INTRODUCTION
As a destroyer of mankind, tuberculosis has no equal...
VA Moore (1)
Tuberculosis [TB] has been a major cause of suffering and death since times immemorial. Thought to be one of the oldest human diseases, the history of TB is at least as old as the mankind. Over the years, not only the medical implications but also the social and economic impact of TB has been enormous.
There have been references to this ancient scourge in the Vedas [vide infra] and it was called “rajayakshma” [meaning “wasting disease”]. Hippocrates [460-377 B.C.] called the disease “pthisis”, a Greek word which meant “to consume”, “to spit” and “to waste away“ (2,3). The word “consumption” [derived from the Latin word “consumere”] has also been used to describe TB in English literature. The Hebrew word “schachepheth” [meaning “waste away”] has been used in the Bible. J.L. Schonlein, Professor of Medicine at Zurich, is credited to have named the disease “tuberculosis” (1). The word “tuberculosis” is a derivative of the Latin word “tubercula” which means “a small lump” (2,4,5). Several names have been used to refer to TB in the years gone by. Acute progressive TB has been referred to as “galloping consumption”. Pulmonary TB has been referred to as “tabes pulmonali”. Tuberculosis cervical lymphadenitis has been called as “scrofula”, “King's Evil”, “stroma”. Abdominal TB has been called as “tabes mesenterica”. Cutaneous TB has been called “lupus vulgaris”. Vertebral TB has been called as “Pott's disease”. Oliver Wendell Holmes referred to the disease as “white plague” (6). While scores of other diseases like smallpox and plague killed millions of people, their reign has been relatively short-lived. Tuberculosis has been ever present and is resurging with a vengeance.
TUBERCULOSIS IN ANCIENT TIMES
It is thought that TB probably existed in cattle before its advent in man.
muncami tva havisa jivanayakam
agnatayaksmad uta rajayakshma...
[I deliver you by means of oblation so that you may live from the unknown disease and from the “rajayakshma”]
[RV, X,161,1]
In the Krishna Yajurveda Samhita, there is reference to how, Soma [Moon] had been affected by “yakshma”. Since “Soma”, who was the “King and Ruler” was affected by “yakshma”, it came to be known as “rajayakshma” [Figure 1.1].
In Sanskrit, the disease has been called “rajayakshma”, “ksayah”, and “sosa”.
Rajayakshma ksayah soso rogarad iti cha smritah
naksatranam, dvijanam cha rajno bhud yad aym pura
yach cha raja cha yakshma cha rajayakshma tato matah
[Vagabhatta, Ast-s and Ast-hrd, Nidana V, 1-2]
Krodho yakshma jvaro roga eko ‘rtho dukhasamjnitah
yasmat sa rajnah prag asid rajayakshma tatomatah
[Charaka Samhita, Chikitsasthanam VIII, 11]
Changes resembling those caused by TB have been described in the skeletal remains of neolithic man (7). Terms such as “lung cough” and “lung fever” have been used in ancient Chinese literature to describe a disease which might have been TB (8). There have been references to what could have been TB in the Code of Hammurabi of the Babylonian era (6). Evidences of TB lesions of bone have also been found in Egyptian mummies dating back to 3400 B.C. (7).2
Figure 1.1: Krishna Yajurveda Samhita, II kanda, III prasna, V anuvaka, 25th stanza, where the legend of “Soma” being afflicted with “rajayakshma” is described
Mycobacterium tuberculosis has been demonstrated microscopically in the mummy of a child of five years (8).
There are several references to conditions resembling TB in Greek literature by Homer [800 B.C.], Hippocrates, Aristotle [384-322 B.C.] and Plato [430-347 B.C.], Galen [129-199], Vegetius [420] were also familiar with consumption. Arabic physicians Al Razi [850-953], Ibn Sina [980-1037] correlated lung cavities with skin ulceration.
During the middle ages, there are records of healing touch of monarchs was being used to treat “scrofula” [King's Evil]. King Charles II bestowed the royal touch on an astounding 92,102 patients with “scrofula” (9). By around 1629, death certificates in London specified the disease as “consumption” which was a leading cause of death. By this time the contagious nature of TB was strongly believed though there were people who contested this opinion. The Republic of Lucca is credited to have passed the first legislative action aimed at controlling TB in the world (4,9). This was followed by similar measures in several Italian cities and Spain.
