 health personnel were trained on soft skills through 526 District Level soft skill trainings Around 3325 Mid Media Activities were conducted for creating awareness among the communities on Tuberculosis care and control More than 6,300 Rural Health Care Providers (RHCPs) were trained in identifying TB
Printing and display of Patients Charter Training district level networks of PLWHAs
District level:
Selecting and training local NGO networks Sensitization and meetings with Community Groups Training health staff in soft skills Capacity building of CBOs in each district and their quarterly meetings with DTOs Select and facilitate training of rural health Sputum Collection Centers
Prakash continues treatment as well as helps to create awareness on TB

This is the story of Mr. Prakash Ahirwar from Khatoli village in block Binaganj, Guna District, Madhya Pradesh. A farm labourer, he was suffering from cough (since many days) and weight loss. He was tested positive for tuberculosis, and he started taking medicine from a private practitioner. Despite taking treatment, his health was deteriorating day by day. Many times, he felt a shiver going all through his body, especially through the chest. This made him discontinue the DOTS many times. He was fed up with his life and was almost on the point of ending his life. Once there was a GKS meeting conducted in the village by one of the Mother-NGOs (MNGOs) from the CHAI-Axshya team. Mr. Prakash was referred to the MNGO team by a community volunteer. The MNGO team counselled him to visit the District Hospital and get a test done. He was confirmed positive. Due to poor health, he was advised treatment with observation. The MNGO took initiative for counselling Mr. Prakash and was told about the importance of regular and continuous treatment. They also told him about the need to get hospitalized and about the benefits of the observational treatment Prakash Ahirwar as he was very weak. Till date, he continues his treatment as prescribed by the doctors. He is also involved in creating TB awareness and referring patients with TB symptoms to the nearby DMC.
Kapil Shrivastav, DC Gwalior & Guna
Health Action
March 2013
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Auto-driver helps out a TB-infected person

Mr.Murugan, a 48 year-old, auto-rickshaw-driver from Edallakudi, Nagercoil, Kanyakumari district, is playing the role of a social worker and counsellor. He helped out a tuberculosis-infected person, and her family who are his regular customers. Mrs.Kajith Beevi, aged 37, is the mother of four children. Three are girls, two of whom got married and settled in Arab countries and the last one (fourth one) is a 15year- old son doing his 10th standard. The third daughter has completed her studies and is staying with mother and younger son. Kajitha Beevis husband is working in Saudi Arabia. Kajitha Beevi developed TB symptoms and she consulted a famous private hospital at Thiruvananthapuram, where she was diagnosed with TB of lungs. Both lungs are damaged and the prognosis is very low. They have spent more than Rs.1000 00, for test and treatment. Kajithas husband was afraid that his wife will spread the disease to the children and therefore she was locked in a room and the maid was taking care of her. Meanwhile Urban health nurses from Vattavilai Urban Health Centre, Nagercoil municipality, were visiting the area on regular visits. Mrs. Sujakala, UHN, Mrs. Shanthi UHN, and Mrs.Devasundari UHN, tried to motivate the husband but he refused to change his mind. At this juncture, Murugan, an auto-driver, well known to this family, and to the husband of Kajitha, was used as a motivator by the health workers. Eventually he agreed to visiting District Tuberculosis Centre Asaripallam, located in Kanyakumari Medical College hospital campus. She was diagnosed as sputum-positive TB and they arranged for DOTs treatment in Vattavillai urban health centre. Mr.Murugan personally took care in taking the patient for DOTs treatment. The urban health nurses and Mrs.Sophy, through health visitor, counselled the patient and her husband during the treatment period and through their motivation all the family members were made to realize that TB is curable and government DOTs treatment is the best strategy for tuberculosis.
(Benjamin Franklin, District Coordinator, Kanyakumari,Tamil Nadu)
symptomatics; referrals, sputum collection and transportation and default retrieval. Over 4375 community volunteers (CVs) were trained in identifying TB symptomatic, sputumcollection and transportation and default retrieval TB Forums were established in all 96 districts, where 2500 members are actively working and successfully
advocating the needs and challenges of the affected community. Total 380 Axshya villages have been developed with the support and involvement of PRIs & CBOs Over 16,000 Sputum samples were collected from TB symptomatics and transported to DMCs; 987 were found positive for tuberculosis and initiated on treatment. Over 12,248 TB symptomatics were referred to DMCs, out of 6249 reached and 1251 were found positive for TB and initiated on treatment. More than 500 initial/default/missed doses/ retreatment default cases retrieved by the community volunteers and put them back on treatment.
(The author is Director-General, the Catholic Health Association of India, Secunderabad The project is gearing up for Phase II starting from 1, April 2013)
Health Action
March 2013
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District TB Officers Speak...

