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In India there is a need to re-assess the role of generally identifiable risk factors for development of tuberculosis (e.g. old age, poverty and poor socio-economic status). The present study was look into the socio-economic and demographic characteristics of patients of tuberculosis (TB) vis-à-vis those with other respiratory diseases in the area in and around Chandigarh and around country . Case-control study in Two hundred and fifty consecutive cases of TB and an equal number of patients with pulmonary diseases other than tuberculosis as controls were interviewed as per a pre-designed, structured questionnaire that inquired into several socio-economic and demographic variables besides the clinical details. Univariate and multiple logistic regression analyses were carried out to obtain odds ratios separately for each variable. The mean age of patients suffering from tuberculosis was 35-56 years . There were 168 men (67.2%) and 82 (32.8%) women among the cases. Persons suffering from tuberculosis were more frequently found to have the worst of the socio-economic conditions for all the variables. Odds ratio increased by 3.14 for every decrease of Rs.500/- in the income level per person per month below Rs.2000/-. Similarly, the OR increased by 3.66 with increasing number of persons per room. The poorer housing, toilet facilities, water supply and consumer articles also significant for Indian economy. In multivariate logistic regression analysis, the age, level of education, crowding, type of housing, water supply and number of consumer articles in the household was found to be independently and significantly associated with a higher risk of TB. So there is a significant SES-health gradient in TB prevalence; tuberculosis risk increases with lowering of socio-economic status. Tuberculosis, socio-economic factors, epidemiology, risk factors has been found in poverty states of Punjab , Haryana , Himachal Pradesh, Jammu & Kashmir, western parts of Uttar Pradesh and With the recent resurgence of tuberculosis Uttranchal. There is an imperative need to reassess whether the age-old risk factors for the development MATERIAL & METHODS of disease (e.g. old age, malnutrition, poverty, poor socio-economic status) are still operating or not, A case-control study design, which included especially in the developing countries. A recent 250 consecutive cases of tuberculosis, aged 12 years publication from the National Institute of or more was adopted. The case definitions included Tuberculosis, Bangalore , has summarized all the Pulmonary tuberculosis (PTB) with sputum smear available literature on the sociological aspects of positive for Acid Fast Bacilli (AFB) or a strong tuberculosis. There are very few studies in recent clinical/radiological suspicion of PTB with a times that have studied the socio-economic aspects documented response to anti-tubercular drugs. of this deadly disease. In the present study we have Extra pulmonary tuberculosis with demonstrable looked into the socio-demographic characteristics AFB in smear/culture from clinical specimen a of patients of tuberculosis seen at a tertiary care histopathology consistent with tuberculosis. The referral institute located in Chandigarh in Northern control group consisted of 250 patients with India and having a catchments area spread over the pulmonary diseases other than tuberculosis. SOCIO-ECONOMIC STATUS Increased odds ratio for persons with poor housing tuberculosis control cannot be expected to lead (i.e. those living in ‘Kutcha’ house and/or houses to eradication of tuberculosis unless matching which get wet/flooded during monsoon) to have TB, and forceful efforts in prevention through found in the present study has a plausible physical improvement in socio-economic status are also explanation. It is known that a viable bacillus that is initiated. dried out or exposed to sunlight often is phenotypically too weak to start an infection. Unawareness can increase the risk of transmission . and development of disease. We also found an inverse relationship between age and increased risk for TB. This is contrary to the reported higher risk of tuberculosis in the elderly people . But the observations study are consistent with the results of the prevalence studies from part of the country, where majority of patients belonged to 15-55 years of age. Although the increased susceptibility of the elderly to tuberculosis cannot be denied, the total load in the younger age groups is much larger in the developing countries like India . Data on socio-economic risk factors for tuberculosis in India are sparse. In a study on socioeconomic impact of TB, it was shown that tuberculosis imposes high direct and indirect costs on the patients, leads to loss of wages for an average of 3 months and leads to school drop-outs in about 20% children. The