DIAGNOSIS
Why, when one comes near consumptives... does one
contract their disease, while one does not contract
dropsy, apoplexy, fever, or many other ills?....
Aristotle
In the early days, diagnosis of TB was based on symptoms and signs. In Charaka Samhita [Nidanasthana, VI, 14], heaviness in the head, coughing, dyspnoea, hoarseness of voice, vomiting of phlegm, spitting of blood, pain in the sides of the chest, grinding pain in the shoulder, fever, diarrhoea and anorexia have been described as the eleven symptoms of TB. Furthermore, a physician who is well versed in the aetiology, clinical presentation and premonitory symptoms of “consumption” was considered to be a “Royal Physician” [Charaka Samhita, Nidanasthana, VI, 17].
The earliest classical descriptions of TB in Greek literature date back to the writings by Hippocrates. Aretaeus the Cappodocian [50 B.C.], in his book The causes and symptoms of chronic diseases gave a very accurate description of TB and mentioned that fever, sweating, fatigue and lassitude were symptoms of the TB. He suggested testing the sputum with fire or water was of diagnostic value (7). Galen described that patients with “consumption” manifest cough, sputum, wasting, chest pain and fever and considered haemoptysis to be pathognomonic of the disease (6).
Following the pioneering efforts by Andreas Vesalius [1514-1564] post-mortem examination was performed frequently. This method of study facilitated understanding of pathological findings, such as, lung cavities, empyema among others. Franciscus de Boe [1614-1672] [also known as Sylvius] for the first time associated small hard nodules discovered in various tissues at autopsy with symptoms of “consumption” which the patients suffered during their life-time though his explanation for the same was not correct (7). John Jacob Manget in 1700 gave the description of classical miliary TB (10). The clinical presentation of consumption was described in detail by Thomas Willis [1621-1675]. Richard Morton [1637-1698] had described several pathological appearances of “pthisis” in his treatise Pthisiologica (4–6,7).
Meaningful clinical examination became possible with the description of the technique of percussion by Leopold Auenbrugger [1722-1809]. However, Auenbrugger's work was virtually ignored until the time of Jean Nicolas Covisart [1775-1821], who rediscovered and propagated the technique. Gaspard Bayle [1774-1816] accurately described many of the pathological changes of TB, but unfortunately succumbed to the disease which he probably contracted while performing autopsy studies (11). The technique of physical examination of the lung was further refined by the invention of stethoscope by Rene Theophile Hyacinthe Laënnec [1781-1826], who was a student of Corvisart and a friend of Bayle. Sadly, Laennec, his younger brother, mother and two uncles all succumbed to TB (6).
Fracastorius [1443-1553] is credited to have originated the “germ theory” and believed that TB was contagious. He also mentioned about antiseptics in his chapter on the treatment of TB. In 1720, the English physician Benjamin Marten conjectured, in his publication A new theory of consumption, that TB could be caused by “certain species of animalcula or wonderfully minute living creatures”, which, once they had gained a foothold in the body, could generate the lesions and symptoms of the disease.3 He also stated that
“it may be therefore very likely that by an habitual lying in the same bed with a consumptive patient, constantly eating and drinking with him, or by very frequently conversing so nearly as to draw in part of the breath he emits from the lungs, consumption may be caught by a sound person...I imagine that slightly conversing with consumptive patients is seldom or never sufficient to catch the disease” (12)
For unknown reason the work of Marten went into oblivion for a long time. The likely reason could be that he was thinking very much ahead of his time. Jean Antoine Villemin [1827-1892] in a series of experiments provided conclusive evidence that TB was indeed a contagious disease though some workers of that era did not accept these results. He presented his results to the Academie de Medcine on December 5, 1865 and stated that TB was a specific infection caused by an inoculable agent (3,6).
“During my wandering through medicine, I encountered sites where gold was lying around. It needs a lot of serendipity to distinguish gold from ignobility; this, however, is not a particular achievement.”