AXSHAYA Project is contributing very well towards achieving the objective and target of the RNTCP with the involvement of the community /MNGOs and CBOs and RHCP. We cannot achieve independently, so we need your support and more commitment in work in the coming months. Dr.R.Trivedi, DTO, Garwah Project Axshya is doing good work in the periphery of the district sensitizing the tribal community to eliminate social stigma and helping RNTCP to achieve the goal. Dr.Hemant Kumar,DTO, Gumla Project Axshya is one of the good Programmes and it has to support RNTCP to achieve 100% of the programme goal. Dr.Ugesh Ram DTO of Lohardaga Project Axshyas IEC activities have helped the RNTCP in our Tumkur District by improving self referrals due to creation of awareness. It also has helped in the collection and transport of sputum samples from remote PHCs to DMC. Dr. Asma Tabassum, DTO, Tumkur Project Axshya since last 21 months has successfully taken the initiative in Dewas District for controlling TB and RNTCP programme for educating and reaching out to the masses. Project Axshya also includes sputum transportation and also training of people belonging to various organizations which has helped the District Tuberculosis Centre, Dewas. We have full trust that in the coming years, Project Axshya will give its full co-operation for controlling TB in the District. DTO,Dewas
Project Axshya is supporting District-Level RNTCP since last 2 years. We are getting support in various fields like Sputum Transportation, Treatment Adherence, Training to Health Staffs/ NGOs, Conducting Medical Camps, World TB Day, and International Womens Day. Its active participation in the programme is really a boost to the RNTCP. The District Axshya Project Co-coordinator is very active and energetic. We expect this type of support in future also. DTO,Kasargod,Kerala I am impressed by CHAI AXSHYAs support in many community-led initiatives in the district since inception of the project, in April 2011. CHAI-AXSHYA has contributed to RNTCP performance in the district of Firozpur and we are looking forward to having many coordinated efforts to curtail the disease of TB! Dr. Naveen Shetty, DTO,Firozpur Project Axshya has started work in Seraikela Kharsuwan district with RNTCP from July-12. Sri. Sunil Dungdung, the District Coordinator, plays an active role in this programme. He has trained many health staff, volunteers, General Rural Practitioners, NGOs and other DOTS providers. The partner NGOs of Project Axshya are helping in referral, sputum collection and follow-up. These activities are quite satisfactory and I hope to get better support from CHAI in future. Dr.AP Sinha, DTO, Seraikela Involvement of Project Axshya in RNTCP is really good fortune to me as a DTO. Axshya has contributed a lot by supporting the District-level ACSM activities and some special initiatives like training and involvement of AYUSH doctors. Dr. Krishnaveni, DTO, Kollam,Kerala
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The plus point of Axshya is the positive thinking, enthusiastic, and disciplined coordinators under the leadership of Joltin Rappai, the Assistant Programme Manager . We become very energetic when we work together. So if at all we have other peripheral ACSM activities, Axshya has the ability to co-ordinate with all sorts of people. The diamond thing is the TB Forum, diamond in the sense of rigidity and sparkle. We have just begun to polish it, hope it will sparkle more in the coming days. Dr Shabna DS, DTO, Thiruvananthapuram, Project Axshya has proved to be a strong helping hand for RNTCP to receive its targets. It has helped the RNTCP to achieve its targets. It has helped the RNTCP to serve people in tuberculosis control upto the grassroots level. My good wishes MOTC- Dr. A.P.Chaitanaya, TU-Hazaribagh The RNTCP has not been able to focus on awareness which is equally important as treatment. One of the best things I find in Axshya is the soft skill training. This training has to be given to all the medical staff including officers. The present status make it clear that it will show good outcome in the near future. If Axshya programme could provide nutrition support to the TB patients, it will be very much helpful. Rajratan Khsatriya, STS, Seraikela We on behalf of the RNTCP team from Hazaribagh express our sincere gratitude to Project Axshya for
extending their valuable services in TB case-detection and sputum collection and transportation. I wish them all the best for their effort in the district. Dr. Om Prakash Rawani,DTO-Hazaribagh taking the joint meeting of ICTC & DMC. Project Axshya is a pillar of constant innovation, excellence, commitment, strength and dedication. It has stood true to its core mission: to help in RNTCP, TB project. I am sure that our honest and hard work and constant innovation in every aspect of the work will help us. I want to congratulate each one of its staff for the relationship we have shared for the last two years. Mr.Arvind Kumar Verma, STS The Catholic Health Association of India is always taking active part in various activities, both at Taluka and Village levels undertaken By DTO Kolhapur Under the RNTCP programme. The District Coordinator of CHAI Mr. Girish Gavandi co-ordinates well with the various RNTCP health staff like STS, STLS at taluka levels. CHAI actively participates in various health camps, programmes, and important festivals. They come forward with innovative ideas in various community gatherings, rallies, competitions and stakeholders meetings to create awareness among the community about tuberculosis. Dr. Pravin Naik, DTO,Kolhapur This is to certify that CHAI and Sarvodaya Seva Pratisthan jointly have done good work with RNTCP in 11 villages and they could create lots of awareness. This is a very appreciable activity. Please continue the programme. Medical Officer,Siddhnerli PHC. Kothpur
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TB Patients, Communities, RHCP and TB Forum Members Testify...