importance of socio-economic development in enhancing anti-TB efforts has been repeatedly emphasized. Also, successful implementation of tuberculosis control programme is likely to have a direct tangible economic and social benefit. In the present study, the multivariate analysis showed an association of TB with overcrowding, poorer housing, lesser education and lower number of consumer articles. This is in agreement with results observed in literature. Low income had increased odds only in the lowest income category, which was statistically not significant. This could be attributed to the fallacies in reporting income, which could otherwise be assessed from other parameters such as the number of consumer items. Exactly how poverty may lead to tuberculosis remains unclear. Poor SES with its attendant poor education is associated with poor knowledge of TB, risks of infection and dissemination, and with inadequate and/or delayed availability of health care. Poverty also results in poor nutrition and low body weight, which are likely to render the immune system more vulnerable to the invading organisms8. Over-crowding increases the risk of disease transmission9,10. Aerosol droplets containing tubercle bacilli are discharged into the atmosphere when a open case of tuberculosis coughs or sneezes. Fine droplet nuclei remain suspended in the air stream that reaches the alveolar space, thereby starting the infection. Overcrowding, by decreasing the degree of air space that is shared, results in increased exposure to M. tuberculosis. The existence of a SES-health gradient with respect to risk of tuberculosis. Most public health efforts are focused on control of tuberculosis through treatment of patients. It is not surprising that cost-effective strategies such as directly observed therapy have emerged and to a large extent have been successful, even within populations of lower SES. But, the current predominantly treatment-based approach to Sociological aspects of Tuberculosis is not suitable for all Indian people. MDR-TB reflects the poor primary management of the disease. It is mainly caused by the failure to ensure compliance, rather than the failure of the drugs to cure. The highest priority in fighting MDR-TB therefore must be its prevention. DOTS treatment for TB patients is the most cost effective method of preventing MDR TB and the concerned health personnel, in the public as well as the private sector must adhere meticulously to RNTCP diagnostic and treatment guidelines. However, in the evolving situation of TB control activities in India , the RNTCP appears to be moving gradually towards the provision of accurate and reliable DST facilities and treatment services for MDR-TB patients. The use of the most cost-effective regimens and the provision of support to the patients, to ensure direct observation and completion of treatment, must be provided and sustained as integral to the programme. It needs to be realized that patients with MDR-TB will have, at best, only one chance for cure with second line drugs provided free under the RNTCP. TB MANAGEMENT IN INDIA The RNTCP established a network of RNTCP accredited quality-assured Intermediate Reference Laboratories (IRL), providing culture and DST services for the RNTCP. Concurrently, a network of DOTS Plus sites, as per international guidelines, capable of enrolling and providing care and management for MDR-TB cases would be established. A total of 24 DOTS Plus sites are planned to be established across the country over the next five years, with a view to have in place RNTCP DOTS Plus services that are capable of enrolling for treatment at least 5000 “new” MDR-TB patients every year by 2010. The first DOTS Plus sites will be established in the states of Gujarat and Maharashtra and will be ready to enroll the first patients during 2006. The cost of MDR-TB treatment at US$ 1600 is prohibitive, compared to less than US$ 10 for RNTCP DOTS treatment. Some of the major challenges in providing cost-effective MDR treatment in the field include: provision of daily DOT over an extended period of 24-27 months; ensuring uninterrupted supply of DOTS Plus drugs; provision of services to manage the anticipated frequent, and sometime severe, adverse drug reactions; managing the contacts of MDR-TB patients, provision of social support to the patients and their families during treatment; and ensuring the establishment of long term sustainable DOTS Plus services under the RNTCP. Under RNTCP Phase II, it is planned to first establish a network of RNTCP accredited quality-assured Intermediate Reference Laboratories (IRL), providing culture and DST services for the RNTCP. Concurrently, a network of DOTS Plus sites, as per international guidelines, capable of enrolling and providing care and management for MDR-TB cases would be established. References:
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