World TB Day: Lung health needs to remain High on the agenda in a post-covid world

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Two epidemics continue to ravage global lung health. One, an infectious disease, primarily affecting the lungs and killing hundreds of thousands of people globally, annually. This disease has killed millions over the years and continues to ravage the world, and particularly nations such as India and China even in the 21st Century. Seems familiar to but is not COVID. It is tuberculosis, often known simply as TB.

The other epidemic is a man-made crisis of global proportions. Currently, 1.3 billion people in the world consume tobacco in smoked and smokeless forms such as cigarettes, bidis, zarda, gutkha, etc. These products come packaged attractively and often very cheap, and have generations hooked to the nicotine they deliver. Consuming these products leads to premature death with cancer, heart disease and lung disease among more than half of their consumers.

What happens when these two public health threats join hands and threaten to choke the very air we breathe?

TB and tobacco use are intricately linked. Nearly 40% percent of TB deaths are associated with tobacco use. It is proven that exposure to tobacco smoke increases the risk of both TB infection and disease. Tobacco smokers have twice the risk of developing TB when compared to non-smokers. Patients with TB who smoke have twice the risk of death during TB treatment. There is substantial evidence to link smoking with TB and poor treatment outcomes. Smoking bidis and cigarettes damages the lungs and makes them more susceptible to TB. Tobacco use also interacts at an immunologic and cellular level to reduce antitubercular treatment efficacy. Although similar data are not available for Indian forms of oral smokeless tobacco products (gutkha, zarda), those products also contain carcinogens and are known to adversely impact the users’ immunity.

With nearly 2.6 million TB patients, India is the highest TB burden-country accounting for one-fourth (25 percent) of the global incidence. Every year, around a quarter of a million people die due to TB in India. That is 2 deaths due to TB every 5 minutes. Also, with nearly 300 million tobacco users, India has a quarter of the world’s tobacco consumers. Tobacco use kills nearly a million users annually in India.

India set an ambitious target to achieve “END TB” goals of 80 percent reduction in incidence and 90 percent reduction in deaths by 2025, which is 5 years earlier than the stipulated timeline. India rebranded its RNTCP (Revised national TB control programme) to NTEP (National TB Elimination Programme) in 2020, to underscore this ambition. Currently, NTEP oversees treatment centres spread across the country and community, and a strict protocol for administering WHO prescribed DOTS treatment. DOTS consists of a combination of key anti-TB drugs for six months under observation and adherence monitoring.
India has made great strides in the NTEP. During 2018, among patients with drug-sensitive TB initiated on antitubercular treatment, an overall success rate of 81 percent was recorded in India. The successful implementation of the DOTS regime is a public health win. However, the present annual rate of decline of TB incidence is around 3 percent and needs to be accelerated to 11 percent to achieve the desired 2025 target.

Tobacco cessation improves the respiratory tract’s ciliary function and local immunological responses, thereby improving cure rates in people with TB. This TB-tobacco connection is not known or practised by those delivering DOTS, thus missing out on a public health win-win. E.g. The section for tobacco use history in the medical records of TB patients is more often than not left blank. Even if it is ticked, there is no opportunistic intervention in the form of giving brief advice on quitting and then referring to a cessation clinic. Addressing tobacco use and achieving tobacco cessation among TB patients may be crucial to meeting India’s End TB goal for 2025.

Proactively enabling tobacco cessation is essential for improving treatment outcomes in TB patients as well as reducing population-level TB incidence in the long run. The last round of national tobacco use survey for India (GATS 2017) showed that 8.4 percent of the current smokers had intended to quit smoking in the next one month and 38.5 percent of the tobacco users made a quit attempt in the previous 12 months, among whom 71.7 percent attempted without any assistance. As a result, less than 1/4th of all those who attempted to quit sustained abstinence for at least 3 months. Besides, only 4.1 percent and 8.6 percent of them used pharmacotherapy and counselling advice respectively.

Quitting tobacco use without support is proven to be ineffective and unsustainable for most users. Over the past few decades, clinical research into cessation treatments has given us medications proven to manage the nicotine cravings during quitting. These include nicotine replacement therapy (NRT) products such as nicotine gums, patches and lozenges, and medicines such as bupropion and varenicline.

NRTs are even on the WHO’s model essential list of medicines, thus underscoring the need to have them available and affordable for treating tobacco addiction globally. A range of behavioural counselling techniques have also been developed and proven to address the habit. A combination of these treatments, tailored to individual needs, and delivered by trained healthcare professionals, has the highest proven likelihood of success to quit tobacco and not relapse.

Improving cessation rates requires the practical implementation of the recommendations of Article 14 of the WHO’s Framework Convention on Tobacco Control (FCTC), to which India is a signatory. The Article states that all parties “shall take effective measures to promote cessation of tobacco use and adequate treatment for tobacco dependence.” ‘Offer to help quit tobacco use is also one of the six MPOWER strategies (the ‘O’ in the MPOWER) for tobacco control advocated by WHO. However, the implementation of Article 14 has been sluggish, placing nearly a billion would-be quitters at risk of premature death, globally.

In India, the infrastructure is now put in place at each district level in the form of tobacco control cells and cessation rates should see an improvement if the necessary tools and services are available. That’s where the bottleneck lies. Healthcare practitioners do not get any or adequate training in prescribing cessation medications or providing cessation support to their patients. Myths persist among healthcare practitioners on nicotine itself, and many wrongly consider nicotine to be carcinogenic. This leads to poor support to patients for quitting tobacco, sub-optimal cessation outcomes, more failed attempts to quit, and a large residual population of tobacco users who face premature death due to continued tobacco use. Designing an effective tobacco cessation programme for TB patients is the need of the hour in India.

The proven success of DOTS for TB patients can have its mirror-image for tobacco cessation. Brief advice, accompanied by NRT and/or pharmacotherapy, should be considered as the first line of treatment for tobacco cessation among TB patients. This would be possible only with adequate training to healthcare professionals across various levels, including primary care doctors, DOTS centre staff, and secondary and tertiary level of specialists such as psychiatrists and chest physicians. Refresher training courses on tobacco cessation are needed on a regular basis for healthcare professionals across the healthcare system. The training should also focus on motivating government as well as private sectors to record the use of tobacco products for all patients and offer appropriate and comprehensive support for quitting tobacco.

India and indeed the rest of the world are slowly recovering from 2 relentless years of the COVID pandemic. The Covid pandemic forced the Government to increase annual budgetary spend from 1.35 to 2.1% of the GDP. The official figures for deaths due to COVID in India in the past two years are stated to be near the half-million mark. It is important to see these numbers in context. The epidemics of TB and tobacco are responsible for an ongoing death toll that is far higher than COVID, and yet continue to be neglected and under-resourced. In fact, focus on COVID in the past two years also meant diversion of resources away from TB diagnosis and treatment services.

This year’s theme of World TB Day is “Invest to end TB”. It is amply clear that smart investment in training and resourcing of healthcare providers that enables cross functional collaboration in the TB elimination and tobacco control programmes of India has the potential to deliver quick and sustainable wins for the nation’s public health. The cost of NRT remains unacceptably high, and the availability and variety of the products is limited.

Innovation into affordable and accessible nicotine replacement products and digital health tools such as apps is seriously underfunded and does not seem to be a priority for the healthcare industry. Better targeted investment in tobacco cessation innovation has the potential to dramatically reduce the dual burden from tobacco and TB in India. The increased GDP spend on health should be sustained in the coming years, allocating more resources to restoring the nation’s lung health. As we all let out a collective sigh of relief from a pandemic just past, let this be an opportunity to maintain a healthy investment in our lungs.

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