I was suffering from tuberculosis for more than a year. But I did not have the courage to share about the disease with my family. So I could not take any medicine. But AXSHAYA project counselled not only me but my family members also. After 8 months of taking medicine I am totally cured. Now I am motivating persons suffering from TB for taking treatment. Mr.Indradeo Bhuiya (Cured TB patient) I will take medicine and complete the treatment. Now I know I will be the cause of many TB patients if I do not take medicine properly. Mr.Nandu Munda (TB patient) Project Axshya has helped us to improve our knowledge level on TB, and today we believe that we have a responsibility to make our district TBfree. We will try our best to contribute towards TB control. Dr. Nanjundappa, President, RMP Association, Tumkur I did not know that TB could be so dangerous. Now I know TB will spread to all near by. I will take medicine and try not to spread to anybody. When people like you come to see me I feel very good. I thank Iswar Sir for his caring, (Iswar Chndra an RHCP trained under Axshya programme). Mr.Parme Sardar, a TB patient I got knowledge about tuberculosis from CHAI Axshya Project. I am currently a patient of TB and taking regular TB medicines. I am very grateful to you for the guidance given to me. I wish you best of luck in your future work. Thank you Mr.Sambhaji 99Khot TB patient under treatment Through Project Axshya, CHAI has taken a good initiative to bring awareness about TB in the community, for which we take this opportunity to congratulate them. Especially the efforts taken by CHAI
through project Axshya in association with PLHIV is much appreciated. We also appreciate the work with best wishes for their efforts. Thank you! Mr. Bahadur Yadav, JNP+ &TB Forum Member People suffering from tuberculosis are getting motivated through Project Axshya. I am able to share my success of treatment with TB patients in the TB forum and I am strongly motivating the TB patients that Government medicine is best for TB cure. Many poor TB patients get nutritional support through TB forum in our district and I see hope in the faces of so many TB patients who are attending the TB forum meetings. I wish to share my experience to many more patients that I have been cured of tuberculosis and am able to work, and earn like any other person and take care of my family. Mr.Shanmugam, Secrtary-TB Forum on Axshya Project, Kanyakumari Dt Axshya is a very good programme. Through this we are able to reach very interior areas. As per the training received, we will work for TB patients. We are planning to contact government agencies and trying to raise fund for nutrition support. Hope our plans will be successful. TB Forum Member The villagers come to me and I give them medicine. In the beginning, I have given lots of medicine to people who came for treatment including TB patients. After getting training from CHAI, if people come with cough I send them to DMC with Axshya programmes referral slip. I personally have attended community awareness meetings. The response of villages is good. Gradually, people are becoming aware of TB. It is just an initial period, still referral has increased. Results will be seen from the next year. RHCP; Iswar Chandra Mahto
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Reducing Stress in Type 2 Diabetic Patients through Yoga

