'Be The Change' in tuberculosis control among women

Although women get diagnosed for tuberculosis (TB) later than men, treatment outcomes among women are better than men with higher TB treatment success rate and lower default (drop-out) rate in the female patients. Among the unreached people who need TB care, a significant number of them are likely to be poor and probably women. There is a lot more we need to do to bring in the desired change in diagnosing people with TB as early as possible and treating them with standard regimens successfully.

"We need to integrate gender-specific home-based care for TB to reduce transport cost and time loss" said Mamta Jacob from Global Health Advocates (GHA) who was a keynote speaker at the recently held meet on TB and women in New Delhi, India, to mark the International Women's Day (8th March 2011).

"Partnering with traditional practitioners, establishing linkages with mental health programme for quality counselling, raising awareness among healthcare workers of atypical symptoms of TB in women (like psychological and emotional distress, lack of haemoptosis) are some of the initiatives we need to scale up to reach the unreached women with TB" said Mamta Jacob.

"Privacy in healthcare settings for women is also important. It is difficult for a woman to overcome social inhibitions and produce diagnostic quality sputum for TB test in a overcrowded and public setting like a public hospital for example. Also counselling is so crucial in TB control among women, especially family counselling, when a woman is the only TB patient in the family. This will go a long way to counter stigma and discrimination related to TB and also raise TB treatment literacy and infection control knowledge among family members" said Mamta Jacob.

Dr Nerges Mistry, Director of the Foundation for Medical Research, Mumbai, India, was another keynote speaker who presented the content from the National Rural Health Mission (NRHM) Module 7 which lists the role of ASHA workers in TB treatment phase. This was an eye-opener because one can only wish if this is implemented in letter and spirit to bring in a significant desired change we wish to see in TB control.

The NRHM Module 7 lists the following as the role of ASHA workers in TB treatment phase:
- ASHA workers could serve as the DOTS provider in their village and ensure compliance
- Since the treatment is of long duration, the ASHA worker has a key role in motivating the patient to complete the treatment and prevent them from stopping midway or drop out
- Recognising the side-effects of the drugs and knowing how to deal with side-effects of drugs and making sure of drug-availability at the health facility will help ASHA workers to do this more effectively
- Encourage the patient to take sufficient nutrition during treatment and moderate rest at least for the first two months
- The family of the patient should be counselled to take precautions at home especially for children and elder persons who can contract the disease quickly
- When coughing, the patient must put a protective clean cloth over his mouth to prevent spread of droplets or leave the house and cough in a nearby open space. The cloth should be washed in hot water or with disinfectant thoroughly on a regular basis.
- The patient should not have close contact with spouse, children and infants and the elderly within the family at least for two months after starting treatment. Simple hygiene precautions will help in preventing transmission of TB within the family
- ASHA workers must keep a watch on the other family members to detect early signs of TB in the members and if necessary, get them examined from time to time
- Ensure BCG vaccination of children at birth. This can help prevent TB among small children
- TB is also a stigmatising disease. Confidentiality of patient identity must be maintained
- Awareness of TB related symptoms and the approach to achieving a cure through self-reporting for examination must be stressed at community gatherings as also the importance of good nutrition and taking of complete treatment
- Relapse of TB in patients who have had previous treatment is possible. Many times, such patients are considered as new patients. The record of previous treatment should be made known to the health facility where the patient presents for re-treatment so that a different drug regimen may be prescribed

With such measures already in place in NRHM and commitment of India's Revised National TB Control Programme (RNTCP) to engage ASHA workers in TB control, the compelling need is to walk the talk!

Malnutrition and food insecurity can exacerbate the risk of TB disease; other threats such as rising tobacco use and diabetes among women, can also mean an increasing burden of TB.

"Due to domestic responsibilities, a woman is least likely to express her illness. She is most likely to have poor access to financial resources and is probably at times afraid of getting permission from husband or mother-in-law to get healthcare services for her illness" said Global Health Advocates (GHA). Also the risk for mother to child transmission of TB is estimated to be 15 per cent within 3 weeks of birth, said Mamta Jacob. Although there is no vertical transmission of TB, said Dr KS Sachdeva, Chief Medical Officer (CMO) at RNTCP in India.

"Women wait twice as long as men to seek treatment for TB, which can increase the severity of their illness, decrease the success of treatment, and raise the risks that they will infect others" said Mamta Jacob. According to a study done by Tuberculosis Research Centre (TRC) Chennai, 100,000 women are rejected by their families due to TB in India every year, and 300,000 children drop out of schools because either they themselves or one of their parents develop active TB disease.

According to the fact-sheet on women and TB of the Stop TB Partnership, women can play a critical role in TB care and control as educators, organizers and providers. Hope the TB programmes will involve them furthermore as equal partners with dignity at all levels.

One clear action point for public health, gender and social justice stakeholders is to seriously and genuinely scale up possible collaborative activities between existing programmes addressing gender inequalities, reproductive and sexual health, maternal and child healthcare, and TB.

Bobby Ramakant - CNS