Robert Koch (13)
Robert Heinrich Herman Koch [Figure 1.2], son of a mining engineer, was born on December 11, 1843 in Clausthal village in the Harz mountains (3,6,14,15). Koch pursued medical studies at the Gottingen University in 1862 and qualified maxima cum laude in 1866 with his M.D. thesis on succinic acid. On March 24, 1882 Koch announced the discovery of the tubercle bacillus during the monthly evening meeting of the Berlin Physiological Society. In 1884, he published a more comprehensive paper Die aetiologic der tuberculose in the second volume of the Reports of the Imperial Health Office. In 1905, he was awarded the Nobel Prize for his contributions in the field of TB research (3,5,6). In 1982, a century after Dr Koch's announcement, the World Health Organization [WHO] and the International Union Against Tuberculosis and Lung Disease [IUATLD], now called The Union proposed the 24th March as the “World TB Day” as a part of a year-long centennial effort under the theme “Defeat TB: Now and Forever.” Thereafter, since 1996, 24th March is celebrated as “World TB Day” every year (16,17). The event was intended to educate the public about the devastating health and economic consequences of TB, and its continued tragic impact on the global health. Each “World TB Day” addresses a different theme [Table 1.1]. Robert Koch died on May 27, 1910, aged 66 years.
It was Robert Koch who finally demystified the secret of the cause of TB and after thousands of years, the organism finally revealed itself to humans. Though, Robert Koch was wrong in his belief that tuberculin would cure TB, tuberculin became an invaluable tool for the diagnosis of latent TB infection (18).
Figure 1.2: Robert Koch: the discoverer of Mycobacterium tuberculosisReproduced with permission from “Rubin SA. Tuberculosis. The captain of all these men of death. Radiol Clin North Am 1995;33:619-39 (reference 6)”
With the advent of Wilhelm Conrad Roentgen [1845-1923], the technique of radiological imaging became available. Francis Williams in Boston, L. Bouchard and A. Beclere in France, John MacIntyre and David Lawson in Britain were pioneers in the use of radiography in the study of TB (3,6).4 By this time, the deep mystery that was TB became demystified to some extent in that basic concepts of the agent, the pathology as a result of it and its detection became established ushering in the era of definitive diagnosis of TB.
TREATMENT
In the Yajurveda, there are references to Soma performing a “yagna” [sacred offering] seeking cure from TB. Since ancient times amulets, invocations, charms, Royal touch and prayers have been used to treat TB. Chemicals such as arsenic, sulphur, calcium, several vegetable, plant and animal products including excreta of humans and animals, blood letting have been used over the centuries in the fond hope of curing TB. Robert Koch, soon after his discovery of the tubercle bacillus, ambitiously introduced the treatment using “Koch's lymph” with disastrous results. It was later known that the substance was a glycerin extract of the tubercle bacillus and was named as “tuberculin” (3,6).
During the 19th century, bed rest and change in environment emerged as important forms of treatment of TB. Hermann Brehmer, Peter Dettweiler, George Bodington, Edward Livingston Trudeau, were all pioneers of the sanatorium movement. Hermann Brehmer, a Botany student suffering from TB, was instructed by his physician to seek out a healthier climate. He travelled to the Himalayan mountains where he could pursue his botanical studies while trying to rid himself of the disease. He returned home cured and began to study medicine. In 1854, he presented his doctoral dissertation bearing the title, “Tuberculosis is a curable disease”. In the same year, he built an institution in GÖrbersdorf where, in the midst of fir trees, and with good nutrition, patients were exposed on their balconies to continuous fresh air. This set up became the blueprint for the subsequent development of sanatoria (12). During this period, surgery was extensively used for the treatment of TB. The reader is referred to the chapter “Surgery for pleuropulmonary tuberculosis” [Chapter 46] for the details.
Efforts by Albert Calmette and his assistant Camille Guérin resulted in the introduction of bacille Calmette-Guérin [BCG] vaccine (19). Pioneering work of Selman Waksman led to the introduction of streptomycin as an effective anti-TB drug. Jorgen Lehman was instrumental in the discovery of para-amino salicylic acid [PAS]. With the availability of these drugs and isoniazid, the era of modern predictably effective treatment ushered in. With the introduction of rifampicin, the treatment duration could be further shortened to the present-day six-month short-course chemotherapy.