Mrs.Shanthi M.Sc (N) Ph.D* Dr.Karoline Rajkumar, M.Sc(N), Ph.D**
YOGA & HEALTH
he system of yoga therapy is not symptomatic as it believes in treating the person as a whole. This holistic approach of yoga, in a nutshell, would focus to bring all the abnormalities of the body and mind physiology back to normal and restore positive health. Regular practice of yoga helps to increase glucose utilization. It also helps to attain ideal body weight. It develops stamina and provides a sense of well being.
Specific practices recommended for diabetes
pancreas, which is likely to stimulate pancreatic function.
Mechanism of yoga
Secretion of glucagons which increase sugar in the Recommendations regarding practice of blood is enhanced by stress. Yoga effectively reduces yoga The patient must learn to control diabetes in a holistic stress, thus reducing glucagon and possibly improving manner, recognizing the effects of stress, emotional insulin action. imbalance, dietary and living habits on the disease Muscular relaxation, development and improved blood condition. supply to muscles might enhance insulin receptor Start with simple movements and positions before expression on muscles causing increased glucose progressing gradually to complicated postures. uptake by muscles and thus Throughout the programme, reduced blood sugar. monitor glucose levels. Take Blood pressure plays a great appropriate medicinal dosages as role in the development of and when required. After several diabetes and related weeks, one may be able to complications, which is proven reduce such dosages. to be benefited by yoga. Practice in the morning and Yoga reduces adrenalin, norevening for 40 to 60 minutes, the adrenaline and cortisol in blood, recommended series of postures which are termed as stress according to ones capacity. hormones. This is a lively Practice before meals, but after mechanism of improvement in consuming liquids. insulin action. Avoid exertion (i.e) heavy Many yogic postures do muscular activity. Perform the produce stretch on the Suriyanamaskar movements slowly and smoothly,
March 2013
Suriyanamaskar Todasana Ardhachakrasana Supta pavanamuktasana Shalabhasana Paschimottanasana Vajrasana Shavasana Pranayama
Health Action
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Secretion of glucagons which increase sugar in the blood is enhanced by stress. Yoga effectively reduces stress, thus reducing glucagon and possibly improving insulin action
stretching the limbs and joints, and gently compressing the abdomen, without straining. Maintain the postures for a comfortable length of time. Focus on the breath during the maintenance period of the posture, with the eyes closed or focused on one point, as a means of learning to focus the mind and to manage stress and tension in the body. Perform shavasana, by complete relaxed pose on the back, systematically relaxing all the parts of the body, at the end of the session. Obese patients can start with different asanas, cleansing processes, pranayama and relaxation. Lean (Continued from page 26) Bill as a uniquely vulnerable group. Specifically, they should be given access to nutritious supplements under the provisions of the Food Security Bill. E. Actionable Options The question of delivery mechanisms is important. A number of practical options exist. First, under the National Rural Health Mission, there are existing Village Health Sanitation and Nutrition Committees. Through these, TB patients can access nutritious food through the local anganwadi, local ICDS centres or ASHA workers. The second option is to distribute the nutritious
and thin patients should start with relaxation and pranayama and practice in a relaxed manner. Many studies have confirmed that the practice of postures can rejuvenate the insulin producing cells in the pancreas of diabetes and helps the patient to control the causes of diabetes. Pranayamis found useful in diabetes as alternate nostril breathing has calming effect on the nervous system, which reduces stress level, helping in diabetes treatment. Yoga is a simple and economical therapeutic modality. So people belonging to any age group can perform during all seasons, and it is highly useful to people who travel frequently.
(*Lecturer in Nursing, Rani Meyyemmai College of Nursing, Annamalai University **Professor of Nursing, Rani Meyyemmai College of Nursing, Annamalai University The authors acknowledge various sources which are available on request)
supplements through the Public Distribution System infrastructure. About 80% of TB patients are from rural areas. However, since TB is a problem for the poor in urban areas, the PDS system can also be retained as an option for BPL-TB patients in urban areas. There are other options could be piloted and expanded at the district and state levels as appropriate. F. Moving Forward What are the implications of this proposed inclusion of poor TB patients in the Food Security Bill? These following areas must be considered: the number of patients, duration of treatment and breadwinner effects. Every year, about 1.5 million new TB patients are identified in India. Out of this, approximately 7, 50,000 are BPL TB patients and they will definitely benefit from this inclusion. Second, for how much time would this inclusion apply? The duration of nutritional support can be from a minimum of 6 months to 24 months. This will be connected to the duration of the TB treatment. Finally, there is a third implication. TB affects far more men than women. Thus, it is possible that if a BPL individual contracts TB, then it is likely that such a male member may be a breadwinner. If the breadwinner (whether male or female) is found to suffer from TB, then the entire family also suffers. So ensuring that TB patients are included in the Food Security Bill will extend the positive reach of this very important policy intervention.
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What are the implications of this proposed inclusion of poor TB patients in the Food Security Bill? These following areas must be considered: the number of patients, duration of treatment and breadwinner effects. Every year, about 1.5 million new TB patients are identified in India. Out of this, approximately 7, 50,000 are BPL TB patients and they will definitely benefit from this inclusion.
DIET & HEALTH
Rediscovering the forgotten

Milletsfor health
Aparna Kuna, Supraja.T, Sucharitha.S
illets are small seeded annual cereal grains from a group of grassy plants with short slender culm and small grains possessing remarkable ability to survive under severe drought. They can be cultivated in all types of soils and sustains adverse climatic conditions and they have excellent rejuvenating capacity compared to other cereal crops. Dietary modification, weight control, and regular exercise are the main approaches in the management of degenerative diseases, diet being the sheet anchor. New research findings indicate the potential value of diets in prevention of such disorders. Infact, the preventive role of corrective nutrition is an ever evolving process. Thus, for the health conscious genre of the present world, millets are perhaps one more addition to the proliferating list of healthy foods, owing to their nutritional superiority. Although millets are nutritionally superior to cereals, yet the utilization is limited. The major factor discouraging their cultivation and consumption with improvement in living standard or urbanization is the drudgery associated with its processing. However, there is a need to restore the lost interest in millets which deserves recognition for their nutritional qualities and potential health benefits. Millets are claimed to be the future foods for better health and nutrition security. In India, eight millets species (Sorghum, Finger millet, Pearl millet, Foxtail millet, Barnyard millet, Proso millet, Kodo millet and Little millet) are commonly cultivated under rainfed conditions. The various kinds are millets - their scientific, popular and common names are given in the table. Like other cereals, major and minor millets are predominantly starchy. The protein content is nearly equal among these grains and is comparable to that of wheat and maize. Pearl and little millet are higher in fat, while finger millet contains the lowest fat. Barnyard
millet has the lowest carbohydrate content and energy value. One of the characteristic features of the grain composition of millets is their high ash content. They are also relatively rich in iron and phosphorus. Finger millet has the highest calcium content among all the food grains. High fibre content and poor digestibility of nutrients are other characteristic features of sorghum and millet grains, which severely influence their consumer acceptability. Millets are rich in B vitamins (especially niacin, B6 and folic acid), calcium, iron, potassium, magnesium and zinc. Generally the whole grains are important sources of B-complex vitamins, which are mainly concentrated in the outer bran layers of the grain. Millets do not contain vitamin A, although certain yellow endosperm varieties contain small amounts of - carotene, a precursor of vitamin A. No vitamin C is present in the raw millet grains. Millets do not contain gluten which makes them appropriate foods for those with celiac disease or other forms of allergies/intolerance of wheat. However, millets are also a mild thyroid peroxidase inhibitor and probably should not be consumed in great quantities by those with thyroid disease.
Health benefits
Lignans, an essential phytonutrient present in millets, are very beneficial to the human body. Under the action of interstitial friendly flora, they are converted to mammalian lignans, which act against different types of hormone-dependent cancers, like breast cancer and also help reduce the risk of heart disease. Regular consumption of millet is very beneficial for postmenopausal women suffering from signs of cardiovascular disease, like high blood pressure and high cholesterol levels. Intake of whole grains like millet and fish by children has been shown to reduce the occurrence of
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Nutritive value of millets
Health Action
March 2013
Types of millets grown in India and their popular names