TUBERCULOSIS IN ARTS AND LITERATURE
Youth grows pale, and spectre thin, and dies
John Keats
Ode to a Nightingale
‘Tis called the evil:
A most miraculous work in this good king;
Which often since my here-remain in England
I have seen him do. How he solicits heaven,
Himself best knows; but strangely visited people,
All swollen and ulcerous, pitiful to the eye,
The mere despair of surgery, he cures,
Hanging a golden stamp about their necks,
Put on with holy prayers; and ’tis spoken,
To the succeeding royalty he leaves
The healing benediction
William Shakespeare
Macbeth, IV, iii, 146
There have been references to TB in several works of fiction. There are references to TB in William Shakespeare's plays such as the “consumptive lover” of Much Ado About Nothing and “scrofula” in Macbeth. Charles Dickens describes the sufferings of Little Blossom in David Copperfield. Thomas Mann's The Magic Mountain contains one of the most well-known descriptions of TB sanatorium. Little Eva of Harriet Beecher Stowe's Uncle Tom's Cabin, Milly Theale in Henry James’ The Wings of the Dove, Marguerite Gautier in Alexander Dumas’ La Dame aux Cameilas also suffered from TB.
TB does not respect anybody. Several important personalities, statesmen, writers, poets, performing artists have been consumed by TB [Table 1.2]. John Keats and Percy Bysshe Shelley symbolised the era of the “romantic consumptive youths of the 19th century” (3). The image of John Keats conveyed by the writings of contemporaries of his era is that of a fragile poet who fell victim to TB because his sensitive nature had been unable to withstand contact with a crude world (3). In a well-known anecdote, when his friend John Brown discovers a drop of blood on the sheet while examining him, Keats says:
“I know the colour of that blood. It's ‘arterial blood’...
That blood is my death warrant, I must die … (3)
Shelley, a fellow poet also suffered from TB pleurisy but did not succumb to the disease. On hearing the passing of Keats, Shelley wrote:
From the contagion of the world's slow stain
He is secure, and now can never mourn
A heart grown cold, a head grown gray in vain;
Nor, when spirit's self has ceased to burn,
With sparkless ashes load an unlamented urn...
The Bronte family included six children all of whom succumbed to TB. Maria and Elizabeth died at a very young age. The son died of consumption, alcohol and opium. Emily [Wuthering Heights] and Charlotte [Jane Eyre] died aged 29 and 39 respectively. It was thought that, their father Rev. Patrick Bronte was the source of infection. The families of Ralph Waldo Emerson and Henry David Thoreau were also wiped out by consumption (3,6).
Several famous Indians had also succumbed to TB. The list includes the famous mathematician Srinivasa Ramanujan, writer Munshi Prem Chand, Kamala Nehru, among others.5
|
RISK FACTORS
Historically, several genetic, social, environmental and biological determinants of health have been identified as risk factors for TB. Role of genetic factors in the causation of TB has been covered in the chapters “Genetic susceptibility parameters in tuberculosis” [Chapter 6] and “Genetics of susceptibility to tuberculosis” [Chapter 7]. No account of the history of TB would be complete without a reference to this modern foe. The impact of the twin disaster of human immunodeficiency virus [HIV] infection and TB on human suffering has been covered in the chapter “Tuberculosis and human immunodeficiency virus infection” [Chapter 35]. The deadly interaction between diabetes mellitus [DM] and TB is being increasingly recognised world over and has lead to the institution of bi-directional screening for TB and DM (20–22). Evidence has become available suggesting that use of immunomodulator drugs [biologicals] has been associated with the development of fatal TB in rheumatoid arthritis (22,23). Data are also emerging suggesting that tobacco smokers have about three-fold higher risk of TB than non-smokers; even after adjustment for other factors (24,25).
DRUG-RESISTANT TUBERCULOSIS
With the introduction of anti-TB drugs in the mid-1940s, the era of cure for TB became a reality. Within a short period of about a half-century, the menace of drug-resistant TB [DR-TB] became a serious threat to TB control. The 1990s witnessed mutlidrug-resistant TB [MDR-TB], then the early years of the new millennium have witnessed the menace of extensively drug-resistant TB [XDR-TB]. The impact of X/MDR-TB on TB control is covered in “Drug-resistant tuberculosis” [Chapter 42].