Crop
Sorghum vulgare Pennisetumtyphoideum Eleusinecoracana
Popular name
Common names
Setariaitalica
Major Millets Sorghum / Jowar Great millet, guinea corn, kafir corn, aura, jwari, cholam, kaoliang, milo, milo-maize Pearl millet / Bajra Pearl millet, cumbu, spiked millet, bajri, bulrush millet, candle millet, dark millet Finger millet / Ragi African millet, koracan, ragulu, wimbi, bulo, telebun, Bhav, Nachni, Mandia, Kezhvaragu, Moothari Foxtail millet / Moha millet / Korra Italian millet, German millet, Hungarian millet, Siberian millet, Korra, Kangni, Kash, Thenai, Moha, Kakankora
Minor Millets Panicummiliaceum Proso millet / Varagalu French millet, common millet, hog millet, broom-corn millet, Russian millet, brown corn, Panivaragu, Varagalu, Kashpingu, Chinna Echinochloafrumantacea Barnyard millet / BonthaChamalu Sawa millet, Japanese barnyard millet, Bontachamalu, Sama, Samai, Kudiraivalu, Shamul Paspalumscrobiculatum Kodo millet / Arikalu Varagu, Kodra, Haraka, Kodus, Arikalu, Mankodra, Kodoadhan Panicummiliare Panicumsumatrense Little millet / Samai Kangni, Gadro, Kutki, Samai, Kash. Ganuharr, Chama, Sava, Suan, Goudli
Recent research has indicated that the regular consumption of millet is associated with reduced risk of type 2 diabetes mellitus. This is mainly due to the fact that whole grains like millet are a rich source of magnesium, which acts as a co-factor in a number of enzymatic reactions in the body, regulating the secretion of glucose and insulin. Millet is very easy to digest; it contains a high amount of lecithin and is excellent for strengthening the nervous system. Insoluble fiber present in millets not only speeds intestinal transit time (how quickly food moves through the intestines), but reduces the secretion of bile acids (excessive amounts contribute to gallstone formation), increases insulin sensitivity and lowers triglycerides (blood fats). Millet is highly nutritious, nonglutinous and like buckwheat and quinoa, is not an acid forming food so is soothing and easy to digest.
Utilization of millets for development of value added products
wheezing and asthma. A high source of fiber, millet is very beneficial against breast cancer in post-menopausal women. According to research and recent studies, consumption of millet can help women combat the occurrence of gallstones, as they are a very high source of insoluble fiber. Millets are very high in phosphorus content, which plays a vital role in maintaining the cell structure of the human body. The key role of this mineral is that it helps in the formation of the mineral matrix of the bone and is also an essential component of ATP (adenosine tri-phosphate), which is the energy currency of the body.A single cup of millet provides around 24% of the bodys daily phosphorus requirement.
Millets are high energy, nutritious foods recommended for the health and well-being of infants, lactating mothers, elderly, adolescents and convalescents. However, the foods produced from them traditionally and industrially, have short keeping qualities due to the presence of high fat content in the millet flours. This constraint to extended utilization and properties of millet foods is being responded to through research and development in improved processing. Their good nutritional values including high levels of quality protein, ash, calcium, iron and zinc, which make millet nutritionally superior than most cereals, are now being enhanced through efficient utilization in product development and value addition.
(Department of Foods & Nutrition, Postgraduate & Research Centre Acharya N G Ranga Agricultural University, Hyderabad)
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IMMUNIZATION & HEALTH
Vaccination in Children
Suchithra B.S Vaccination schedule

Vaccination has its own time, period and schedule. According to the age, weight and progress of the milestones of the baby, the vaccine schedule can be altered but not much. The dosage of vaccination remains the same among babies but may be different for adults. Many of the local governments now offer free and low-cost vaccinations in their regions. For instance, polio drops are available. Babies are born with protection against certain diseases because antibodies from the mother get passed to them through the placenta. After birth, breastfed babies get the continued benefits of additional antibodies in breast milk. But in both cases, the protection is temporary.
vaccine is a biological preparation that improves immunity to a particular disease. A vaccine typically contains an agent that resembles a disease-causing microorganism, and is often made from weakened or killed forms of the microbe. The agent stimulates the bodys immune system to recognize the agent as foreign, destroy it, and remember it, so that the immune system can more easily recognize and destroy any of these microorganisms that it later encounters. Vaccines can be prophylactic (e.g. to prevent or ameliorate the effects of a future infection by any natural or wild pathogen), or therapeutic (e.g. vaccines against cancer)
Importance of vaccination
Prevention of disease is the key to public health. It is a general saying that prevention is always better than cure. Vaccines prevent the disease in the people who receive them and protect them who come into contact with the people who are not vaccinated. Vaccines also help in preventing infectious diseases that were once common in the country. Such diseases include polio, pertussis (whooping cough), diphtheria, measles, rubella (German measles), mumps, Haemophilus influenza type b (Hib) and tetanus. Parents are constantly concerned about the health and safety of their children and take many steps to protect them. These steps range from child-proof door latches to child safety seats. In the same way, vaccines work to protect infants, children, and adults from illness and death caused by infectious diseases. Even diseases that have been eliminated in this country such as polio are only a plane ride away. Another benefit of vaccination is cost. The cost to cure the actual disease will be much more compared to the cost of vaccination for the same disease. For instance, if you get the typhoid vaccination, the cost will be much lesser than the cost of treating the typhoid once your child is actually infected by typhoid. Hospitalization, medicines and injections will be very costly to treat the typhoid and the vaccination is available with very low cost.
Immunization
Immunization (vaccination) is a way of creating immunity to certain diseases by using small amounts of a killed or weakened microorganism that causes the particular disease. Microorganisms can be viruses such as the measles virus, or they can be bacteria such as pneumococcus. Vaccines stimulate the immune system to react as if there were a real infection it fends off the infection and remembers the organism so that it can fight it quickly should it enter the body later. Some parents may hesitate to have their kids vaccinated because theyre worried that the children will have serious reactions or may get the illness the vaccine is supposed to prevent. Because the components of vaccines are weakened or killed and in some cases, only parts of the microorganism are used theyre unlikely to cause any serious illness. Some vaccines may cause mild reactions such as soreness where the shot is given or fever, but serious reactions are rare. The risks of vaccinations are small compared with the health risks associated with the diseases theyre intended to prevent.
(Lecturer, Nitte Usha Institute of Nursing Sciences, Mangalore; The author acknowledges various sources which are available on request)
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HEALTH BITS HEALTH BITS

Climb stairs slowly to burn more fat
Look before you leap! Ascending one step at a time actually burns more calories than leaping up multiple stairs, a new study has found. Although more energy is initially expended when taking two steps per stride, over time, more energy is burnt up when you take your time, according to scientists from the University of Roehampton. Researchers found climbing five flights of stairs five times a week an ascent of 15m burnt an average of 302 calories if stairs were taken one at a time. However, taking two steps with every stride will only burn 260 calories, they said. Times of India, 15 December 2012 the patterns in your voice. All you need to do is relax and read a 3 minute-passage into the software in your phone. It compares the recording to pre-programmed information in the database about physiological changes that indicate stress. The software reflected 81 per cent and 76 per cent accuracy, when tested indoors, depending on the sound quality. The team has made the system a plugin into an Android application called BeWell. Insight-The Consumer Magazine, November-December 2012 Form IV (See Rule 8)
Good reading for good health

Reading is one habit gradually losing ground among teenagers in the age of television, social networks and the internet. The next time you try to tempt your kind to prefer a book to TV or video game, mention that reading books is good for health. Researchers at Magdalen College Oxford, UK found that reading exercises the whole brain; imagining what is happening is as good at activating the brain as doing it. Another research also found that simply 6 minutes of reading can reduce stress levels by more than two-thirds, compared to listening to music or taking a walk. Further, a study published in Archives of Neurology from the University of California, Berkley, found that reading on a daily-basis from a young age could help prevent Alzheimers disease, reports Dailymail, UK. Insight-The Consumer Magazine, November-December 2012
STATEMENT OF OWNERSHIP
1 Place of Publication 2 Periodicity of Publication 3 Printers Name Whether Citizen of India (If foreign, state the country of origin) Address : : : : : Secunderabad Monthly (12 issues per year) Dr (Sr) Placida Vennalilvally, at Jeevan Press, Sikh Village, Secunderabad 500 009 Yes Health Accessories For All (HAFA), Post Box No.2153, 157/6 Staff Road, Gunrock Enclave, Secunderabad 500 003, AP Dr (Sr) Placida Vennalilvally Yes
4 Publishers Name Whether Citizen of India (If foreign, state the country of origin) 5 Editors Name Whether Citizen of India (If foreign, state the country of origin)
: :
: :
N. Vasudevan Nair (Editor-in-charge) Yes
A team of software developers at Intel in Santa I, Dr (Sr) Placida Vennalivally, hereby declare that the particulars given above are true to the best of my knowledge and belief. Clara, USA, has developed Stress Sense, the new stress-sensing software that identifies stress from 15/02/2013 Sd/Health Action March 2013
New mobile app can feel your stress level
6 Names and addresses of individuals who own the Newspaper and partners or share-holders holding more than one per cent of total capital :
Health Accessories For All (HAFA), Post Box No.2153, 157/6 Staff Road, Gunrock Enclave, Secunderabad 500 009, AP
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LETTERS
Cover is apt for the theme