INDIA AND TUBERCULOSIS CONTROL
Research carried out in India has had a tremendous impact on TB and this experience has been of immense value in the control of TB worldwide. The first sanatorium in India was started in 1906 in Tilonia, Rajasthan. Subsequently, other sanatoria were set-up in Almora in 1908 and Pendra Road, Central Provinces in Madhya Pradesh, at about the same time. The first sanatorium outside the patronage of Christian missionary organisations, called Hardinge Sanatorium was established at Dharampur, near Shimla in 1909 with the help of donations from some Mumbai-based philanthropists, mainly Parsis, under the banner of the Consumptives’ Homes Society. The first Government-run sanatorium [King Edward Sanatorium] was started at Bhowali in Uttarakhand [Figure 1.3]. The Union Mission Tuberculosis Sanatorium [UMTS] was established in Arogyavaram, Madanapalle, Chittoor district, Andhra Pradesh in 1915 [Figure 1.4A]. With the advent of the National Tuberculosis Programme [NTP] in 1962, the UMTS was converted to a general hospital called the Arogyavaram Medical Centre [Figure 1.4B] which is continuing to function even today. Till the mid-1950s, important TB research activity in India was pioneered by researchers [Figure 1.4C] at the UMTS sanatorium (26,27).
India became a member of the International Union Against Tuberculosis in 1929. From the funds generated in response to the appeal made on behalf of the government by the then Vicereine Lady Linithgow, and the King George V Thanksgiving [Anti-Tuberculosis] Fund, the Tuberculosis Association of India [TAI] was formed in February, 1939. In 1940, the TAI and Government of India jointly set-up the New Delhi Tuberculosis Centre as a model clinic. In 1951, the clinic was upgraded as first TB Training and Demonstration Centre in the country. In 1941, the Lady Linlithgow sanatorium was setup at Kasauli (26–29). The subsequent years saw the establishment of the Tuberculosis Chemotherapy Centre [TCC] at Chennai [then called Madras] and the National Tuberculosis Institute [NTI] at Bengaluru [then called Bangalore].
National Institute for Research in Tuberculosis, Chennai
In October 1955, on the request of the Government of India, the WHO sponsored the visit to India of three representatives of the British Medical Research Council [BMRC] to advise on studies designed to provide information on the mass domiciliary application of chemotherapy in the treatment of pulmonary TB (30).6
Figure 1.3: King Edward Sanatorium at Bhowali, Nainital, Uttarakhand state [A,B]. Late Dr Tarachand, originally a physician, who became a famous thoracic surgeon and his wife Dr Shanti Tarachand [expert in anaesthesiology] are well-known names at this Sanatorium. The museum in the sanatorium houses many of the surgically resected gross pathology specimens [C to F]
Figure 1.4A: Lord Pentland, Governor of the then Madras State opened the Union Mission Tuberculosis Sanatorium at Madanapalle on July 19, 1915, seen along with Dr Christian Frimodt-Moller, the first Medical Superintendent and members of the Governing Body[Kind courtesy: Dr B Wesley, Director, Arogyavaram Medical Centre, Madanapalle]
Figure 1.4B: The Union Mission Tuberculosis Sanatorium, at Arogyavaram, Madanapalle, Chittoor district, Andhra Pradesh, that later became the Arogyavaram Medical Centre
This was particularly relevant as the number of patients with TB far outnumbered the number of beds available for their admission at that time. It was feared that outpatient treatment might prove inadequate for the treatment of the disease, and that a high proportion of patients so treated might become chronic excretors of drug-resistant organisms and might pose a serious public health risk if use of domiciliary chemotherapy was widespread. With the knowledge then available, it was agreed that it would be premature to begin mass domiciliary application of chemotherapy, even in a limited area. It was finally decided to undertake a controlled comparative study of the treatment of patients at home and in a sanatorium initially, and to follow up the family contacts.7 Patients were to be admitted to study from among those routinely diagnosed by the chest clinic service of a large city. In order to implement these decisions, the TCC was established at Madras [Chennai] in 1956 [Figure 1.5A] as a five-year project, under the joint auspices of the Indian Council of Medical Research [ICMR], the Government of Tamil Nadu, the WHO and the BMRC. This Centre started its activities with eight international staff members belonging to the WHO and a team of national staff members drawn from the ICMR and the Government of Tamil Nadu under the dynamic leadership of Dr Wallace Fox of the BMRC. The Centre was housed in two main blocks, in a one-and-a-quarter hectare campus on Spur Tank Road, Chetput, in the heart of Chennai city. The Centre, which had an initial lease of life of only five years and had faced the threat of closure in 1961, has evolved further. In keeping with the wide sphere of activities of the Centre, the ICMR in 1978 renamed the TCC as the “Tuberculosis Research Centre” [TRC] (30) [Figure 1.5B]. The TRC was renamed on August 1, 2011 as National Institute for Research in Tuberculosis [NIRT] [Figure 1.5C]. Presently, a permanent institute under the ICMR, the NIRT is an internationally recognized institution for TB research. It is a Supranational Reference Laboratory and a WHO Collaborating Centre for TB Research and Training [Figure 1.5D]. Recently, an International Centre for Excellence in Research [ICER], in collaboration with NIH, was established at the Centre.