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Forthcoming themes 2013

(The order is subject to change) Critical Review of NRHM Use of Steroids and Health 12th Five Year Plan and Health Environmental Health Rheumatic Heart Disease Critical Review of Diagnostic Centres Respiratory/ Gastro-intestinal/ Renal/ and Endocrine Disorders 70 Years of CHAI, 25 Years of Health Action Use of Cosmetics Medical Education Disabilities Iatrogenic Diseases Malaria
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Health Action gives sufficient knowledge on various health-related topics. It is very enriching. The articles are written in such a way as to impress both professionals as well as common readers. Mini K T, Kottayam Kerala
CHAIs Journey...
Motto: Love of Christ Compels Us
VISION
The Catholic Health Association of India (CHAI) upholds its commitment to bring health for all. It views health as a state of complete physical, mental, social and spiritual wellbeing, and not merely the absence of sickness. Accordingly, CHAI envisions an INDIA, wherein people Are assured of clean air, water and environment; Do not suffer from any preventable disease; Are able to manage their health needs; Are able to control the forces which cause ill health; Enjoy dignity and equality and are partners in decisions that affect them, irrespective of caste, creed, religion or economic status, and
Health Action Health Action March 2013 March 2013
Respect human life and hold and nurture it to grow into its fullness.
MISSION
In order to realize the vision, CHAI endeavours to
Promote COMMUNITY HEALTH, understood as a process of enabling the people, especially the POOR and the MARGINALIZED, to be collectively responsible to attain and maintain their health and demand health as a right, and ensure availability of health care of reasonable quality at reasonable cost. Control Communicable Diseases as they cause a huge public health burden as well as take a heavy toll of human life in the country; and Provide Relief to Disaster Victims in the country and bring the affected to the normal level of functioning.
(To be continued...)
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Health Action
March 2013
40

Health Action: Special Issue On TB (March 2013)

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Health Action: Special Issue On TB (March 2013)

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Vol 26 No.3 MARCH 2013

Thought for the Month

India Annual Rs.300 Life (12Years.) Rs.2500 Single Copy Rs. 30

Foreign Annual US $ 50 Life US $ 500

March 2013 March 2013

Improving access to tuberculosis care and control

Patterns of presentation (Timetable)

Clinical features Symptoms

Clinical features in the HIV-positive patient

Differential diagnosis of pulmonary tuberculosis

Engaging communities in the fight against TB R

Gaon Kalyan Samiti

Health systems strengthening

Evolving TB Control Strategies in India

Strategic vision to move towards universal access

National Strategic Plan (2012-2017)

Case-finding and Diagnostics:

Patient-friendly Treatment Services

Engagement of Private Sector:

Scale-up of Programmatic Management of Drug Resistance -TB

Human Resource Development

Scale -up of Joint TB-HIV Collaborative Activities:

Advocacy, Communication and Social Mobilization:

What will NSP achieve?

Monitoring and Evaluation, Surveillance and Impact Assessment:

Research to inform TB Control policy and practice:

Tuberculosis and Silicosis at Workplace

Situational analysis study

Major findings of the study

Interactions with focal persons at industries

Experiences of LEPRA India in TB Control in Andhra Pradesh

Dr. J. Subbanna* and Dr. Aparna S Srikantam**

LEPRA Indias foray into Tuberculosis Control Programme

TB Forum Members (Discussions)

Investing in safe and effective vaccines

Social Stigma Attached to TB

Social impact of TB stigma

Frequently-Asked Questions on Tuberculosis

How is tuberculosis caused?

Benefits of DOTS/ Why DOTS?

Can tuberculosis be cured in HIV co-infection?

For how long must tuberculosis treatment be taken?

What is multi-drug-resistant tuberculosis?

What is DOTS that is being implemented?

What is the duration of treatment for multi-drugresistant tuberculosis?

How many people die from TB in India every year?

Knowledge, Attitudes and Practices on TB

he core objective of the Baseline Survey was to

Health Service Providers (HSP)

Non-Governmental Organisations/ Community-Based Organisations

World TB Day: 24 March 2013

Key facts about TB

Project Axshya has helped the State in reaching the unreached...

Why should BPL TB patients be included in the Food Security Bill?

(Continued on page 34)

Key project activities State level:

Geographic Coverage of CHAI-Axshya Project

What has been achieved so far

Prakash continues treatment as well as helps to create awareness on TB

Auto-driver helps out a TB-infected person

District TB Officers Speak...

TB Patients, Communities, RHCP and TB Forum Members Testify...