Figure 1.4C: Pioneers of research at Union Mission Tuberculosis Sanatorium, Arogyavaram, Madanapalle: Dr PV Benjamin [left panel], Dr Johannes Frimodt-Moller [middle panel], and Dr KT Jesudian [right panel][Kind courtesy: Dr B Wesley, Director, Arogyavaram Medical Centre, Madanapalle]
Figure 1.5: Tuberculosis Chemotherapy Centre, Madras [Chennai] [A]; Tuberculosis Research Centre, Madras [Chennai] [B]; renaming of Tuberculosis Research Centre as National Institute for Research in Tuberculosis [C,D][Kind courtesy: National Institute for Research in Tuberculosis]
Figure 1.6: Pioneers of research at Tuberculosis Chemotherapy Centre, Madras [Chennai]: Dr Wallace Fox [left panel]; Professor D.A. Mitchison [middle panel]; and Dr Hugh Stott [right panel][Kind courtesy: National Institute for Research in Tuberculosis, Chennai]
The Madras Experiment
Pioneering researchers who worked at TCC, TRC, NIRT are shown in Figure 1.6. The findings of the “Home-Sanatorium study” conducted by the TRC, Madras [Chennai], have found their way into several journals and textbooks on TB. The finding that TB patients can be effectively treated as outpatients and continue to live in their homes without added risk to their family contacts has revolutionised the whole concept of the management of TB (30). These pioneering studies also form the conceptual basis for the modern-day “DOTS”.
National Tuberculosis Institute
In order to formulate an effective strategy to control TB in India, the NTI was established under Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India, at Bengaluru [then, called Bangalore] in 1959, and was formally inaugurated on September 16, 1960 by Pandit Jawaharlal Nehru, the first Prime Minister of India (31). The NTI is located in the northern part of the Bengaluru near Rajamahal Guttahally on a sprawling field of 23 acres of land [Figure 1.7A]. The main central old building of oriental architecture called “Avalon”, was a palace belonging the erstwhile Maharaja of Mysore [Figure 1.7B]. The NTI has grown rapidly and has been designated as the WHO Collaborating Centre for TB research and training since June 1985. The NTI plays an important role in organising training activities in TB control for medical and paramedical personnel, in policies and procedures consistent with the WHO recommended DOTS strategy. Other functions of the NTI include monitoring and supervising TB control programme in the country, to plan, co-ordinate and execute research in TB epidemiology in India.
National Institute of Tuberculosis and Respiratory Diseases
The Lala Ram Sarup [LRS] TB hospital was established by TAI in 1952. It was upgraded into an autonomous institute, the LRS Institute of Tuberculosis and Respiratory Diseases under the Ministry of Health and Family Welfare in 1991 by the Government of India. The institute has recently been renamed in 2012 as National Institute of Tuberculosis and Respiratory Diseases [NITRD] (32). The LRS TB hospital functions in the NITRD. The WHO and the Global Laboratory Initiative [GLI] have recently recognised Microbiology Laboratory at NITRD as a National Centre of Excellence in 2014 for the WHO/GLI TB Supranational Reference Laboratory Network. The NITRD [Figure 1.8] has been designated by the WHO as a WHO Collaborating Centre [WHO CC] in TB Training [WHOCC No. IND-128] on November 6, 2014. The NITRD-WHO CC was opened on World TB Day 2015. The NITRD is a key player in TB control in India.
National JALMA Institute for Leprosy and Other Mycobacterial Diseases
The India Centre of Japanese Leprosy Mission for Asia [JALMA] was established in Agra by the Japanese in 1963 and was managed by a Tokyo based voluntary organisation JALMA (33). On April 1, 1976 the India Centre of JALMA was officially handed over to the Government of India and subsequently to the ICMR. This was named as Central JALMA Institute for Leprosy in 1976 and has been renamed as “National JALMA Institute for Leprosy and other Mycobacterial Diseases [NJILOMD]” in 2005 [Figure 1.9].
Figure 1.8: National Institute of Tuberculosis and Respiratory Diseases [NITRD], Lala Ram Sarup [LRS] TB hospital, New Delhi
The NJILOMD is equipped with the state-of-the art facilities such as well-equipped laboratories, modern hospital and well-set Field Programmes at Model Rural Health Research Unit [MRHRU] at Ghatampur and a satellite centre at Banda, serves as a National Reference Laboratory [NRL] for TB for 4 states [Assam, Himachal Pradesh, Uttarakhand and Eastern Uttar Pradesh] and repository centre for mycobacterial strains. The institute has a major thrust on research in TB and other mycobacterial diseases (33).
The history of TB and time line of various TB diagnostic tests are shown in Figures 1.10 and 1.11 respectively.
Revised National Tuberculosis Control Programme
Considered to be one of the most spectacular cost-effective health interventions ever conceived, the Revised National Tuberculosis Control Programme [RNTCP] of the Government of India, which began in 1997, now covers the whole country. The RNTCP has been the fastest expanding programme, and the largest in the world in terms of patients initiated on treatment. The reader is referred to the chapter “The revised national tuberculosis control programme” [Chapter 53] for details on this topic.
Involvement of Medical Colleges in Tuberculosis Control
The RNTCP has the unique distinction of involving medical colleges in TB control (34). This topic is covered in detail in the chapter “The role of medical colleges in tuberculosis control” [Chapter 48].
Tuberculosis Notification
In order to have complete information of all TB cases, the Government of India declared TB to be a notifiable disease on May 7, 2012 (35). Accordingly, all health care providers including government, private, non-governmental organisations, individual practitioners are expected to notify TB cases.
Figure 1.9: National JALMA Institute for Leprosy and other Mycobacterial Diseases, Agra. Inset: Main gate
National Antituberculosis Drug-resistance Survey
The RNTCP, in collaboration with the NTI, Bengaluru; U.S. Centers for Disease Control and Prevention and the WHO; has initiated the first national anti-TB drug-resistance survey (36,37). In this survey covering 120 TB units in 24 states, 13 drugs including all first-line and most of second-line anti-TB drugs were tested. The survey was conducted in a representative sample of both newly diagnosed sputum smear-positive pulmonary TB cases [Category I] and previously treated sputum smear-positive pulmonary TB cases [Category II] (36,37).
Other New Innovations
Since the beginning, the RNTCP had provided thrice-weekly intermittent treatment (38–41). With more recent evidence accumulating, the programme has introduced daily treatment from 2016 and the entire country is being covered in a phased manner. The RNTCP is also scaling up the newer diagnostic modalities, namely, cartridge-based nucleic acid amplification tests [CBNAAT], such as, Xpert MTB/RIF and line probe assay [LPA] for early diagnosis of TB and molecular detection of drug susceptibility. The evidence-based Indian Extrapulmonary TB [INDEX TB] guidelines have been published in 2017 (42). Active case finding in vulnerable populations under the RNTCP is also being studied (43,44). Introduction of newer anti-TB drugs, such as bedaquiline and delamanid under conditional access program, under RNTCP is underway (45).
CHANGING GLOBAL FACE OF TUBERCULOSIS CONTROL
The recent paradigm shift in efforts directed at TB control globally is highlighted in the chapters “Building partnerships for tuberculosis control” [Chapter 50], Integrating Community-based Tuberculosis Activities into the Work of Non-governmental and Other Civil Society Organisations [The ENGAGE-TB Approach]” [Chapter 51] and “WHO's new end TB strategy” [Chapter 52].10
EPILOGUE
A look at the history of TB [Figure 1.10] and time line of various TB diagnostic tests [Figure 1.11] reveals that it took several thousands of years for humans to identify the causative organism, another 60 years to arrive at effective treatment. Towards the end of the twentieth century, the twin disaster of HIV and TB and X/MDR-TB seem to be on the verge of threatening to ruin the mankind. While it is heatedly debated that TB is “resurging”, this may hold true for the industrialised countries. But in the third-world countries like India, TB never seems to have “disappeared” to “resurge” later. TB has always been with us, only revealing itself every now and then and making us wiser.11
ACKNOWLEDGEMENTS
The authors wish to acknowledge the help rendered by Vedic scholars K Gopala Ghanapatigal, Vedaparayandar, Tirumala Tirupati Devasthanams, Tirupati, and V Swaminatha Iyer, Retired Principal, Kendriya Vidyapeetha, Guruvayoor, Kerala, India, for their invaluable help in tracing the references to TB in the Vedas.
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